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ANSWERS
You are reviewing the chart of a PT who is receiving
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heparin therapy for a DVT. Which intervention should the
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RN anticipate taking if the PTs aPTT is 96 seconds?
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1. Increase heparin infusion rate by 2mL/hr
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2. Continue monitor the heparin infusion as prescribed
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3. Request a prothrombin time PT
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4. Stop the heparin infusion - CORRECT ANSWERS ✔✔4.
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Stop the heparin infusion- pt is above the therapeutic
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range of 1-5-2 times the control. should discontinue to
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prevent harm |\
You are providing teaching to a PT who is 2 days post op
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following a heart transplant. Which following statements
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should the nurse include in the teaching?
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1. You may no longer be able to feel chest pain
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2. Your level of activity intolerance will not change
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3. after 6 months you will no longer need to restrict you
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Na
,4. You will be able to stop taking immunosuppressants
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after 12 months - CORRECT ANSWERS ✔✔1. You may no
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longer be able to feel chest pain- transplant PTs no longer
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feel chest pain due to denervation of the heart
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ER nurse is assessing PT with bradydysrhythmia. Which
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finding should he expect? |\ |\ |\
1. Confusion
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2. Friction Rub
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3. HTN
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4. Dry skin - CORRECT ANSWERS ✔✔1. Confusion- as a
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result of decreased tissue perfusion
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You are caring for a PT who had an anterior MI. PTs hx
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shows she is 1 wk post op open cholecystectomy the RN
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knows that which intervention is contraindicated?
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1. Administering IV morphine
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2. giving O2 at 2L NC
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3. Helping client to BSC
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4. Assisting in thrombolytic therapy - CORRECT ANSWERS
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✔✔4. Assisting in thrombolytic therapy- having surgery
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within 3 wks is a contraindication for thrombolytic therapy
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,You are caring for a PT who has endocarditis. Which
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finding should you recognize as a complication?
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1. Ventricular depolarization
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2. Guillain Barre Syndrome
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3. Myelodysplastic syndrome
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4. Valvular disease - CORRECT ANSWERS ✔✔4. Valvular
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disease- damage will occur as a result of inflammation or
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infection of the endocardium |\ |\ |\
You are caring for PT with BP of 254/139, you recognize
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the PT is in a hypertensive crisis. Which action should you
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take first?
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1. Obtain blood samples for testing
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2. Tell the PT to report vision changes
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3. Place HOB at 45 degrees
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4. Initiate IV access - CORRECT ANSWERS ✔✔3. Place
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HOB at 45 degrees-ABC's this will promote respiratory
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status and promote venous return reducing workload on
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heart
**Initiate IV access- not first action |\ |\ |\ |\ |\
, When performing a cardiac assessment what is the point
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of maximal impulse?
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1. 2nd intercostal space right to the sternum
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2. 2nd intercostal space left to the sternum
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3. 5th intercostal space to the left of thermal border
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4. Left 5th intercostal space in the midclavicular line -
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CORRECT ANSWERS ✔✔4. Left 5th intercostal space in
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the midclavicular line-this is best to hear the apex of the
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heart which is considered maximal impulse
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You are caring for a PT who is experiencing Afib. You
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should report what finding to the provider?
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1. Slurred speech
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2. Irregular pulse
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3. Dependent edema
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4. Persistant fatigue - CORRECT ANSWERS ✔✔1. Slurred
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speech- greatest risk is an embolus and this can indicate
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embolus
You are assessing a PT with Left sided heart failure. What
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manifestation should you expect to find? |\ |\ |\ |\ |\