Proctored Cardiac and Respiratory

Correct Answer: A. Emphysema

Rationale:

Emphysema is a form of chronic obstructive pulmonary disease (COPD) characterized by the destruction of alveolar walls and loss of lung elasticity, leading to air trapping and hyperinflation of the lungs. This results in the classic barrel chest appearance due to an increased anteroposterior (AP) chest diameter.

Key Characteristics of Emphysema:

Barrel chest (due to lung hyperinflation)

Pursed-lip breathing (helps control exhalation and prevent airway collapse)

Dyspnea on exertion

Diminished breath sounds

Use of accessory muscles to breathe

Minimal sputum production

Pink complexion (hence the term "pink puffers")

Why the Other Options Are Incorrect:

B. Pneumonia

Infection of the lung tissue causing inflammation and fluid accumulation in the alveoli. Symptoms: Cough, fever, crackles, dyspnea, pleuritic chest pain. Does not cause a barrel chest.

C. Chronic Bronchitis

A form of COPD involving excess mucus production and chronic inflammation of the airways. Symptoms: Productive cough for at least 3 months per year for 2 consecutive years, cyanosis, wheezing. Patients are called "blue bloaters", but barrel chest is less prominent than in emphysema.

D. Asthma

A reversible airway obstruction caused by inflammation and bronchospasms. Symptoms: Wheezing, dyspnea, chest tightness, cough. Does not typically cause barrel chest unless it becomes chronic and severe.

Key Takeaway:

Emphysema leads to lung hyperinflation, which causes barrel chest, dyspnea, and pursed-lip breathing. It is part of COPD, often due to smoking or long-term exposure to airborne irritants.

Correct Answer: D. Pulmonary angiography

Rationale:

Pulmonary angiography is the gold standard and most definitive diagnostic test for pulmonary embolism (PE) because it provides a direct visualization of blood flow in the pulmonary arteries. It involves injecting a contrast dye into the pulmonary vasculature and using imaging (typically CT or fluoroscopy) to detect any obstructions.

Why the Other Options Are Incorrect:

A. Chest X-ray

Not a definitive test for PE. May help rule out other conditions like pneumonia or pneumothorax but often appears normal in PE. Sometimes shows nonspecific findings like atelectasis or pleural effusion.

B. Arterial Blood Gas (ABG) Analysis

Can indicate hypoxemia (low oxygen levels) and respiratory alkalosis (from hyperventilation), but not specific for PE. Used as a supportive test, not for definitive diagnosis.

C. D-dimer Test

A screening test that measures fibrin degradation products (indicating clot breakdown). High sensitivity but low specificity—many conditions (infection, pregnancy, trauma) can cause elevated D-dimer. A normal D-dimer can help rule out PE, but a positive result does not confirm it.

Key Takeaway:

Pulmonary angiography is the most definitive test for pulmonary embolism, as it provides direct imaging of a clot blocking pulmonary circulation. However, in clinical practice, a CT pulmonary angiography (CTPA) is commonly used due to its non-invasive nature and high accuracy.

Correct Answer: D. ST-segment elevation

Rationale:

ST-segment elevation on an electrocardiogram (ECG) is the most indicative finding of an acute myocardial infarction (MI), specifically a ST-elevation myocardial infarction (STEMI). It occurs due to complete occlusion of a coronary artery, leading to myocardial ischemia and injury.

Other ECG Changes Associated with MI:

Inverted T waves: Indicate ischemia but are not as specific for an acute MI as ST elevation.

Pathologic Q waves: Suggest previous or evolving infarction.

Why the Other Options Are Incorrect:

A. Prolonged PR interval

Indicates first-degree heart block, which affects AV node conduction but is not indicative of an MI.

B. Peaked P waves

Suggest right atrial enlargement (e.g., pulmonary hypertension, chronic lung disease) but are not associated with MI.

C. Inverted T waves

Indicate ischemia but are not the most definitive sign of an MI. T-wave inversions may also be seen in other conditions like pericarditis or electrolyte imbalances.

Key Takeaway:

ST-segment elevation is the most significant ECG indicator of an acute myocardial infarction (STEMI) and requires immediate intervention to restore coronary blood flow (e.g., PCI or thrombolytics)

Correct Answer: B. Prednisone

Rationale:

Prednisone is a corticosteroid that helps manage chronic asthma by reducing inflammation and suppressing the immune response in the airways. It is typically used for long-term control in severe asthma or during acute exacerbations to decrease airway swelling and mucus production.

Why the Other Options Are Incorrect:

A. Albuterol

A short-acting beta-agonist (SABA) used for quick relief of acute asthma symptoms (rescue inhaler). Does not reduce inflammation—it works by relaxing bronchial smooth muscles to improve airflow. Not for long-term inflammation control.

C. Theophylline

A methylxanthine that relaxes airway muscles and improves breathing but is less commonly used due to its narrow therapeutic range and potential side effects (toxicity, arrhythmias). Does not directly reduce inflammation like corticosteroids.

D. Ipratropium

An anticholinergic bronchodilator used primarily for chronic obstructive pulmonary disease (COPD) rather than asthma. Sometimes used in acute asthma exacerbations, but not a first-line treatment for chronic asthma.

Key Takeaway:

For chronic asthma, inhaled corticosteroids (ICS) like budesonide or fluticasone are preferred for long-term control. Prednisone, an oral corticosteroid, is often used for short-term management of severe asthma exacerbations.

Correct Answers:

A. Carotid stenosis

C. Renal insufficiency

D. Coronary artery disease

Explanation:

Chronic hypertension can cause end-organ damage, which affects vital organs such as the heart, kidneys, brain, and arteries. The prolonged high pressure in blood vessels leads to structural and functional damage in these organs.

A. Carotid stenosis

Hypertension contributes to atherosclerosis, which can lead to narrowing of the carotid arteries. Carotid stenosis increases the risk of stroke due to reduced blood flow to the brain or embolization from plaque rupture.

C. Renal insufficiency

Chronic hypertension damages the small blood vessels in the kidneys, leading to reduced kidney function and eventual renal insufficiency or chronic kidney disease (CKD). Uncontrolled hypertension is one of the leading causes of kidney failure requiring dialysis.

D. Coronary artery disease (CAD)

Hypertension accelerates the development of atherosclerosis in the coronary arteries, leading to coronary artery disease. CAD increases the risk of myocardial infarction (heart attack) and heart failure.

Why the Incorrect Answers Are Wrong:

B. Diabetes mellitus

Hypertension and diabetes often coexist, but chronic hypertension does not cause diabetes. Instead, diabetes is caused by insulin resistance or beta-cell dysfunction, though hypertension can worsen diabetic complications.

E. Isolated systolic hypertension

Isolated systolic hypertension (ISH) is a type of hypertension, not a result of end-organ damage. ISH is common in older adults due to arterial stiffness, but it is a risk factor for end-organ damage rather than a consequence.

F. Familial hypercholesterolemia

Familial hypercholesterolemia (FH) is a genetic disorder that results in extremely high cholesterol levels. It increases the risk of cardiovascular disease but is not caused by chronic hypertension.

Summary:

Chronic hypertension damages the arteries and organs over time, leading to carotid stenosis, renal insufficiency, and coronary artery disease. It does not cause diabetes mellitus, isolated systolic hypertension, or familial hypercholesterolemia, though it may worsen some of these conditions. Controlling blood pressure is essential to preventing these complications.

Correct Answer: A. Bathe and eat slowly with periodic rest.

Rationale:

Patients with COPD experience dyspnea (shortness of breath) and fatigue, which can make self-care activities challenging. Pacing activities and incorporating rest periods helps conserve energy and prevents excessive oxygen demand. Eating slowly reduces the risk of breathlessness, and bathing at a relaxed pace prevents overexertion.

Why the Other Options Are Incorrect:

B. Walk short distances without oxygen.

If the patient requires supplemental oxygen, it should not be discontinued. Walking without oxygen could lead to hypoxia, causing dizziness, fatigue, or respiratory distress.

C. Perform all activities of daily living (ADLs) and then rest.

 Performing all ADLs in one go can cause excessive fatigue and breathlessness. It is better to spread activities throughout the day with rest periods to prevent exhaustion.

D. Bathe right after eating, and then rest.

 Bathing immediately after eating can increase oxygen demand, leading to breathlessness. Resting before and after activities is a better approach.

Key Takeaway:

Patients with COPD should pace activities, take rest breaks, and perform self-care slowly to conserve energy and avoid worsening symptoms. Option A is the best choice.

Correct Answers:

A. Oxygen equipment

C. Pulse oximeter

 D. Sterile dressing

Rationale:

A thoracentesis is a procedure where a provider inserts a needle into the pleural space to remove excess fluid for diagnostic or therapeutic purposes. Since this procedure carries risks such as respiratory distress, pneumothorax, or bleeding, the nurse must ensure essential supplies are readily available.

Oxygen equipment (A) 

Thoracentesis can lead to hypoxia or respiratory distress, especially if a large volume of fluid is removed. Oxygen should be available in case the client requires supplemental oxygen after the procedure

Pulse oximeter (C) 

Continuous oxygen saturation (SpO₂) monitoring is critical to detect early signs of hypoxia or respiratory complications. The nurse should closely monitor SpO₂ readings during and after the procedure.

Sterile dressing (D 

After the procedure, the insertion site must be covered with a sterile dressing to prevent infection and bleeding. The nurse should monitor for drainage, bleeding, or signs of infection.

Why the Other Options Are Incorrect

Incentive spirometer (B) 

Although an incentive spirometer is used postoperatively to prevent atelectasis, it is not required immediately for a thoracentesis. The client is typically monitored for respiratory distress first, and deep breathing exercises may be encouraged later.

Suture removal kit (E) 

A thoracentesis does not involve sutures since the procedure uses a needle, not an incision. The insertion site typically closes on its own with a sterile dressing.

Key Takeaways:

 Ensure oxygen equipment is available in case the client experiences respiratory distress

 Use a pulse oximeter to monitor oxygen saturation before, during, and after the procedure

 Apply a sterile dressing after the procedure to reduce the risk of infection

 An incentive spirometer is not necessary during or immediately after a thoracentesis.

A suture removal kit is not needed because no sutures are used in this procedure.

Correct Answer: A. Administer antihypertensive medication for blood pressure.

Rationale:

An abdominal aortic aneurysm (AAA) is a life-threatening condition where the aorta weakens and bulges, posing a high risk for rupture if blood pressure is not controlled. The client’s blood pressure is elevated at 160/98 mmHg, which increases stress on the aneurysm and raises the risk of rupture. The priority intervention is to administer antihypertensive medication to reduce blood pressure and minimize strain on the aortic wall before surgery. Beta-blockers or IV antihypertensive agents (such as labetalol or nitroprusside) are commonly used to achieve controlled blood pressure.

Why the Other Options Are Incorrect:

B. Monitor that urinary output is 20 mL/hr.

Urine output should be at least 30 mL/hr to indicate adequate kidney perfusion. A urine output of 20 mL/hr is too low and suggests decreased renal perfusion, possibly due to poor circulation from the aneurysm. The nurse should monitor urine output closely and report decreased output rather than consider it an acceptable finding.

C. Withhold pain medication to prepare for surgery.

Pain control is essential for clients with AAA to prevent increased sympathetic nervous system activation, which can further elevate blood pressure. Opioids like morphine can help reduce pain and also lower blood pressure by reducing stress and anxiety. Pain medication should not be withheld, but instead carefully administered while monitoring for hypotension.

D. Take vital signs every 2 hours.

Vital signs should be monitored more frequently in a client with AAA, especially with elevated blood pressure and tachycardia. Frequent monitoring (e.g., every 15 to 30 minutes) is needed to detect early signs of aneurysm rupture (e.g., severe pain, hypotension, tachycardia, pallor). Monitoring every 2 hours is not frequent enough for a high-risk, unstable client.

Key Nursing Actions for a Client with AAA Awaiting Surgery:

Control blood pressure with antihypertensive medications to reduce rupture risk.

Monitor vital signs frequently (every 15 to 30 minutes).

Assess for worsening symptoms (e.g., severe back/abdominal pain, hypotension, tachycardia—possible rupture).

Manage pain with prescribed analgesics.

Monitor urine output (should be at least 30 mL/hr to ensure adequate kidney perfusion). Thus, the correct answer is administer antihypertensive medication for blood pressure.

Correct Answer: B. Prepare for replacement of the missing clotting factor.

Rationale:

Hemophilia is a genetic bleeding disorder caused by a deficiency of clotting factors VIII (Hemophilia A) or IX (Hemophilia B), leading to prolonged bleeding and spontaneous joint hemorrhages (hemarthrosis). When a client with hemophilia experiences joint pain and swelling following an injury, it is likely due to internal bleeding into the joint (hemarthrosis) rather than typical inflammation. The priority intervention is to replace the missing clotting factor (factor VIII for Hemophilia A or factor IX for Hemophilia B) to promote clot formation and stop the bleeding.

Why the Other Options Are Incorrect:

A. Obtain blood samples to test platelet function.

Platelet function is normal in hemophilia; the problem is a lack of clotting factors, not platelet dysfunction. Testing platelet function will not help manage acute bleeding in this situation.

C. Administer aspirin for the client’s pain.

Aspirin is contraindicated in hemophilia because it inhibits platelet aggregation and increases the risk of bleeding. Instead, acetaminophen (Tylenol) is recommended for pain relief as it does not affect clotting.

D. Place the bleeding joint in the dependent position.

Keeping the joint in a dependent (lowered) position can worsen bleeding by increasing blood flow to the area. Instead, the joint should be elevated and immobilized to reduce swelling and bleeding.

Key Nursing Actions for a Client with Hemophilia Experiencing Joint Bleeding (Hemarthrosis):

Administer clotting factor replacement immediately to stop bleeding.

Apply ice to the affected joint to reduce swelling and bleeding.

Elevate and immobilize the joint to minimize movement and further bleeding.

Use acetaminophen for pain relief, avoiding aspirin and NSAIDs.

Monitor for signs of excessive bleeding and prepare for additional clotting factor administration if needed. Thus, the correct answer is prepare for replacement of the missing clotting factor.