Cardiac Exam
A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse? 1. Increased blood volume 2. Hyperactivity of the heart 3. Increased cardiac sufficiency 4. Decreased force of contraction
4. Decreased force of contraction A direct relationship exists between systolic blood pressure and the force of left ventricular contraction. An increased blood volume, not a decreased pulse pressure, is indicated by hypertension. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac sufficiency.
An infant is admitted to the pediatric intensive care unit (PICU) after open-heart surgery for the repair of a ventricular septal defect. Place these nursing assessments in order of priority. 1. Urinary output 2. Respiratory status 3. Heart rate 4. Operative site 5. Intravenous catheter
Correct 1. Respiratory status Correct 2. Heart rate
A client is admitted to the emergency department with chest pain and shortness of breath. An electrocardiogram indicates that the client is experiencing a myocardial infarction. An emergency cardiac catheterization is scheduled. What information should the nurse include in the pre-procedure teaching? 1. Mild sedation is maintained during the procedure. 2. The procedure will take approximately 15 minutes to complete. 3. Ambulation is encouraged shortly after the procedure. 4. It will take approximately 24 hours to determine if blockage is present.
Correct 1. Mild sedation is maintained during the procedure.
A woman comes to the office of her health care provider, reporting shortness of breath and epigastric distress that is not relieved by antacids. To what question would a woman experiencing a myocardial infarction respond differently than a man? 1. "Do you have chest pain?" 2. "Are you feeling anxious?" 3 "Do you have any palpitations?" 4. "Are you feeling short of breath?"
1. "Do you have chest pain?" Females may present with atypical symptoms of myocardial infarction, such as absence of chest pain, overwhelming fatigue, and indigestion. Anxiety, palpitations, and shortness of breath are common clinical manifestations in both males and females who are experiencing a myocardial infarction
The results of a biopsy indicate that a client has a malignant sarcoma of the liver and chemotherapy via regional perfusion is the treatment of choice. The nurse teaches the client that this method of drug administration probably was selected because: 1. Drug therapy can be continued at home with little difficulty. 2. Larger doses of drugs can be delivered to the actual site of the tumor. 3. Toxic effects of the chemotherapeutic drugs are confined to the area of the tumor. 4. Combinations of drugs are used to attack neoplastic cells at various stages of the cell cycle.
2. Larger doses of drugs can be delivered to the actual site of the tumor. Regional perfusion therapy permits relative isolation of the tumor area and saturation with the drug(s) selected. This method of drug administration requires medical and nursing supervision. Although toxic effects are confined mainly to the treated area, some migration may still occur. Combinations of chemotherapeutic drugs are administered via intravenous or oral routes, not via regional perfusion.
A client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The health care provider prescribes 500 mL of D5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which most common side effect of this medication? 1. Nausea 2. Syncope 3. Bradycardia 4. Hypotension
4. Hypotension The major action of intravenous nitroglycerin (Nitrostat IV) is venous and then arterial dilation, leading to a decrease in blood pressure. Nausea is not a common side effect of intravenous nitroglycerin. Syncope is an infrequent effect when nitroglycerin is given intravenously. Reflex tachycardia may occur with the decrease in blood pressure.
A health care provider prescribes tissue plasminogen activator (t-PA) to be administered intravenously over one hour for a client experiencing a myocardial infarction. The nursing priority that is specific to this medication is the assessment of the client's: 1. Respiratory rate 2. Peripheral pulses 3. Level of consciousness 4. Intravenous insertion site
4. Intravenous insertion site The most common adverse effect of a tissue plasminogen activator is bleeding because of the thrombolytic action of the drug. Although respiratory rate, peripheral pulses, or level of consciousness are important for any client with a decreased cardiac output, it is not specific to the administration of a tissue plasminogen activator.
A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs? 1. Urinary output of 30 mL in an hour 2. Central venous pressure reading of 2 mm Hg 3. Baseline pulse rate of 120 that decreases to 110 beats/min within a 15-minute period 4. Baseline blood pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period
Answer 1. Urinary output of 30 mL in an hour A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 2 mm Hg indicates hypovolemia. A baseline pulse rate of 120 that decreases to 110 beats/min within a 15-minute period and a baseline blood pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period indicate improvement but not necessarily adequate tissue perfusion
The health care provider prescribes a progressive exercise program that includes walking for a client with a history of diminished arterial perfusion to the lower extremities. The nurse explains to the client that if leg cramps occur while walking, the client should: 1. Take one aspirin (ASA) twice a day 2. Stop to rest until the pain resolves 3. Walk more slowly while pain is present 4. Take one nitroglycerin tablet sublingually
Answer 2. Stop to rest until the pain resolves Decreasing the demand for oxygen by resting will relieve the pain. Pain will not resolve as long as exercise, thus muscle hypoxia, is continued, regardless of whether ASA is taken. Walking more slowly while pain is present is appropriate for venous insufficiency, not arterial insufficiency. Sublingual nitroglycerin is not indicated for leg cramps
A client had an acute myocardial infarction. For which life-threatening complication should the nurse monitor during the first 48 hours? 1. Pulmonary edema 2. Pulmonary embolism 3. Ventricular tachycardia 4. Right ventricular heart failure
Correct 3. Ventricular tachycardia Approximately 40% to 50% of all deaths result from the life-threatening dysrhythmia of ventricular tachycardia. Pulmonary edema may occur but can be treated aggressively with the expectation of a recovery. Pulmonary embolism may occur but can be treated so that the client recovers. Left ventricular heart failure will be more likely to occur.
A nurse is assessing arterial perfusion in a client who had surgery with placement of a graft for an aneurysm in the left femoral artery. Click the site of the pulse that should be assessed to determine maximum arterial perfusion distal to the operative site.
The pedal pulse is located on the top of the foot and is the most distal peripheral pulse
When a client has a myocardial infarction, one of the major manifestations is a decrease in conductive energy provided to the heart. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart? 1. Heart rate 2. Refractory period 3. Pulmonary pressure 4. Strength of contractions
4. Strength of contractions A direct relationship exists between the strength of cardiac contractions and electrical conductions through the myocardium. The heart rate is related to such factors as sinoatrial (SA) node function, partial pressures of oxygen and carbon dioxide, and emotions. Refractory period is the period when the heart is at rest, not when it is contracting. Pulmonary pressure does not influence action potential; it becomes increased in the presence of left ventricular failure.
Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. The statement by the client that indicates the teaching was effective is, "I should: 1. take the medicine three times a day." 2. avoid activities that are too strenuous." 3. be sure to take my pulse after I have exercised." 4. take one tablet before attempting to climb two flights of stairs."
4. take one tablet before attempting to climb two flights of stairs." The response about taking one tablet before attempting to climb two flights of stairs indicates that the client understands the nurse's teaching. Taking a nitroglycerin tablet before such an activity probably will prevent an episode of angina, which is an example of prophylactic use of a medication. Taking the medicine three times a day is an example of scheduled administration of a medication, not prophylactic use. The statement to avoid activities that are too strenuous indicates avoidance of activity rather than taking medication to prevent angina during the activity. Blood pressure, not pulse, is the parameter most affected by nitroglycerin.
When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse expects that the body initially attempts to compensate by: 1. Producing less antidiuretic hormone (ADH) 2. Producing more red blood cells 3. Maintaining peripheral vasoconstriction 4. Decreasing mineralocorticoid production
Answer 3. Maintaining peripheral vasoconstriction With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. With shock, more ADH is produced to promote fluid retention, which will elevate the blood pressure. Although producing more red blood cells is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure
The nurse caring for a client admitted for chest pain and a myocardial infarction (MI) is preparing to apply nitroglycerin ointment. Before applying, the nurse should: 1. Assess the client's pulse rate. 2. Prepare the site with an alcohol swab. 3. Remove ointment previously applied. 4. Expect the client to be relieved of pain within 20 minutes.
Answer 3. Remove ointment previously applied. Before applying the nitroglycerin ointment, the nurse should remove the previous ointment. If the previously applied ointment is not removed, the client could receive too much medication. The nurse should assess blood pressure reading, not pulse rate. There is no need to clean the site with alcohol before administration. Nitroglycerin ointment is not used to treat acute pain.
A client presenting to the emergency room with chest pain and dizziness was found to be having a myocardial infarction and subsequently suffered cardiac arrest. The emergency room health care team was able to successfully resuscitate the client. Lab work shows that the client now is acidotic. The nurse understands that the acidic serum pH most likely is caused from : 1. Fat-forming ketoacids that are broken down. 2.The client receiving too much sodium bicarbonate during resuscitation efforts. 3. The decreased tissue perfusion that subsequently caused lactic acid production. 4. An irregular heartbeat the client experienced during cardiac arrest.
Answer 3. The decreased tissue perfusion that subsequently caused lactic acid production. Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. Too much sodium bicarbonate causes alkalosis, not acidosis. An irregular heartbeat does not cause acidosis necessarily.
A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Recognizing that adherence to a medical regimen improves with understanding, the nurse explains that the salt must be limited to: 1. Prevent an increase in blood pressure from tissue edema. 2. Reduce the circulating blood volume via a diuretic effect. 3. Reduce the amount of edema present, which interferes with heart action. 4. Prevent further accumulation of fluid, which increases the workload of the heart.
Answer 4. Prevent further accumulation of fluid, which increases the workload of the heart. An increase in total body fluid causes an increase in intravascular volume and cardiac workload. Salt in the diet contributes to fluid retention and edema. Fluid in the interstitial compartment will not increase blood pressure. Excess fluid in the intravascular compartment will increase blood pressure. Limiting sodium will not have a diuretic effect; it will reduce additional fluid retention. Diuretics, not a sodium-restricted diet, reduce the amount of edema present, which interferes with heart action
A client is recovering from a myocardial infarction. Before developing the client's teaching plan, it is important for the nurse to: 1. Identify the learning needs of the client 2. Determine the nursing goals for the client 3. Evaluate the community resources available to the client 4. Explore the use of group teaching for the client
Correct 1. Identify the learning needs of the client For teaching to be meaningful, the client must have a need to learn and a readiness to learn. These factors need to be identified before a teaching plan is formulated. Determining the nursing goals for the client eliminates the client from the goal-setting process; active participation by the client increases motivation and retention. Evaluating community resources is not the initial step; assessment of learning needs comes first. Exploring the use of group teaching for the client is not the initial step; learning needs must be determined first to see if group learning is appropriate; also, group learning must be available as an option.
A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses? 1. Parasympathetic reflexes from the infarcted myocardium cause diaphoresis. 2. Inflammation in the myocardium causes a rise in the systemic body temperature. 3. Catecholamines released at the site of the infarction cause intermittent localized pain. 4. Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
Correct 2. Inflammation in the myocardium causes a rise in the systemic body temperature. Temperature may increase within the first 24 hours as a result of the inflammatory response to tissue destruction and persist as long as a week. Diaphoresis is caused by activation of the sympathetic, not parasympathetic, nervous system and may indicate cardiogenic shock. Pain is persistent and constant, not intermittent; it is caused by oxygen deprivation and the release of lactic acid. The blood pressure increases initially but then drops because there is a decrease in cardiac output.
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take? 1. Determine if this is an allergic reaction 2. Place the client in the supine position and take the vital signs 3. Elevate the client's head and keep the extremities warm 4. Tell the client that this is not a typical sensation after receiving morphine sulfate
Correct 2. Place the client in the supine position and take the vital signs Vertigo is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, increases cardiac output, and increases blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.
A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. The nurse should instruct the client to: 1. Choose only familiar sexual positions 2. Select familiar settings for sexual activity 3. Return to regular sexual activity in two weeks 4. Drink a small glass of wine before engaging in sexual intercourse
Correct 2. Select familiar settings for sexual activity An unfamiliar environment increases stress, which increases cardiac workload. It is advantageous to experiment with positions and find one that is relaxing and permits unrestricted breathing. Return to sexual activity is determined by the client's recovery; sexual activity usually is permitted four to six weeks after a myocardial infarct. Alcohol dilates blood vessels, causing an increase in the workload of the heart.
A client with type 1 diabetes of long duration takes Novolin 70/30 (combination of Novolin N 70% and Novolin R 30%) every morning. At 11:30 AM, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. At 1:30 PM, the client's serum glucose level drops to 30 mg/dL, and insulin coma is diagnosed. The nurse concludes that the reason for the development of acute hypoglycemia is that: 1. Because the client did not eat lunch, glycogenolysis increased after the client took the morning insulin 2. Because of the stress brought on by the chest pain, the use of serum glucose available to the client increased 3. Because the client is taking insulin shots rather then an oral antidiabetic, the client's glucose level dropped more quickly 4. Because of long-term use of insulin, the client's body became sensitive to the insulin dose, causing blood glucose levels to drop erratically
Correct 3. Because the client is taking insulin shots rather then an oral antidiabetic, the client's glucose level dropped more quickly The dose of exogenous insulin causes a rapid drop in the blood glucose level, especially if food is not eaten. Lunch not being eaten after taking Novolin N insulin leads to hyperglycemia. Stress usually contributes to hyperglycemia because of glycogenolysis and gluconeogenesis. The use of insulin over long periods does not build tolerance to insulin or cause blood glucose levels to fluctuate dramatically.
A client who had a myocardial infarction receives a prescription for a beta-blocker and a nitroglycerin patch. The nurse determines that the purpose of the nitroglycerin patch is to decrease the: 1. Pulse rate, thereby strengthening cardiac contractility 2. Cardiac output, thereby reducing the cardiac workload 3. Preload of the heart, thereby reducing the cardiac workload 4. Coronary artery lumens, thereby reducing peripheral resistance
Correct 3. Preload of the heart, thereby reducing the cardiac workload Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect; it dilates coronary arteries, reduces myocardial ischemia, strengthens contractility, and increases efficiency of cardiac output. Decreasing the pulse rate does not strengthen cardiac contractility. Cardiac output is increased, not decreased. Peripheral resistance is affected not by dilating the coronary arteries but by dilating the peripheral arteries.
A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery? 1. Increasing activity tolerance 2. Preventing cardiac dysrhythmias 3. Promoting physical and emotional rest 4. Maintaining potassium and sodium intake
Correct 3. Promoting physical and emotional rest The major goal is to decrease the workload of the heart; physical and emotional rest reduces cardiac oxygen demand. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. There is no indication that the client has a history of dysrhythmias. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart.