Cardiac Med-Surg
The nurse is concerned that the client who had myocardial infarction (MI) has developed cardiogenic shock. Which of these findings indicates shock? Select all that apply. A. Bradycardia B. Cool, diaphoretic skin C. Crackles in the lung fields D. Respiratory rate of 12 E. Anxiety and restlessness F. Temperature of 100.4
B. Cool, diaphoretic skin C. Crackles in the lung fields E. Anxiety and restlessness Correct: The client with shock has cool, moist skin. Correct: Owing to extensive tissue necrosis (MI), the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles. Correct: Owing to poor tissue perfusion, a change in mental status, anxiety, and restlessness are expected. Incorrect Feedback: Incorrect: All types of shock (except neurogenic) present with tachycardia. Incorrect: Owing to pulmonary congestion, the client with cardiogenic shock typically has tachypnea. Incorrect: Cardiogenic shock does not present with low-grade fever; this would be more likely to occur in pericarditis.
The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality?
Carvedilol (Coreg) Correct: Beta-adrenergic blockers reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; they improve morbidity, mortality, and quality of life.
The nurse is teaching the client precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective?
"Eating foods like green beans won't interfere with my Coumadin therapy." Correct: Vitamin K is not found in green beans and will not interfere with the anticoagulant effects of Coumadin.
Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial?
"I don't need to change. It hasn't killed me yet." Correct: This statement indicates maladaptive denial.
When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client states which of these?
"I just started to feel a tearing pain in my belly." Correct: Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.
The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching?
"I should avoid grilling hamburgers." Correct: Cutting out beef or hamburgers made at home is not necessary; however, fast food hamburgers are to be avoided owing to higher sodium content.
The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching?
"I will call the provider if I have a cough lasting 3 or more days." Correct: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified.
The nurse is teaching the young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching?
"If I wear pantyhose, I won't have to wear the stockings the hospital gives me." Correct: Wearing the thromboembolism disease (TED) stockings is a prevention specific to the hospital setting. It is designed to prevent blood clots, unlike regular pantyhose.
Which statement by the client scheduled for a percutaneous transluminal coronary angioplasty indicates a need for further preoperative teaching?
"My angina will be gone for good." Correct: Reocclusion is possible after the procedure.
The client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care?
"My leg might turn very white after the surgery." Correct: Pallor is one of the signs of compartment syndrome, along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis.
The client undergoing coronary artery bypass grafting (CABG) asks why the doctor has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct?
"These arteries remain open longer." Correct: Mammary arteries have remained patent much longer than other grafts.
The client with unstable angina has received education about the acute coronary syndrome. Which of the following indicates that he understood the teaching?
"This is a big warning, I must modify my lifestyle or risk having a heart attack in the next year." Correct: Among people who have unstable angina, 10% to 30% have a myocardial infarction (MI) within 1 year.
The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response?
"This may be caused by a genetic trait." Correct: Hypertrophic cardiomyopathy is often transmitted as a single-gene autosomal dominant trait.
During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response?
"Where might you be able to walk?" Correct: This response calls for cooperation and participation from the client.
The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic?
"Your concerns are valid; we can review some steps to limit disease progression." Correct: This option validates the client's concern and offers needed information.
An LPN/LVN is scheduled to work on the inpatient "step-down" cardiac unit where you are the team leader. Which of these clients would be best to assign to the LPN/LVN?
A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today Correct: The LPN/LVN scope of practice includes administration of medications to stable clients.
An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client will be appropriate for the RN to assign to the LPN/LVN?
A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index Correct: The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and in a lower extremity.
Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider?
A client with pressure in the mid abdomen and profound diaphoresis Correct: Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety.
Which of these clients is best to assign to an LPN/LVN working on the telemetry unit?
A client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea Correct: This client, who needs oxygen only with exertion, is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice.
The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply. A. Chest discomfort or pain B. Tachycardia C. Expectorates thick, yellow sputum D. Sleeps on back without a pillow E. Shortness of breath with exertion
A. Chest discomfort or pain B. Tachycardia E. Shortness of breath with exertion Correct: Decreased tissue perfusion may cause chest pain or discomfort. Correct: Tachycardia may occur as compensation for or as a result of decreased cardiac output. Correct: Dyspnea results as pulmonary venous congestion ensues. Incorrect Feedback: Incorrect: Thick, yellow sputum is indicative of infection; clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Incorrect: Orthopnea, the inability to lie flat, occurs in clients with heart failure.
The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the last appointment. Which actions by the client indicate that teaching has been effective? Select all that apply. A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine
A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic E. Has cut down on caffeine Correct: Clients with hypertension should consume low-sodium foods and should avoid adding salt. Correct: Weight loss can result in lower blood pressure. Correct: Caffeine promotes vasoconstriction, thereby elevating blood pressure. Incorrect Feedback: Incorrect: Although palm oil may be cost saving, it is higher in saturated fat than canola, sunflower, olive, or safflower oil. Incorrect: The goal is to exercise three times weekly.
The nurse is providing community education about prevention of atherosclerosis-related diseases. Which risk factors should the nurse include in the presentation? Select all that apply. A. LDL cholesterol of 160 mg B. Smoking C. Aspirin (ASA) consumption D. Type 2 diabetes E. Vegetarian diet
A. LDL cholesterol of 160 mg B. Smoking D. Type 2 diabetes Correct: Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), client is advised to modify diet and exercise. Correct: Smoking is a modifiable risk factor and should be avoided or terminated. Correct: Diabetes is a risk factor for atherosclerotic disease. Incorrect Feedback: Incorrect: ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease (CAD) to prevent platelet adhesion. Incorrect: A diet high in whole grains, fruits, and vegetables is desirable, to prevent atherosclerosis; vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.
When planning care for a client in the emergency department, the nurse recognizes that which interventions are needed in the acute phase? Select all that apply. A. Morphine sulfate B. Oxygen C. Nitroglycerin D. Naloxone E. Acetaminophen F. Verapamil (Calan, Isoptin)
A. Morphine sulfate B. Oxygen C. Nitroglycerin Correct: Morphine is needed to reduce oxygen demand, preload, pain, and anxiety. Correct: Administering oxygen will increase available oxygen for the ischemic myocardium. Correct: Nitroglycerin is used to reduce preload and chest pain. Incorrect Feedback: Incorrect: Naloxone is a narcotic antagonist that is used for overdosage of opiates. Incorrect: The client is given aspirin to chew; acetaminophen may be used for headache related to nitroglycerin. Incorrect: Owing to negative inotropic action, calcium channel blockers are used for angina, not for myocardial infarction (MI).
The nurse recognizes that which laboratory findings are consistent with acute coronary syndrome (ACS)? Select all that apply. A. Troponin 3.2 ng/mL B. Myoglobin of 234 mcg/L C. C-reactive protein 13 mg/dL D. Triglycerides 400 mg/dL E. Lipoprotein-a (Lp[a]) 18 mg/dL
A. Troponin 3.2 ng/mL B. Myoglobin of 234 mcg/L Correct: Normal troponin should be less than 0.03 ng/mL. Correct: Normal myoglobin should be less than 90 mcg/L. Incorrect Feedback: Incorrect: Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Incorrect: Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Incorrect: Normal lipoprotein-a (Lp[a]) is 18 mg/dL; however, this tests for risk for CAD, not ACS.
The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100. Which of these nursing actions should you delegate to the LPN/LVN?
Administer a clonidine patch for hypertension. Correct: Administering medication is within the scope of practice for the LPN/LVN.
Which statement about diagnostic cardiovascular testing is true?
An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Correct: Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing.
The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure?
Anterior wall Correct: Owing to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure.
The older adult client, 4 hours post coronary artery bypass graft (CABG), has a blood pressure of 80/50. What action should the nurse take?
Assess pulmonary artery wedge pressure (PAWP). Correct: Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation. Hypotension could cause the graft to collapse.
Which statement reflects correct cardiac physical assessment technique?
Auscultate the aortic valve in the second intercostal space at the right sternal border. Correct: The aortic valve is auscultated at the second intercostal space at the right sternal border.
In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis?
B-type natriuretic peptide (BNP) of 760 ng/dL Correct: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL.
The nurse is caring for a client with suspected pericarditis. Which signs and symptoms support this? Select all that apply. A. Squeezing, vise-like chest pain B. Chest pain relieved by sitting upright C. Chest and abdominal pain relieved by antacids D. Sudden-onset chest pain relieved by NSAIDs E. Pain in the chest described as sharp or stabbing
B. Chest pain relieved by sitting upright D. Sudden-onset chest pain relieved by NSAIDs E. Pain in the chest described as sharp or stabbing Correct: The pain of pericarditis is relieved when sitting upright or forward. Correct: The pain of pericarditis may appear abruptly and is relieved by NSAIDs. Correct: The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing. Incorrect Feedback: Incorrect: Squeezing, vise-like chest pain is characteristic of myocardial infarction (MI). Incorrect: Chest and abdominal pain is characteristic of peptic ulcer.
Which of the following atypical symptoms may be present in the female client experiencing myocardial infarction (MI)? Select all that apply. A. Sharp, inspiratory chest pain B. Dyspnea C. Dizziness D. Extreme fatigue E. Anorexia
B. Dyspnea C. Dizziness D. Extreme fatigue Correct: Many women present with fatigue, dyspnea, and light-headedness. Incorrect Feedback: Incorrect: Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Incorrect: Anorexia is neither a typical nor an atypical sign of MI.
The nurse is educating a group of clients about risk factors for cardiovascular disease. Which of these risk factors should be included in the discussion? Select all that apply A. Consuming a diet rich in fiber B. Elevated C-reactive protein levels C. Low blood pressure D. Elevated high-density lipoprotein (HDL) cholesterol level E. Smoking
B. Elevated C-reactive protein levels E. Smoking Correct: Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Correct: Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. Incorrect Feedback: Incorrect: A diet rich in fiber is not a risk factor for cardiovascular disease, rather it is a desirable behavior. Incorrect: Hypertension, not low blood pressure, is a risk for cardiovascular disease. Incorrect: Elevated low-density lipoprotein (LDL) cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.
The nurse is teaching the client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply. A. Truncal obesity B. Hypercholesterolemia C. Elevated homocysteine levels D. Glucose intolerance E. Client taking losartan (Cozaar)
B. Hypercholesterolemia D. Glucose intolerance E. Client taking losartan (Cozaar) Correct: Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol [LDL-C]), HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women, or taking an anticholesterol drug is a sign of metabolic syndrome. Correct: Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Correct: Blood pressure greater than 130/85 or taking antihypertensive medication indicates metabolic syndrome. Incorrect Feedback: Incorrect: A large waist size (excessive abdominal fat causing central obesity)-40 inches (102 cm) or greater for men, 35 inches (88 cm) or greater for women-is a sign of metabolic syndrome. Incorrect: Although elevated homocysteine levels may predispose to atherosclerosis, this is not part of the metabolic syndrome
Which priority problems may be considered for the client with heart failure? Select all that apply. A. Decreased fluid volume related to compromised regulatory mechanism B. Impaired Physical Mobility related to limited cardiovascular endurance C. Impaired Gas Exchange related to ventilation-perfusion imbalance D. Potential for pulmonary edema E. Risk for Ineffective renal Perfusion related to hypervolemia
B. Impaired Physical Mobility related to limited cardiovascular endurance C. Impaired Gas Exchange related to ventilation-perfusion imbalance D. Potential for pulmonary edema E. Risk for Ineffective renal Perfusion related to hypervolemia Correct: Owing to intra-alveolar edema and poor cardiac output, the client is fatigued and has limited endurance. Correct: Owing to intra-alveolar edema and poor cardiac output, the client may develop hypoxemia. Correct: Owing to limited cardiac reserve, the client is at risk for pulmonary edema. Correct: The client with heart failure has poor cardiac output, reduced blood flow to the kidney, and accumulation of pulmonary and peripheral fluid. Incorrect Feedback: Incorrect: The client with heart failure has poor cardiac output, reduced blood flow to the kidney, and accumulation of pulmonary and peripheral fluid.
The nurse is providing a cardiac class for a women's group. The nurse emphasizes that which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. A. Premenopausal B. Increasing age C. Family history D. Abdominal obesity E. Breast cancer
B. Increasing age C. Family history D. Abdominal obesity Correct: Increasing age is a risk factor, especially after 70 years. Correct: Family history is a significant risk factor in both men and women. Correct: A large waist size/abdominal obesity is a risk factor for both metabolic syndrome and MI. Incorrect Feedback: Incorrect: Postmenopausal women are at higher risk for MI. Incorrect: Breast cancer is not a risk factor for myocardial infarction.
The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. A. Hypokalemia B. Sinus bradycardia C. Fatigue D. Serum digoxin level of 1.5 E. Anorexia
B. Sinus bradycardia C. Fatigue E. Anorexia Correct: Digoxin toxicity may cause bradycardia. Correct: Fatigue is a symptom of digoxin toxicity. Correct: Anorexia is a symptom of digoxin toxicity. Incorrect Feedback: Incorrect: Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. Incorrect: This represents a therapeutic value that is between 0.8 and 2.0.
When caring for a client with an 8-cm abdominal aortic aneurysm (AAA), the nurse recognizes that which problem must be addressed immediately to prevent rupture?
Blood pressure 192/102 Correct: Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.
The client has just returned from coronary artery bypass graft (CABG) surgery. For which finding should the nurse contact the surgeon?
Chest tube drainage 175 mL last hour Correct: Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL per hour to the surgeon.
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen?
Client states that she is able to sleep on one pillow. Correct: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers.
When caring for a client who has received recombinant tissue plasminogen activator (t-PA), for a large deep vein thrombosis (DVT), the nurse would be most concerned if the client developed which of these?
Client stating that the year is 1967 Correct: The most serious complication from thrombolytic therapy is intracerebral bleeding, manifested by changes in the level of consciousness.
Which client will be best for the charge nurse to assign to a new graduate RN who has completed 2 months of orientation to the coronary care unit?
Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Correct: The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN.
The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client should the nurse see first?
Client with third-degree heart block on the monitor Correct: Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system is involved. Third-degree heart block usually requires pacemaker insertion.
The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which of the following actions should be taken by the nurse?
Collaborate with the physician to administer a positive inotropic agent. Correct: A positive inotropic agent will increase the force of contraction (SV), thus increasing cardiac output. Recall that SV × HR = CO.
The client who has been admitted for the third time this year for cardiac failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response?
Considers further assessment for depression Correct: This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done.
When administering furosemide (Lasix) to a client who states she does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels?
Consume melons and baked potato. Correct: Melons and baked potato contain potassium.
The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure?
Crackles in the lung fields Correct: Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields.
The nurse suspects that the client has developed an acute arterial occlusion of the right lower extremity based on which of the following? Select all that apply. A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg
D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg Correct: Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Correct: Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Correct: Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Incorrect Feedback: Incorrect: Hypertension presents risk for atherosclerosis but not for acute arterial occlusion. Incorrect: The pulse rate does not indicate occlusion, rather quality. Incorrect: Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.
Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance with prescribed home therapy. Which laboratory test confirms the nurse's suspicions?
Digoxin level of 0.2 ng/dL Correct: A therapeutic digoxin level is 0.8 to 2.0 ng/dL. A level of 0.2 ng/dL indicates that the client has not been taking his digoxin as prescribed.
The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize?
Do not smoke or chew tobacco. Correct: Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causes vasoconstriction and endothelial dysfunction and thickening of the vessel wall, increases carbon monoxide, and decreases oxygen. Because this is highly addicting, beginning smoking in the teen years may lead to decades of exposure.
The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question?
Dopamine (Intropin) Correct: Dopamine is used for its inotropic and vasoconstrictive properties, to raise blood pressure; it should not be used in hypertensive emergency.
After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign?
Facial drooping Correct: During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding.
The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8 Pulse: 48 and irregular Respirations: 20 Potassium level: 3.2 mEq/L What action does the nurse take?
Hold the digoxin, and obtain a prescription for a potassium supplement. Correct: Digoxin causes bradycardia; hypokalemia potentiates digitalis. The nurse seeks to correct this situation through collaboration with the provider.
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure?
Ibuprofen (Motrin) Correct: Long-term use of NSAIDs, such as ibuprofen (Motrin), causes fluid and sodium retention.
A client who is to undergo cardiac catheterization should be taught which essential information?
Keep your affected leg straight for at least 8 hours. Correct: The affected leg must remain straight for 6 to 8 hours after the procedure to allow the arterial puncture to heal well and prevent bleeding.
The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action should the nurse take first?
Listen to the client's posterior breath sounds. Correct: Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds.
Which client has the highest risk for cardiovascular disease?
Man who smokes and whose father died at 49 from myocardial infarction (MI) Correct: Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death.
The nurse is caring for a client with an abdominal aortic aneurysm (AAA). Which finding in the history does the nurse recognize as a risk factor for aneurysm formation?
Marfan syndrome Correct: Marfan syndrome is a risk factor for cardiovascular disorders.
The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs?
Mean arterial pressure is 58 mm Hg. Correct: To maintain tissue perfusion to vital organs, the mean arterial pressure (MAP) must be at least 60 mm Hg.
The visiting nurse is seeing a client post coronary artery bypass graft. Which nursing action should be performed first?
Monitor for dysrhythmias. Correct: Dysrhythmias are the leading cause of prehospital death. The nurse should monitor the client's heart rhythm.
When caring for a client who has undergone a partial left ventriculectomy, which of these new-onset clinical manifestations indicates the need for immediate action by the nurse?
Muffled heart sounds Correct: Muffled heart sounds may be a clinical manifestation of bleeding into the pericardial space; the nurse should assess the client for possible decreased cardiac output and should notify the surgeon.
To validate that the client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests?
Myoglobin and troponin Correct: Myoglobin, troponin, and CK-MB are the cardiac markers used to determine whether MI has occurred.
Which action should the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory?
Obtain client vital signs and a resting electrocardiogram (ECG). Correct: Vital signs and 12-lead ECGs can be assessed by UAP.
Which of these nursing actions should the nurse delegate to a nursing assistant working on the medical unit?
Obtain daily weights for several clients with class IV heart failure. Correct: Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.
The client comes to the emergency department with chest discomfort. Which action does the nurse perform first?
Obtains the client's description of the chest discomfort Correct: A description of the chest discomfort must be obtained before further action can be taken.
When caring for a client with acute myocardial infarction, the nurse recognizes that prompt pain management is essential for which reason?
Pain relief improves the oxygen supply and decreases oxygen demand. Correct: The focus of pain relief is on reducing myocardial oxygen demand.
The client with peripheral arterial occlusive disease has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure?
Pedal pulses Correct: Distal pulses must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).
A client recovering from a cardiac angiography develops slurred speech. What does the nurse do first?
Performs a complete neurologic assessment and notifies the physician Correct: Based on this assessment, the client most probably is suffering a neurologic bleed. Neurologic changes, such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness, should be reported immediately for prompt intervention.
Which intervention will best assist the client with acute pulmonary edema in reducing anxiety and dyspnea?
Place the client in high Fowler's position with the legs down. Correct: High Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.
The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity should the nurse suggest?
Placing a chair in the shower for independent hygiene Correct: Phase 1 begins with the acute illness and ends with discharge from the hospital. It focuses on promoting rest and allowing clients to improve their ADLs based on their abilities.
The client is receiving unfractionated heparin by infusion. Of which finding should the nurse notify the provider?
Platelets 32,000 Correct: Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000.
The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client?
Positions the client to alleviate dyspnea Correct: Positioning the client to alleviate dyspnea will help ease air hunger and anxiety.
The nurse is reviewing the medical record of a client admitted with heart failure. Which of the laboratory results warrants a call to the physician for further instructions?
Potassium 3.0 mEq/L Correct: Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations.
The professional nurse and the nursing student are caring for a group of clients with hypertension. Which of these problems identified by the nursing student correctly identifies the client at risk for secondary hypertension?
Renal failure Correct: Secondary hypertension can be related to renal failure.
The nurse is caring for a client with peripheral arterial occlusive disease (PAD). For which symptoms should the nurse assess?
Reproducible leg pain with exercise Correct: Claudication, leg pain with ambulation due to ischemia, is reproducible in similar circumstances.
The nurse is caring for a client 36 hours post coronary artery bypass grafting (CABG), with a diagnosis of activity intolerance related to imbalance of myocardial oxygen supply and demand. Which of these findings causes the nurse to terminate an activity and return the client to bed?
Respiratory rate 28 Correct: Tachypnea and tachycardia reflect activity intolerance; activity should be terminated.
The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 2 mm Hg. The nurse anticipates which request by the physician ?
Saline infusion Correct: Normal right atrial pressure is 4 to 10 mm Hg; administering saline will restore normal fluid balance.
A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription?
Serum potassium level of 2.8 mEq/L Correct: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy.
A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the physician?
Serum troponin I level Correct: Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications.
Which symptom reported by the client who has had a total hip replacement requires emergency action?
Shortness of breath and chest pain Correct: Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for DVT and PE.
Which vascular assessment technique by the student nurse requires intervention by the supervising nurse?
Simultaneously palpating the bilateral carotids Correct: Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion.
A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history?
Slow heart rate Correct: Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output.
The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis?
Splinter hemorrhages Correct: Splinter hemorrhages are indicative of infective endocarditis.
The nurse is assessing the client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI?
Substernal chest pressure relieved only by opioids Correct: Substernal chest pressure relieved only by opioids is typically indicative of MI.
A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm A-V fistula for dialysis. Which finding should the nurse report to the provider immediately?
Swelling and tenseness in the affected area Correct: Compartment syndrome may develop; swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb.
The client with hypertension is started on verapamil (Isoptin). What teaching does the nurse provide for this client?
Teaches the client to avoid grapefruit juice Correct: Grapefruit juice should be avoided with verapamil because it can enhance the action of the drug.
After receiving change-of-shift report about these four clients, which client should the nurse assess first?
The 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset, frequent premature ventricular complexes Correct: This client's premature ventricular complexes may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity should be done and the physician notified about the dysrhythmia.
Which of these clients who have just arrived in the emergency department should the nurse classify as emergent and needing immediate medical evaluation?
The 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic Correct: This client's history and clinical manifestations suggest possible aortic dissection and shock. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.
All of these client assignments have been made by the charge nurse. Which assignment would you question?
The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 Correct: This client has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. The client should be assigned to an experienced RN, who can assess for end-organ damage and administer intravenous medications. A better assignment would be to assign Client D to an RN and Client C to the LPN/LVN.
Which of the following is essential to report to the provider when caring for a client with Raynaud's phenomenon?
The affected extremity becomes purple and cold. Correct: Cold, mottled extremities are indicative of occlusion, which could lead to gangrene.
All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the physician before the procedure begins?
The client develops wheezes and dyspnea after eating crab or lobster. Correct: The contrast agent injected into the coronary arteries during the arteriogram is iodine based. The client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure.
The nurse is assigned to the following group of clients. Which of these clients should be assessed first?
The client who had percutaneous transluminal angioplasty of the right femoral artery 30 minutes ago Correct: This client should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.
After receiving change-of-shift report in the coronary care unit, which client should you assess first?
The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea Correct: Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; the client needs prompt intervention.
A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective?
The client's weight decreases by 2.5 kg. Correct: The best indicator of fluid volume loss is daily weight; because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid.
The nurse encourages the client to increase his fluid intake after a cardiac catheterization for which reason?
The dye causes an osmotic diuresis. Correct: The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment.
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?
The nurse obtains a bedside commode before administering furosemide. Correct: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.
The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication?
The risk for hypotension Correct: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.
Which assessment finding for a client with left ventricular failure who is receiving pulmonary artery pressure (PAP) monitoring indicates a need for rapid action by the nurse?
The waveform shows that the catheter is continuously in the wedge position. Correct: Because a pulmonary infarction can occur if the catheter is left in the wedged position, the nurse should have the client cough and/or should change the client's position. If the catheter remains wedged, the physician should be notified immediately.
Which statement best reflects correct client education for a client with a blood pressure (BP) of 134/86?
This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. Correct: Although not considered hypertension because the blood pressure is not greater than 140/90, it is consistent with increased risk for heart disease; the client requires further education.
The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement reflects the most correct teaching?
This test evaluates you for potentially fatal cardiac rhythms. Electrophysiology studies (EPS) are invasive tests performed to determine whether the client has lethal dysrhythmias.
The client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction?
Troponin of 5.2 ng/mL Correct: The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL.
The nurse caring for a client who has had AAA repair would be most alarmed by which finding?
Urine output of 20 mL over 2 hours Correct: Renal failure is a complication of AAA repair caused by blood loss or clips applied above to the aneurysm, which may interfere with renal artery perfusion.
The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet?
Use canola oil rather than palm or coconut oil. Correct: Palm and coconut oils are higher in saturated fats and are to be avoided.
The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential?
Validate that the client has remained NPO. Correct: Owing to the risk for aspiration, the client must be NPO before the procedure.
Which teaching should the nurse include for a client with peripheral arterial disease (PAD)?
Walk to the point of leg pain, then rest, resuming when pain stops. Correct: Exercise may improve arterial blood flow by building collateral circulation; walk until the point of claudication, stop and rest, and then walk a little farther.
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions?
Weight loss of 6 pounds since the last visit Correct: Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.
The nurse is educating a group of women about the differences in symptoms of MI in men versus those in women. Which information should be included?
Women may experience extreme fatigue and dizziness as sole symptoms. Correct: Women may have atypical symptoms, including absence of chest pain and extreme dizziness and fatigue.
