Cardiac MedSurg Practice Questions

A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Deflate the cuff slowly and listen for the first audible sounds. Subtract the inspiratory pressure from the expiratory pressure. Identify the first BP sounds audible on expiration and then on inspiration. Palpate the blood pressure and inflate the cuff above the systolic pressure. Inspect for jugular venous distention and notify the provider.

- Palpate the blood pressure and inflate the cuff above the systolic pressure. - Deflate the cuff slowly and listen for the first audible sounds. - Identify the first BP sounds audible on expiration and then on inspiration. - Subtract the inspiratory pressure from the expiratory pressure. - Inspect for jugular venous distention and notify the provider. Step 1: The nurse should auscultate the blood pressure to detect paradoxical blood pressure for a client with possible cardiac tamponade by first palpating the blood pressure and inflating the cuff above the systolic pressure. Step 2: The nurse should deflate the cuff slowly and listen for the first audible sounds. Step 3: The nurse should listen for the first BP sounds audible on expiration and on inspiration. Step 4: This action should be followed by subtracting the inspiratory pressure from the expiratory pressure to determine pulsus paradoxus. A difference of >10 mmHg can indicate cardiac tamponade. Step 5: The nurse should inspect for jugular venous distention, muffled heart sounds, and decreased cardiac output and notify the provider of the results.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the in a low-Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously Rationale: Extreme dyspnea, tachycardia, and lung crackles in a client with heart failure indicate pulmonary edema, a life-threatening event. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

Four days after an acute anterior wall myocardial infarction (MI), a 63-year-old client progresses from a first-degree atrioventricular (AV) block to a second-degree Mobitz II AV block over 6 hours. Although the client is asymptomatic, the nurse should anticipate instituting which intervention? 1. Assisting with pacemaker implantation 2. Administering digoxin 3. Administering lidocaine by I.V. bolus 4. Increasing the I.V. fluid infusion to 175 ml/hour

1. Assisting with pacemaker implantation Progression of an AV block, a conduction defect, in the presence of an anterior wall MI is an indication for pacemaker implantation. Administering digoxin would most likely potentiate the client's AV block. Lidocaine is indicated for treatment of ventricular arrhythmias, not conduction defects. Increasing the infusion of I.V. fluids in the presence of an MI could precipitate heart failure.

When assessing a client's radial pulses, the nurse finds them to be irregular, with the apical pulse rate about 10 beats faster than the radial pulse rate. The nurse would suspect which cardiac arrhythmia? 1. Atrial fibrillation 2. Second-degree atrioventricular (AV) block 3. Ventricular tachycardia 4. Sinus bradycardia

1. Atrial fibrillation Irregular radial pulses in conjunction with up to a 10-beat difference between the apical and radial pulse rates indicate atrial fibrillation. Second-degree AV block is a conduction defect evidenced by a slow rate (atrial rate two to four times faster than ventricular rate), progressively lengthening or fixed PR interval, and normal P wave and QRS complex. Ventricular tachycardia is evidenced by a rate of 100 to 250 beats per minute, no PR interval, wide and bizarre QRS complex, and abnormal conduction through ventricular tissue. Sinus bradycardia refers to a heart rate less than 60 beats per minute with all other electrocardiogram waveforms within normal parameters.

A client's cardiac rhythm suddenly changes on the monitor. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia

1. Atrial fibrillation Rationale: Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.

A client develops symptomatic sinus bradycardia. Which medication would the nurse expect to administer? 1. Atropine 2. Lidocaine 3. Amiodarone 4. Procainamide

1. Atropine Atropine is used to treat sinus bradycardia in clients who are symptomatic. Lidocaine, amiodarone, and procainamide are used to treat ventricular tachycardia and ventricular fibrillation.

After assisting with insertion of a temporary transvenous pacemaker, which assessment data would be most important to document? 1. Cardiovascular response to the pacemaker 2. Emotional state 3. Activity level 4. Pacemaker information (e.g., type, settings)

1. Cardiovascular response to the pacemaker After insertion of a temporary transvenous pacemaker, the client's telemetry, pulse, and blood pressure should be closely monitored to ensure proper pacemaker capture and function. Pacemaker information and the client's emotional state and activity level also should be documented. However, these areas are not as critically important as is the client's cardiovascular response. The client's activity levels usually are restricted to bed rest.

The nurse is assisting a client diagnosed with R/O myocardial infarction (MI) to ambulate to the bathroom when the client starts complaining of chest pain. Which inventions should the nurse implement? (Select all that apply.) 1. Escorting the client back to the bed 2. Administering oxygen via nasal cannula 3. Instructing the client to take slow deep breaths 4. Administering subinguinal nitroglycerin (NTG) 5. Calling a code via the telephone 6. Placing the client in Trendelenburg's position

1. Escorting the client back to the bed 2. Administering oxygen via nasal cannula 4. Administering subinguinal nitroglycerin (NTG) Chest pain is a sign of angina that may lead to an MI. The nurse must first prevent further exertion by the client by escorting him back to the bed. The nurse should then administer oxygen to increase perfusion to the heart muscle and subinguinal NTG to increase vasodilatation to the myocardium. Taking deep breaths will not help the chest pain, the client is not coding at this time, and placing the client with his head downward will not help relieve chest pain.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Which factor is highest priority with regard to this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output with cerebral and myocardial ischemia.

1. It can develop into ventricular fibrillation at any time. Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. Ventricular tachycardia can deteriorate into ventricular fibrillation with cardiac arrest at any time. Clients frequently experience a feeling of impending doom. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness).

Which clinical manifestation would the nurse expect to assess in a client diagnosed with pericarditis? 1. Sharp, sudden pain over the precordium, radiating to the left scapular region 2. Weakness, fatigue, and petechiae of the anterior trunk and conjunctivae 3. Crushing chest pain radiating down the left arm plus nausea and vomiting 4. Hepatomegaly, jugular vein distention (JVD), and dependent peripheral edema

1. Sharp, sudden pain over the precordium, radiating to the left scapular region Sharp, sudden pain over the precordium that radiates to the left scapular region is a characteristic clinical manifestation of pericarditis and inflammation of the pericardium (e.g., sac that surrounds the heart). The pain may be aggravated by breathing or movement. Weakness, fatigue, and petechiae of the anterior trunk and conjunctivae indicate endocarditis. Crushing chest pain radiating down the left arm accompanied by nausea and vomiting is associated with a myocardial infarction. Hepatomegaly, JVD, and dependent peripheral edema are manifestations of right-sided heart failure.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm

1. Sinus tachycardia Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normalwidth PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute.

The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. Which associated findings would the nurse anticipate in the assessment? Select all that apply. 1. Syncope 2. Dizziness 3. Palpitations 4. Hypertension 5. Flat neck veins

1. Syncope 2. Dizziness 3. Palpitations Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats per minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Hypertension and flat neck veins are not associated with the loss of cardiac output.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How would the nurse interpret the client's neurovascular status? 1. The neurovascular status is expected because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon needs to be called. 3. The neurovascular status is slightly deteriorating and needs to be monitored for another hour. 4. The neurovascular status shows adequate arterial flow, but venous complications are arising.

1. The neurovascular status is expected because of increased blood flow through the leg. Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter defibrillator. Which assessment is the nursing priority? 1. Anxiety level of the client and family 2. Activation status and settings of the device 3. Presence of a MedicAlert card for the client to carry 4. Knowledge of restrictions on post-discharge physical activity

2. Activation status and settings of the device Rationale: The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to care after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Airway patency 3. Oxygen flow rate 4. Level of consciousness

2. Airway patency

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Check the client's status. 3. Call the primary health care provider. 4. Document the lack of complexes.

2. Check the client's status. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment. Test-Taking Strategy: Note the strategic word, priority.

A middle-aged client with coronary artery disease has been hospitalized three times in the last 6 months, suggesting noncompliance with the medication regimen. When preparing the client for discharge this time, which intervention should the nurse implement? 1. Reteaching the client about the medication and dosing schedule 2. Collecting more data to help identify reasons for noncompliance 3. Teaching the client's family about the medication and need for compliance 4. Arranging for outpatient follow-up examinations to ensure compliance.

2. Collecting more data to help identify reasons for noncompliance To ensure compliance, the nurse needs more information to determine if there is a specific reason why the client is not complying with the medication regimen. The client may have a valid reason, such as financial constraints or lack of accessibility to the pharmacy, that needs to be identified and addressed. It is questionable whether or not reteaching would be effective for this client. Teaching the family and arranging for outpatient follow up may help with compliance, but these also may cause the client to feel a loss of control over his condition and its management.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which fnding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

2. Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

For the client experiencing a cardiac arrest, which nursing intervention should the nurse implement first? 1. Assessing the client's blood pressure 2. Establishing a patent airway 3. Auscultating heart sounds 4. Assisting with defibrillation

2. Establishing a patent airway If a client experiences cardiac arrest, the first action is to establish a patent airway and then administer artificial ventilation and oxygen. Resuscitation measures need to be started immediately because of the life-threatening nature of a cardiac arrest. Valuable time is wasted by assessing the client's blood pressure or auscultating for heart sounds, because circulation must be restored within approximately 4 minutes after the onset of cardiac arrest to prevent irreversible brain damage. Defibrillation is used after initial resuscitation efforts have been initiated.

A client with a history of type 2 diabetes is admitted to the hospital with chest pain and scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin

2. Metformin Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld before and after cardiac catheterization.

When assessing a client with angina, which assessment data is considered a common precipitating factor for pain? 1. Exposure to warmth 2. Smoking 3. Prolonged rest 4. Eating a light meal

2. Smoking Any activity that increases myocardial oxygen demands, such as smoking, can lead to anginal pain. Smoking also causes vasoconstriction that can precipitate anginal attacks. Exposure to cold and subsequent constriction, not exposure to warmth that causes dilation, may precipitate anginal pain. Rest typically relieves anginal pain, except with anginal pain caused by vasospasm. In this case, chest pain may occur at rest. Light meals are recommended; heavy meals should be avoided because increased oxygen is needed to digest food.

A client with a prosthetic heart valve has a nursing diagnosis of "deficient knowledge." Which intervention is most important for the nurse to include in the client's discharge teaching plan? 1. Reporting cold or flulike symptoms promptly 2. Taking antibiotic prophylaxis for invasive procedures 3. Daily pulse rate assessment 4. Maintenance of bed rest for any chest pain

2. Taking antibiotic prophylaxis for invasive procedures Because of the increased risk for endocarditis from transient bacteremia, the client needs instruction about notifying all health care providers who may perform invasive procedures that he has a prosthetic heart valve. Prophylactic antibiotics should be given before the procedure to prevent transient bacteremia. The client needs to report any unexplained fever, not cold or flulike symptoms. Daily pulse assessment and bed rest are not necessary. Pulse assessment is a teaching topic for clients with pacemakers; bed rest is a teaching topic for clients with myocardial infarction.

Which behavior indicates that a client diagnosed with heart failure is being compliant with the discharge teaching plan? 1. The client demonstrates better nutrition habits by gaining 10 lb. 2. The client returns to the hospital as an inpatient less frequently. 3. The client significantly improves the activity level. 4. The client attends all the medication teaching classes.

2. The client returns to the hospital as an inpatient less frequently. Less frequent hospital admissions indicate that the client is experiencing better heart function and therefore must be complying with his discharge plan. Weight gain may be a result of fluid retention from possible noncompliance with medications (e.g., diuretic therapy) or with dietary recommendations for a low sodium intake. A significant improvement in activity level usually is not possible for clients with CHF. Medication teaching classes is but one aspect of his discharge plan. Although attendance at the classes may help with compliance, it does not ensure his compliance.

A client with myocardial infarction is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock? 1. Pulsus paradoxus 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

2. Ventricular dysrhythmias Rationale: Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure become apparent. Pulsus paradoxus is a finding associated with cardiac tamponade

Before discharge, a client who is receiving cardiac rehabilitation after a myocardial infarction (MI) should be able to do which activity? 1. Bed rest with sitting up in a chair twice each day 2. Walking the length of the hallway twice each day 3. Isometric exercises three times daily 4. Walking up and down two flights of stairs daily

2. Walking the length of the hallway twice each day Before discharge, a realistic goal of cardiac rehabilitation for a client after an MI is the client's ability to walk the hallway twice daily. The client should not be on bed rest except in the initial post-MI period. Cardiac rehabilitation begins on admission. Isotonic exercises are recommended. Isometric exercises, which strain the heart (such as in Valsalva's maneuver), are to be avoided. At this time, the client would be unable to climb two flights of stairs. However, this may be a goal for later in the cardiac rehabilitation period.

A client is having frequent premature ventricular contractions. The nurse would place priority on assessment of which information? 1. Causative factors, such as caffeine 2. Sensation of fluttering or palpitations 3. Blood pressure and oxygen saturation 4. Precipitating factors, such as infection

3. Blood pressure and oxygen saturation Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.

After being diagnosed with an acute myocardial infarction (MI) and stabilized, a female client denies pain. Her vital signs and heart rhythm are stable but she appears agitated and uses her call light more often. Which nursing intervention would be the initial step in addressing the client's needs? 1. Assessing her blood pressure more frequently 2. Explaining that another episode is unlikely 3. Encouraging her to discuss her feelings about the MI 4. Telling her not to worry because she is being closely monitored

3. Encouraging her to discuss her feelings about the MI Because the client's vital signs are stable, she is most likely experiencing anxiety related to the acute event. The nurse should encourage her to express her feelings about the MI to help reduce her anxiety level. Assessing her blood pressure more frequently would be appropriate if her vital signs were not stable. Plus, frequent checks would tend to increase her already heightened level of anxiety. Explaining that another episode is unlikely or telling her not to worry ignores her feelings and blocks further communication. False or empty reassurance does not meet her needs.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action would the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Monitor for any rhythm change. 4. Notify the primary health care provider.

3. Monitor for any rhythm change. Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the primary health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

Assessment of a client diagnosed with heart failure reveals moderate dyspnea, clammy and very pale skin, and cough producing frothy, blood-tinged sputum. Based on these findings, the nurse suspects that the client is experiencing which complication? 1. Angina 2. Myocardial infarction (MI) 3. Pulmonary edema 4. Endocarditis

3. Pulmonary edema Frothy, blood-tinged sputum appearing in conjunction with dyspnea and clammy, pale skin indicates pulmonary edema with interstitial fluid overload in the lungs because of left ventricular failure. Although dyspnea and clammy, pale skin may coexist with angina or MI, frothy, blood-tinged sputum would be absent. Weakness, fatigue, fever, diaphoresis, arthralgia, and petechiae typically are evidence of endocarditis.

While performing discharge teaching for a client with chronic heart failure, the nurse should stress which topic? 1. The need for a high-impact aerobic exercise program 2. A high-sodium, low-potassium diet 3. The signs and symptoms of pulmonary edema 4. The possibility of the need for surgical procedures

3. The signs and symptoms of pulmonary edema For the client with chronic CHF, teaching topics must include the signs and symptoms of pulmonary edema. This condition is a medical emergency situation requiring prompt evaluation and treatment. Otherwise, it could progress to death. A structured exercise program involving daily low-impact aerobic exercises also would be included. However, this topic is less of a priority than the signs and symptoms of pulmonary edema. Dietary instructions should address an intake of low-sodium, high-potassium foods, especially if the client is receiving diuretic therapy. Discussion of possible surgical procedures is inappropriate for the client with chronic CHF.

The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions

3. Ventricular tachycardia Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses per minute. The rhythm is regular.

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I need to notify my cardiologist if my feet or legs start to swell." 2. "I am supposed to report to my cardiologist if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have this problem, we are going to stop walking in the mall every morning."

4. "My spouse told me that since I have this problem, we are going to stop walking in the mall every morning." Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and needs to be avoided. If bradycardia occurs, the client needs to contact the primary health care provider or cardiologist. Clients need to also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client would be able to continue morning walks with their spouse.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/ dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1. Check the serum albumin level. 2. Check the urine specific gravity. 3. Continue to monitor urine output. 4. Call the primary health care provider.

4. Call the primary health care provider. Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine 0.5 to 1.2 mg/dL (44 to 106 mcmol/L). Continuing to monitor urine output or checking other parameters can wait. Urine output lower than 30 mL/hr is reported to the PHCP for urgent treatment.

The nurse is assisting to defibrillate a client in ventricular fibrillation. Which intervention is a priority after placing the pads on the client's chest and before discharging the device? 1. Ensure that the client has been intubated. 2. Set the defibrillator to "synchronize" mode. 3. Administer an amiodarone bolus. 4. Confirm the cardiac rhythm.

4. Confirm the cardiac rhythm. Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Defibrillation should not be delayed for administration of any drugs, including amiodarone.

Discharge teaching for a client diagnosed with coronary artery disease should include which nursing intervention? 1. Decreasing intake of dietary fiber 2. Eating two hours before exercising 3. Decreasing cigarette smoking 4. Participating in regular exercise

4. Participating in regular exercise The client should participate in a regular exercise program, such as walking, swimming, or low-impact aerobics, for at least 20 to 30 minutes a day plus a warm-up and cool-down time. A high-fiber diet is encouraged to help decrease the cholesterol level. The client should avoid eating for 2 hours before exercise because digestion increases blood supply to the GI system and decreases supply to heart muscle. The client must quit smoking.

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mmHg, reports dizziness. Which intervention would the nurse anticipate will be prescribed? 1. Administer digoxin. 2. Defbrillate the client. 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing.

4. Prepare for transcutaneous pacing. Rationale: Sinus bradycardia is noted with a heart rate of less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply.) A."You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." C. "You'll feel a cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr."

A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure." Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure.

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your bloodstream." D. "Treatment with heparin will dissolve the clot and keep other clots from forming."

A. "Your body has a process called fibrinolysis that will eventually dissolve the clot."

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take? A. Administer antihypertensive medication for blood pressure B. Monitor to ensure the client's urinary output is 20 mL/hr C. Withhold pain medication to prepare the client for surgery D. Take the client's vital signs every 2 hr

A. Administer antihypertensive medication for blood pressure The nurse should administer antihypertensive medication for elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall. Incorrect Answers:B. The nurse should ensure the client has adequate kidney profusion, as determined by a urinary output of at least 30 mL/hr. Oliguria can indicate a rupture of the aneurysm. C. The nurse should administer pain medication because pain occurs due to pressure from the aneurysm on the lumbar nerves. Pain can also cause hypertension. D. The nurse should take the client's vital signs at least every 15 minutes to monitor for a sudden drop in blood pressure, which can indicate a rupture of the aneurysm.

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include? A. Avoid IM injections B. Assess the client for ecchymosis once per shift C. Do not allow the client to have visitors D. Encourage daily flossing between teeth

A. Avoid IM injections This client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures such as an IM injection which can increase the client's risk of bleeding.

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Beef liver B. Oranges C. Turnips D. Whole milk

A. Beef liver The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, fish, and poultry. A 3 oz serving of beef liver contains 4.17 mg of iron.

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

A. Erythropoietin Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure. Incorrect Answers: B. Erythromycin is used to treat infections. There is no indication that this client is experiencing an infection. C. Filgrastim is used to stimulate the production of neutrophils. There is no indication that this client is experiencing neutropenia. D. Calcitriol is used to prevent hypocalcemia in clients who have chronic kidney disease. There is no indication that this client is experiencing hypocalcemia.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Jugular vein distension B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

A. Jugular vein distension B. Moist crackles D. Increased heart rate The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses.

A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? A. Omega-3 fatty acids B. Antioxidants C. Vitamins A, D, and C D. Beta-carotene

A. Omega-3 fatty acids B. Antioxidants are substances that occur naturally in many fruits and vegetables, as well as in nuts, grains, and even some meat, poultry, and fish. Beta-carotene; vitamins A, C, and E; and selenium are some of the most commonly known antioxidants. Studies have suggested that antioxidants can slow or even prevent the development of cancer; however, they are not found in fish oil. C. Vitamins A, D, and C are not found in fish oil. D. Beta-carotene is the precursor to vitamin A. Beta-carotene functions as a fat-soluble antioxidant, which can help protect the body from deleterious free-radical reactions. It is not found in fish oil.

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age- A. Peripheral vascular resistance increases. B. The sensitivity of blood pressure-adjusting baroreceptors increases. C. Blood is hyper coagulable and clots more quickly. D. Cardiac medications are less effective.

A. Peripheral vascular resistance increases. Incorrect Answers: B. The sensitivity of blood-pressure regulating baroreceptors decreases with aging, causing postural and postprandial hypertension, which can affect perfusion. C. Older adults are more prone to bleeding complications, particularly hemorrhage. Anticoagulation therapy requires constant and careful monitoring of clotting times. D. Older adults are more likely to develop toxicity from cardiac medications, especially severe adverse effects from thrombolytic therapy.

A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? A. Turkey on whole-wheat bread B. Hamburger and french fries C. Frankfurter on a white roll D. Macaroni and cheese

A. Turkey on whole-wheat bread The primary dietary alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole-wheat bread has a relatively low sodium content.

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1 kg (2.2 lb) in 1 day B. Pitting edema +1 C. Client report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

A. Weight gain of 1 kg (2.2 lb) in 1 day A weight gain of 1 kg (2.2 lb) in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's heart failure is worsening. Incorrect Answers: B. Pitting edema (a visible finger indentation after application of pressure) alerts the nurse that the client has retained fluid and indicates fluid in the client's tissues. Pitting edema is rated on a scale of mild (+1) to severe (+3). Pitting edema of +3 suggests the client has developed fluid volume overload and worsening heart failure. C. A client who is in the early stages of heart failure might report a cough that is irritating, occurs at night, and is nonproductive. D. BNP levels increase as a result of the ventricular hypertrophy in heart failure. A BNP level above 100 pg/mL is indicative of heart failure. Levels continue to increase with the severity of the condition.

A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? A.BNP of 200 pg/mL B.Bradycardia C.Fluid restriction of 3 L per day D.4 g sodium diet

A.BNP of 200 pg/mL The nurse should identify that a client who has heart failure will have an elevated human B-type natriuretic peptide (BNP) level of >100 pg/mL. Endogenous BNP is released into the client's bloodstream due to decreased cardiac output, a process called natriuresis.

A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first? A. Press the analyze button on the machine B. Stop CPR and move away from the client C. Push the charge button to prepare to shock D. Apply the defibrillator pads to the client's chest

After obtaining the AED, the nurse should first apply 2 large adhesive defibrillator pads on the client's anterior chest wall to enable the machine to analyze the rhythm and deliver the shock appropriately if indicated. One pad should be applied to the upper right chest area above the client's nipple and to the right of the sternum, and the second pad should be applied to the left lower chest area below the client's nipple and pectoral muscle. The pads should be applied without interrupting CPR.

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy

B. Ankle swelling The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis. Incorrect Answers:A. Absent pedal pulses are a manifestation of peripheral arterial disease rather than venous insufficiency. C. Hair loss of the affected extremity is a manifestation of peripheral arterial disease rather than venous insufficiency. D. Thin, dry, atrophied skin is a manifestation of peripheral arterial disease rather than venous insufficiency.

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension

B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension The formation of large amounts of micro-emboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distention due to internal bleeding.

A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply.) A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6-hr period D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride

B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the blood steam. In addition, the nurse should ask another nurse to check the packed RBCs label against the medical record for safety verification. The nurse should ensure that the client's complete name and identification number match and that the blood group name and number are correct. If there is any type of discrepancy, the nurse should not infuse the blood and should notify the blood bank. Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs.

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the client's fatigue and pallor? A. Magnesium 2.0 mEq/L B. Hgb 6.5 g/dL C. WBC count 9.6/mm3 D. Creatinine 0.8 mg/dL

B. Hgb 6.5 g/dL The expected reference range of Hgb is 14 to 18 g/dL for men and 12 to 16 g/dL for women. Therefore, a client who has an Hgb level of 6.5 g/dL has anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallor, dizziness, and tachycardia.

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluids to 1,000 mL per day B. Measure the client's abdominal girth daily C. Check IV sites every 4 hr for bleeding D. Administer an enema as needed for constipation

B. Measure the client's abdominal girth daily The nurse should measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk of bleeding due to delayed clotting. Incorrect Answers: A. The nurse should not restrict fluids in a client who has thrombocytopenia. Most clients require 2,000 mL to 2,400 mL of fluids per day to decrease the risk of dehydration and promote regular bowel function. C. The nurse should plan to check the client's IV sites every 2 hours for bleeding because a reduced platelet count increases the risk of bleeding due to delayed clotting. D. The nurse should not plan to administer an enema to a client who has thrombocytopenia due to the increased risk of bleeding from delayed clotting.

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes

B. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? A. Pallor B. Jaundice C. Absence of hair on the legs D. Poor nail bed capillary refill

C. Absence of hair on the legs A progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider.

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A. Thick, white coating on the client's tongue B. Decreased pulse rate C. Paresthesias in the hands and feet D. Joint pain in the extremities

C. Paresthesias in the hands and feet The nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected finding of pernicious anemia. Other manifestations include weight loss and fatigue.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? A. Have the client gently blow clots from the nose every 5 min B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the client's neck D. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions. Incorrect Answers:A. The nurse should instruct the client to refrain from blowing his nose for 24 hours after the epistaxis stops. The formation of clots will terminate the nosebleed. Having the client blow his nose will dislodge any clots that do form and cause the bleeding to continue. B. The nurse should place the client in a sitting position, leaning forward. If the client positions his head and neck backward, blood will drain into the stomach, causing nausea and vomiting. C. The nurse should apply an ice pack or cool compress to the client's nose and face to help control epistaxis.

A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity

D. Iron toxicity A client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as in sickle cell anemia.

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? A. The percentage of blood the ventricles pump during each beat B. The amount of blood the left ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume

D. The heart rate times the stroke volume Cardiac output is the product of the client's heart rate and stroke volume (the amount of blood the left ventricle pumps with each contraction). In systolic heart failure, the heart cannot pump enough oxygenated blood into the circulation, causing cardiac output to decrease.