Cardiac PassPoint
What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?
promote arterial and venous circulation
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. What should the nurse instruct the client to do to achieve this goal?
stop smoking
The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which change on the client's chart to the health care provider?
urine output
Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the lab tests (see chart). What should the nurse do first?
withhold the captopril
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as
a third heart sound (s3)
A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority intervention at this time?
assessing the client
A client with sepsis has continued to deteriorate and has become unresponsive. The nurse has inserted an intravenous line and assisted with the initiation of mechanical ventilation. Which is the highest priority for the nurse at this time?
confirm the placement of the endotracheal tube
The nurse is assessing a client with a known history of chronic heart failure. Which finding indicates poor perfusion to the tissues?
cool, pale extremities
An older adult is admitted to the hospital with nausea and vomiting. The client has a history of heart failure and is being treated with digoxin. The client has been nauseated for a week and began vomiting 2 days ago. Laboratory values indicate hypokalemia. Because of these clinical findings, the nurse should assess the client carefully for:
digoxin toxicity
A fourth heart sound indicates
failure of the ventricle to eject all blood during systole
The nurse is using evidence-based practice to ensure the patency of a client's arterial line. Which action should the nurse perform?
flush the line each time a port is used
The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse?
immediate defibrillation
The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation and the client becomes unresponsive. The nurse should anticipate which intervention?
immediate defibrillation
The plan of care for a client with hypertension taking propranolol hydrochloride should include:
instructing the client to notify HCP of irregular or slowed pulse rate
A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. What should the nurse include in the plan of care for this client?
monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (PT/INR)
