Cardiovascular
Which finding is a risk factor for hypovolemic shock? a) gram-negative bacteria b) antigen-antibody reaction c) hemorrhage d) vasodilation
C) hemorrhage Explanation: Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock
A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? a) Potassium level of 3.1 mEq/L (3.1 mmol/L) b) Sodium level of 152 mEq/L (152 mmol/L) c) Calcium level of 7.5 mg/dl (0.4 mmol/L) d) Magnesium level of 2.5 mg/dl (0.1 mmol/L)
A) Potassium level of 3.1 mEq/L (3.1 mmol/L) Explanation: Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.
When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply. a) Take and record daily pulse rate. b) Avoid air travel because of airport security alarms. c) Immobilize the affected arm for 4 to 6 weeks. d) Avoid using a microwave oven. e) Avoid lifting anything heavier than 3 lb (1.36 kg).
A) Take and record daily pulse rate. B) Avoid lifting anything heavier than 3 lb (1.36 kg). Explanation: The nurse must teach the client how to take and record the pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to heal and full range of motion to return. The client should avoid heavy lifting until approved by the health care provider (HCP). The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function
A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m. (0700), before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to: a) assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. b) notify the next shift to hold the daily 5 p.m. dose of warfarin. c) give the client an I.M. vitamin K injection and notify the physician of the results. d) call the physician to request an increase in the warfarin dose.
A) assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. Explanation: For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the physician of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a physician's order. The nurse should notify the physician before holding a medication scheduled to be administered during another shift.
Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The nurse should advise the client to exercise using a stationary bicycle and intermittent training because of the client's: a) diabetic neuropathy. b) Raynaud's disease. c) transient ischemic attacks. d) muscle atrophy.
A) diabetic neuropathy. Explanation: A common complication of diabetes is diabetic neuropathy. Diabetic neuropathy results from the metabolic and vascular factors related to hyperglycemia. Damage leads to sensory deficits and peripheral pain. Muscle atrophy can result from disuse, but it is not a direct consequence of diabetes. Raynaud's disease is associated with vasospasms in the hands and feet. Transient ischemic attacks involve the cerebrum.
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include: oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/min. The oxygen flow rate is set at 2 L/min. The nurse should first: a) increase the oxygen flow rate from 2 to 4 L/min. b) obtain a sample for arterial blood gas analysis. c) provide reassurance to the client. d) call the health care provider (HCP) immediately.
A) increase the oxygen flow rate from 2 to 4 L/min. Explanation: The first action is to increase the oxygen flow rate from 2 to 4 L/min to help ensure adequate oxygenation for the client. Although it is important to notify the HCP for additional prescriptions and to obtain further assessment data, such as arterial blood gas measurements, it is a priority to support the client's cardiopulmonary system. It would be appropriate to reassure the client while these other interventions are occurring
A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The nurse should first: a) inquire about the onset, duration, severity, and precipitating factors of the heaviness. b) offer pain medication for the chest heaviness. c) administer oxygen via nasal cannula. d) inform the health care provider (HCP) of the chest heaviness.
A) inquire about the onset, duration, severity, and precipitating factors of the heaviness. Explanation: Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the HCP.
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? a) "I like to soak my feet in the hot tub every day." b) "I have my wife look at the soles of my feet each day." c) "I walk only to the mailbox in my bare feet." d) "I stopped smoking and use only chewing tobacco."
B) "I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities
The client with heart failure asks the nurse about the reason for taking enalapril maleate. The nurse should tell the client: a) "This drug will constrict your blood vessels and keep your blood pressure from getting too low." b) "This drug will dilate your blood vessels and lower your blood pressure." c) "This drug helps your heart beat more forcefully." d) "This drug will slow your heart rate down."
B) "This drug will dilate your blood vessels and lower your blood pressure." Explanation: Enalapril maleate is an angiotensin-converting enzyme inhibitor that prevents conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor and also contributes to aldosterone secretion. Thus, enalapril decreases blood pressure through systemic vasodilation. Enalapril does not cause increased vasoconstriction, which would raise blood pressure. The medication has no effect on myocardial contractility or the heart's conduction system.
A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority? a) A client's monitor shows frequent paced beats with capture. b) A client's cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions. c) A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. d) A client's monitor shows sinus tachycardia with frequent premature atrial contractions (PACs).
C) A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. Explanation: The client whose cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation takes priority. This cardiac rhythm change may cause clots to shower from the atria, placing the client at risk for a stroke. The client whose cardiac monitor reveals sinus tachycardia with isolated premature ventricular contractions is not experiencing a life-threatening situation; therefore, he does not take priority. Frequent paced beats with capture is a normal finding for a client with a pacemaker. Sinus tachycardia with premature atrial contractions is not a priority situation
A client whose condition remains stable after a myocardial infarction gradually increases activity. To determine whether the activity is appropriate for the client the nurse should assess the client for: a) cyanosis. b) weight loss. c) dyspnea. d) edema.
C) dyspnea. Explanation: Physical activity is gradually increased after a myocardial infarction while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When any of these symptoms appears, the client should reduce activity and progress more slowly. Edema suggests a circulatory problem that must be addressed but does not necessarily indicate overexertion. Cyanosis indicates reduced oxygen-carrying capacity of red blood cells and indicates a severe pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss indicates several factors but not overexertion.
Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level? a) blood pressure b) body temperature c) pulse rate d) respiratory rate
C) pulse rate Explanation: The client who is on a progressive exercise program at home after a myocardial infarction should be taught to monitor the pulse rate. The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The client should also be taught to discontinue exercise if chest pain occurs
While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. The nurse should: a) call for help and place the client in a wheelchair. b) administer nitroglycerin. c) stop and assess the client further. d) measure the client's blood pressure and heart rate.
C) stop and assess the client further. Explanation: The nurse should stop and assess the client further. A chair should be available for the client to sit down. Obtaining the client's blood pressure and heart rate are important when exercising. These values can be used to predict when the oxygen demand becomes greater than the oxygen supply. Calling for help is not necessary for the midsternal burning. If the health care provider (HCP) has prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen balance
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. His temperature is 99.8° F (37.7° C). His blood pressure is 104/68 mm Hg. His pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? a) Slow the I.V. fluid to prevent any more swelling at the puncture site. b) Encourage the client to perform isometric leg exercise to improve circulation in his legs. c) Document the findings and recheck the client in 1 hour. d) Contact the physician and report the findings.
D) Contact the physician and report the findings Explanation: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the physician immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.
A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention? a) Reduce the nausea and vomiting and stabilize the blood glucose. b) Monitor and manage potential complications. c) Decrease the anxiety and reduce the workload on the heart. d) Control the pain and support breathing and oxygenation.
D) Control the pain and support breathing and oxygenation. Explanation: Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: a) temperature. b) pulse. c) respirations. d) blood pressure.
D) blood pressure. Explanation: Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the health care provider (HCP) and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
An 80-year-old client is admitted 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: a) chronic renal failure. b) metabolic acidosis. c) exacerbation of heart failure. d) digoxin toxicity.
D) digoxin toxicity. Explanation: Nausea and vomiting, along with hypokalemia, are likely indicators of digoxin toxicity. Hypokalemia is a common cause of digoxin toxicity; therefore, serum potassium levels should be carefully monitored if the client is taking digoxin. The earliest clinical signs of digoxin toxicity are anorexia, nausea, and vomiting. Bradycardia, other dysrhythmias, and visual disturbances are also common signs. Chronic renal failure usually causes hyperkalemia. With persistent vomiting, the client is more likely to develop metabolic alkalosis than metabolic acidosis.
A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents: a) atrial repolarization. b) atrial depolarization. c) ventricular repolarization. d) ventricular depolarization.
D) ventricular depolarization. Explanation: The QRS complex on the ECG strip represents ventricular depolarization. Atrial repolarization usually occurs at the same time as ventricular depolarization and is impossible to distinguish on the ECG. The T wave represents ventricular repolarization. The P wave represents atrial depolarization.
A client with peripheral artery l disease has femoral-popliteal bypass surgery. The primary goal of the plan of care after surgery is to: a) prevent infection. b) provide education. c) relieve pain. d) maintain circulation.
D) maintain circulation. Explanation: Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent. Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.
A client is receiving cilostazol for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports: a) "I am able to walk further without leg pain." b) "I do not have headaches anymore." c) "I am having fewer aches and pains." d) "My toes are turning grayish black in color."
A) "I am able to walk further without leg pain." Explanation: Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider (HCP) . Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body.
During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use? a) 1 mg I.V. b) 2 mg I.M. c) 2 mg I.V. d) 0.6 mg I.M.
A) 1 mg I.V. Explanation: To reverse arrhythmias, bradycardia, or sinus arrest, the usual adult dosage of atropine is 0.5 to 1 mg I.V. every 3 to 5 minutes as needed. The drug isn't administered I.M. for the treatment of bradycardia.
To avoid a falsely elevated serum digoxin level after administering oral digoxin, how long should a nurse wait before drawing a blood sample? a) At least 8 hours b) At least 6 hours c) At least 4 hours d) At least 1 hour
A) At least 8 hours Explanation: To avoid a falsely elevated serum digoxin level, a nurse shouldn't draw a blood sample for at least 8 hours after administering oral digoxin and at least 6 hours after administering I.V. digoxin. A nurse usually takes a serum sample immediately before administering the daily maintenance dose, about 24 hours after the previous dose
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of: a) acute pulmonary edema. b) pneumonia. c) right-sided heart failure. d) cardiogenic shock.
A) acute pulmonary edema Explanation: Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: a) begin a jogging program. b) stop smoking. c) elevate the legs above the heart. d) avoid eating low-fat foods.
B) stop smoking. Explanation: Nicotine causes vasospasm and impedes blood flow. Stopping smoking is the most significant lifestyle change the client can make. The client should eat low-fat foods as part of a balanced diet. The legs should not be elevated above the heart because this will impede arterial flow. The legs should be in a slightly dependent position. Jogging is not necessary and probably is not possible for many clients with arterial occlusive disease. A rehabilitation program that includes daily walking is suggested. (
A client has acute arterial occlusion. The health care provider (HCP) has prescribed IV heparin. Before starting the medication, the nurse should: a) test the client's stools for occult blood. b) count the client's apical pulse for 1 minute. c) check the 24-hour urine output record. d) review the blood coagulation laboratory values.
D) review the blood coagulation laboratory values. Explanation: Before starting a heparin infusion, it is essential for the nurse to know the client's baseline blood coagulation values (hematocrit, hemoglobin, and red blood cell and platelet counts). In addition, the partial thromboplastin time should be monitored closely during the process. The client's stools would be tested only if internal bleeding is suspected. Although monitoring vital signs such as apical pulse is important in assessing potential signs and symptoms of hemorrhage or potential adverse reactions to the medication, vital signs are not the most important data to collect before administering the heparin. Intake and output are not important assessments for heparin administration unless the client has fluid and volume problems or kidney disease.
