cardiovascular
Point of maximal impulse (PMI)
Where heartbeat is best palpable on chest wall; 5th intercostal space, midclavicular line
A nurse caring for a patient following insertion of pacemaker. What statement indicates potential complication of insertion procedure?
"I can't get rid of these hiccups." Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.
A patient who has a history of angina has an ECG scheduled at 1100. What statement by the client requires the nurse to contact the provider for possible rescheduling?
"I smoked a cigarette this morning Smoking prior to this test can change the outcome & places client at additional risk. The procedure should be rescheduled if client has smoked before the test.
A nurse caring for a client who is scheduled for a CABG in 2 hr. What client statement need further clarification by the nurse?
"I took my warfarin last night according to my usual schedule." Clients scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to surgery to prevent excessive bleeding.
A nurse is providing teaching to a patient 2days postop following a heart transplant.What should the nurse include in the teaching?
"You might no longer be able to feel chest pain." Heart transplant clients usually are no longer able to feel chest pain due to denervation of the heart.
The nurse should identify that an INR of ____is within the desired reference range for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.
2.0 to 3.0
A nurse is providing teaching for a group of clients. Which client is at risk for PAD?
A client who has diabetes mellitus Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.
Persistent cough
A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.
A nurse is assessing a patient who has pulmonary edema related to heart failure.What finding indicates effective treatment?
Absence of adventitious breath sounds Adventitious breath sounds occur when there is fluid in the lungs. The absence indicates that the pulmonary edema is resolving.
A nurse is carrying for a client who had an anterior myocardial infarction. the patient is one week postoperative following an open cholecystectomy. nurse should recognize that the following intervention is contraindicated
Assisting with thrombolytic therapy The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
A nurse is reviewing lab results of male clients with PAD. The nurse should plan dietary teaching to the patient with what lab values
Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL The expected reference range of cholesterol is less than 200 mg/dL, HDL above 45 mg/dL for men and above 55 mg/dL for women, and LDL less than 130 mg/dL.
An RN in an ER is assessing a patient who has bradydysrhythmia what findings should the nurse monitor for
Confusion Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.
A nurse caring for a patient with onset of chest pain of 24 hour. The nurse should recognize an increase in what indicates an MI
Creatine kinase-MB Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.
A nurse is caring for a patient with dilated cardiomyopathy. What findings should the nurse expect?
Dyspnea on exertion The nurse should identify dyspnea on exertion as an expected manifestation. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.
The nurse recognizes the patient is in a hypertensive crisis. What intervention should the nurse do first?
Elevate the head of the client's bed. The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of bed to reduce blood pressure & promote oxygenation.
A nurse is admitting a patient with a leg ulcer & history of diabetes. the nurse should use which focused assessments to help differentiate between arterial and venous ulcer
Inquire about presence or absence of claudication. Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
A patient taking with heart failure is taking furosemide. the nurse should monitor for what adverse reaction?
Lightheadedness Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.
The client should apply the nitro patch to an area of intact skin that has enough room for the patch to fit smoothly.
Place the patch on an area of skin away from skin folds and joints.
The nurse is preparing the client for a coronary angiography. What should the nurse report to the provider prior to the procedure?
Previous allergic reaction to shellfish The contrast is iodine-based &Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine.
The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation
Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. What action should the nurse take if the patients aPTT is 96 seconds?
Stop heparin infusion. The nurse should identify that the client's aPTT is above critical value & client is displaying manifestations of bleeding. RN should dc heparin immediately & notify provider
a nurse is caring for a postoperative patient one hour following a AAA repair. what findings can indicate shock and should be reported to provider?
Urine output of 20 mL/hr Urine output < 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
A nurse is caring for a client Who has endocarditis. what finding is a potential complication?
Valvular disease Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is assessing a client with left sided heart failure. What should the nurse expect to find?
Weak peripheral pulses Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.
A nurse is tecahing a patient with heart failure.
Weight gain of 0.9 kg 2 lb in 24 hr the nurse should determine that the priority finding is a weight gain of 1 to 2 lb in 1 day & is an indication of fluid retention resulting from worsening heart failure. client should report this immediately.
Clients who have hypertension should limit
alcohol intake,Tobacco, and begin A regular exercise program. These will help reduce blood pressure
The nurse should report an elevated blood pressure 160/80 mm Hg following a CABG because increased vascular pressure can
cause bleeding at the incision sites.
Weakness and irregular heart rate indicate that the client is at the greatest risk for
electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
Tendonitis is an adverse effect of
fluoroquinolone antibiotics.
The nurse should identify that ______ might temporarily convert the client's heart rate to normal sinus rhythm.
vagal stimulation The nurse should have a defibrillator &resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.
The nurse should examine this area, the QRS complex, of the rhythm strip to evaluate for
ventricular depolarization.
The nurse should examine this area, the T wave, of the rhythm strip to evaluate for
ventricular repolarization.
C-reactive protein increases soon after the beginning of an inflammatory process, such as
rheumatoid arthritis, and is not specific to cardiac muscle.
What area of the ECG strip should the nurse examine for atrial depolarization?
The nurse should examine this area, the P wave, of the rhythm strip to evaluate for atrial depolarization.
