CARDIOVASCULAR
27. A client is diagnosed with angina. The nurse reviews the client's diagnostic and laboratory results, knowing that which finding is indicative of myocardial ischemia?
D. S-T wave depression on electrocardiogram (ECG) Rationale: Ischemia represents a decreased amount of oxygen to the myocardium. Ischemia may be detected on an ECG by changes in the S-T wave or by T-wave inversion. EEG and potassium level findings are not directly related to coronary ischemia.
A client diagnosed with unstable angina is returning to the nursing unit after a coronary angioplasty. The nurse observes the client for mental status changes, knowing that a change could indicate which specific complication of this procedure?
A. Cerebral emboli Rationale: Angioplasty involves using a balloon-tipped catheter to displace or flatten the plaque built up along the arterial walls, thereby enlarging the diameter of the vessel. There is a chance for a small piece of the plaque to become dislodged, which could create an embolus. Reactions from the contrast most likely will occur immediately, not when the client returns to the nursing unit. Cerebral hemorrhage and increased intraocular pressure are not directly related to postangioplasty complications.
32. A nurse who is assisting in an ambulatory care clinic takes a client's blood pressure in the left arm and notes that it is 200/118 mm Hg. The first action of the nurse is to:
A. Check the blood pressure in the right arm Rationale: On getting an initially high reading, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse also rechecks the blood pressure in the same arm, but waits at least 2 minutes between readings. The nurse inquires about the presence of kidney disorders, which could contribute to elevated blood pressure. The nurse notifies the RN, who contacts the physician because immediate treatment is necessary. However, this should not be done without obtaining verification of the elevation.
40. A client has had a repair of an abdominal aortic aneurysm (AAA). The nurse assigned to assist in caring for the client places highest priority on which the following nursing activities immediately after the surgery?
A. Checking peripheral pulses Rationale: An abdominal aortic aneurysm is a type of aneurysm found in the abdominal aorta. Checking the peripheral pulses are the highest priority immediately after repair of AAA. This indicates whether the graft is patent and perfusing the lower extremities. The client would receive parenteral narcotics immediately after surgery. Prevention of respiratory and circulatory complications (options 2 and 3) is also important but does not supersede determining graft patency.
11. A client has just been admitted to the hospital with a nonhealing arterial ischemic leg ulcer. The nurse inspects the ulcer for which characteristics?
A. Deep, pale, and painful Rationale: Arterial ischemic leg ulcers are characteristically deep, pale, and painful. By contrast, venous stasis ulcers are more shallow, with a ruddy color to the ulcer. Venous ulcers are also painful but less so than arterial ulcers. There is no ulcer that is characteristically painless.
31. A nurse is assigned to care for a client who underwent peripheral arterial bypass surgery 16 hours previously. When collecting data from the client, the client complains of increasing pain in the leg at rest that worsens with movement and is accompanied by parethesias. The nurse should take which action?
A. Notify the registered nurse (RN) Rationale: Compartment syndrome can occur after peripheral arterial bypass surgery. Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs are pain at rest that intensifies with movement and the development of paresthesias. The RN is notified immediately. The RN then contacts the physician, because the client could require an emergency fasciotomy. Therefore options 2, 3, and 4 are incorrect.
37. A nurse is collecting data from client with left sided heart failure. The client states that it is necessary to use three pillows under the head and chest at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing:
A. Orthopnea is the correct answer Rationale: Dyspnea is a subjective problem that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to use pillows to support the head and thorax at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
9. A nurse is caring for a client with a small venous stasis ulcer who has a new order to be out of bed. The nurse plans to obtain which of the following for use in the client's room to best enhance circulatory status of the affected area?
A. Recclining chair is the correct answer Rationale: A venous stasis ulcer occurs as a result of slowing or halted blood flow through a vein. The client should have a reclining chair to allow the legs to be elevated when the client is not resting in bed. Positioning the client with the legs elevated allows gravity to drain the extremities while the client is at rest, thereby increasing venous drainage from the affected leg. An overbed trapeze is used for a client who needs assistance in repositioning himself or herself in bed. A bedside commode may be helpful for a client with limited mobility, but it does not increase circulation to the leg. Warm, heavy blankets could put extra weight on the ulcer and actually reduce venous drainage by causing added vasodilation.
42. A nurse is assisting in performing a cardiovascular assessment on a client. Which of the following items should the nurse check to obtain the best information about the client's left-sided heart function?
A. Status of breath sounds is the correct answer The client with heart failure may present different symptoms, depending on whether the right or left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all signs of right-sided heart function. The status of breath sounds provides information about left-sided heart function.
12. A Client returned form the postanesthesia care unti 8 hours ago after having a femoral-popliteal bypass graft to the left leg. The client exhibits increasing pallor and coolness in the left foot. Capillary refill time is 5 seconds, with a weakly palpable pedal pulse. The client complains of left leg pain that resembles the pain experienced before surgery. The nurse concludes which of the following about the client?
A. is experiencing graft occlusion Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced before surgery. Signs of impaired neurovascular status accompany the occlusion, including pallor, cool temperature, diminished capillary refill, and diminished or absent pedal pulses. If graft occlusion is suspected, the surgeon is notified. The symptoms do not resemble those of deep vein thrombosis. There is no indication that the client has a history of atrial fibrillation, which can result in arterial embolus caused by left atrial thrombus.
21. A nurse has reinforced self care activity instructions to a client after the insertion of an automatic internal cardioverter-defibrillator (AICD). The nurse determines that further instruction is needed if the client makes which of the following statements?
B. "I can perform activities such as swimming, diving, or operation heavy equipment as I need too." Is the correct answer Rationale: An automatic internal cardioverter-defibrillator (AICD) is a device that is implanted in the chest or abdominal area that provides a shock if the client experiences a dysrhythmia such as ventricular fibrillation. Discharge instructions typically include avoiding: tight clothing or belts over the AICD insertion site; rough contact with the AICD insertion site; electromagnetic fields from sources such as electrical transformers, radio/TV/radar transmitters, and metal detectors; and proximity to running motors of cars or boats. Clients must also alert physicians or dentists of the device because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a physician about activities that are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment.
18. A nurse is assigned to assist in caring for a client who has just had insertion of an inferior vena cava (IVC) filter. In the first 24 hours after the procedure, the nurse plans to monitor the insertion site for which of the following?
B. Bleeding Rationale: The care of the client who has had insertion of an IVC filter is similar to that of any surgical client. In the first 24 hours after the procedure, the nurse is most concerned with signs of bleeding. Signs of infection or poor wound healing would not be apparent during this time frame. Option 3 is incorrect.
6. A LPN Is assisting a RN in caring for a client who just underwent cardiac catheterization using the femoral artery approach. The nurse should avoid taking which of the following actions in caring for this client because it is unsafe?
B. Have the client sit upright for a meal is the correct answer Rationale: For 6 hours after cardiac catheterization using the femoral approach (or per physician's orders), the client should not bend or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. This means that having the client sit upright would be contraindicated. The precatheterization medications are generally resumed after the procedure. Asking the client to wiggle the toes to determine neurovascular status is acceptable and should be done because vascular status could be impaired if a hematoma or thrombus were developing. Fluids should be increased to aid in eliminating the contrast medium through the kidneys.
24. A nurse is caring for a client with right-sided heart failure who has been on furosemide (Lasix) daily in the morning for 3 days. The medication has not yet been effective if the client has which of the following?
B. Nocturia with daytime oliguria Rationale: Heart failure is a condition in which the heart cannot pump enough blood to meet the metabolic requirements of body tissues. Fluid pools in the interstitial spaces of the periphery of the body with right-sided heart failure. At night, with the effects of gravity eliminated, fluid reenters the bloodstream and is eliminated by the kidneys, producing nocturia. This indicates that medical therapy is not yet effective. Diuretic therapy administered in the morning results in daytime diuresis.
29. A nurse is assigned to assist in caring for the client with a diagnosis of a dissecting abdominal aortic aneurysm. The nurse avoids doing which of the following while caring for this client?
B. Perform deep palpation of the abdomen. An aneurysm is a localized dilation of the wall of a blood vessel. The nurse avoids deep palpation in the client in which a dissecting aneurysm is known or suspected. Doing so could place the client at risk for rupture. The nurse looks for ecchymosis on the lower back to determine aneurysm leaking and tells the client to report back, neck, shoulder, or extremity pain. An important nursing action is monitoring for changes in vital signs that may indicate signs of a worsening of the condition.
34. A nurse administers acetylsalicylic acid (aspirin) as prescribed before a percutaneous transluminal coronary angioplasty (PTCA) for coronary artery disease to:
B. Prevent thrombus formation. Rationale: A percutaneous transluminal coronary angioplasty (PTCA) is a technique used in the treatment of atherosclerotic coronary heart disease and angina pectoris in which some plaques in the arteries of the heart are flattened against the arterial walls, resulting in improved circulation. Before PTCA the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure. Options 1, 3, and 4 are unrelated to the purpose of administering aspirin to this client.
10. A nurse inspects a client's right lower extremity and finds an open area that measures 4 by 3 cm in size. The are has a deep reddish base and is surrounded by the skin that is edematous, with brownish color to it. Pedal pulses are palpable in the right leg. The nurse interprets that the ulcerated are is due to which of the following predisposing conditions?
B. Venous insufficiency is the correct answer Rationale: The wound described in the question has the characteristics of a venous stasis ulcer. These ulcers are caused by conditions resulting in chronic venous congestion in the extremities. Examples of such conditions include venous insufficiency (varicose veins) and chronic deep vein thrombosis. Pulmonary embolism is a complication of deep vein thrombosis. Arterial insufficiency is accompanied by pain. Typical findings include pale, cool extremities that have diminished or absent pedal pulses. Atrial fibrillation may cause cardiac thrombi, which could break loose and travel to any area of the body, including the legs. This also would cause an acute onset of the classic symptoms found in clients with arterial insufficiency.
30. A client has an abdominal aortic aneurysm. The nurse best detects bleeding from the aneurysm by:
B. measuring abdominal girth every 4 hours. An aneurysm is a localized dilation of the wall of a blood vessel. Bleeding from an aneurysm causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency and may be of some use with detecting bleeding if the pulses are diminished because of reduced circulating volume. However, other signs of hypovolemic shock also may be apparent by that time. Assessment of pain is done routinely, and mild regional discomfort is expected.
25. A nurse is caring for aclient with a diagnosis of chest pain and is suspected of having a myocardial infarction (MI). The physician has ordered laboratory studies to evaluate the client's progress. Which laboratory data report is significant to the diagnosis of an MI
C. Increased creatine Kinase (CK-MB) Rationale: Cardiac enzymes and isoenzymes are used to confirm a myocardial infarction. CK-MB is specific for the heart tissue, CK-MM reflects injury to general skeletal muscle, and CK-BB reflects brain tissue injury. The WBCs tend to increase during acute myocardial infarction. The HCT is not specifically related to an MI.
41. A client schedule for annuloplasty asks the nurse to explain again what the surgical procedure entails. In the planning a response, the nurse should incorporate which of the following points?
C. The valve leaflets are repaired with possible implantation of a prosthetic ring. Is the correct answer Rationale: Annuloplasty is used for mitral or tricuspid regurgitation and involves reconstruction of the annulus and the valve leaflets. Annulus repair may or may not involve insertion of a prosthetic ring. Option 4 describes commissurotomy, whereas options 1 and 2 are types of valve replacement.
5. A licensed practical nurse (LPN) is reinforcing teaching done by the registered nuse (RN) with a client who has been diagnosed with endocarditis. The LPN explains that it is important for this client to use an electric razor rather than a straight razor for shaving because of which of the following? A. An electric razor can be sanitized more easily B. Straight razors harbor too many microorganisms C. The client is at higher risk for infection from any nick or cut D. Any cuts or skin injury should be avoided while taking anticoagulants
D. Any cuts or skin injury should be avoided while taking anticoagulants is the correct answer Clients with endocarditis are at risk for developing thrombi along the walls of the heart, which could become emboli leading to stroke. For this reason, clients with endocarditis are treated with anticoagulant therapy to prevent thrombus formation. Clients on anticoagulants should implement measures to prevent injury and subsequent bleeding. The other options are incorrect because infection rather than bleeding is their primary focus.
13. A nurse is assigned to care for a client with a diagnosis of coronary artery disease. The nurse plans care, knowing that:
D. Chest pain experienced during exercise may indicate ischemia Rationale: Coronary artery disease may go unrecognized for a period of time in persons with a sedentary lifestyle because adequate blood flow to the myocardium may be maintained despite the coronary artery disease. However, during times of emotional stress, increased physical activity, or both, the diseased coronary arteries may not be able to supply the myocardium with adequate blood. The inadequate perfusion of the myocardium, referred to as ischemia, causes pain, yet no damage to the heart muscle occurs. Necrosis is a result of prolonged oxygen deprivation to the myocardium and tissue death (myocardial infarction).
36. A nurse is collecting data from a client admitted to the hospital with a diagnosis of Raynaud's disease. The nurse accurately checks for the symptoms associated with Raynaud's disease when the nurse:
D. Palpates for diminished or absent peripheral pulses. Raynaud's disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. Although palpation of peripheral pulses is correct, it is incorrect to find a rapid or irregular pulse. Peripheral pulses may be normal, absent, or diminished.
33. A hospitalized client has been diagnosed with thrombohplebitis. The nurse plans to avoid doing which of the following during the care of the client?
D. Placing a pillow under the client's knees Thrombophlebitis is the inflammation of a vein accompanied by the formation of a clot. The nurse avoids placing a pillow under the knees of a client with thrombophlebitis because it obstructs venous return to the heart and exacerbates impairment of blood flow. The client is maintained on bed rest as prescribed after a diagnosis of thrombophlebitis is made to prevent the occurrence of pulmonary embolus. The feet are elevated above heart level to aid in venous return, and warm moist heat may be used to aid in comfort and reduce venospasm.