Cardiovascular Disorders

A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60 mm Hg. What should the nurse do first?

Prepare for transcutaneous pacing.

A client is admitted to the telemetry unit with atrial fibrillation. What is the appropriate action of the nurse? Select all that apply.

administer warfarin Apply sequential compression device Apply continuous cardiac monitoring assess for changes in level of consciousnes

A client returns from a left heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client?

dorsal surface of the right foot

A client prescribed enalapril reports symptoms of a persistent dry cough. What is the nurse's best action?

Notify the healthcare provider.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?

The client demonstrates ability to tolerate more activity without chest pain.

A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediately after surgery?

Maintain circulation.

The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best action?

Notify the healthcare provider.

The nurse on the previous night shift documented that the lungs of a client with lung cancer were CTA (clear to auscultation) in all fields. While doing the shift assessment, the day shift nurse noticed decreased breath sounds, especially in the right lower lobe. Which action is the nurse's best choice?

Notify the physician of the change in client status.

A client in the intensive care unit has an arterial line that reads 58/30 mm Hg on the monitor. What is the nurse's first action?

Obtain a manual blood pressure.

A client with deep vein thrombosis has been receiving warfarin for 2 months. The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do?

Return to laboratory for analysis of prothrombin times.

The nurse is administering an IV potassium chloride supplement to a client who has heart failure. What should the nurse consider when developing a plan of care for this client?

The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L.

A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect?

The number of premature ventricular contractions is decreasing.

What measure should the nurse take that will be most helpful in preventing wound infection when changing a client's dressing after coronary artery bypass surgery?

Wash hands before changing the dressing.

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

aortic insufficiency

A client receiving a loop diuretic should be encouraged to eat which foods to prevent potassium loss? Select all that apply.

banana dried fruit orange juice

A client comes to the clinic with back pain that has been unrelieved by continuous ibuprofen use over the past several days. Current prescription medications include captopril and hydrochlorothiazide. Which laboratory value should the nurse address?

blood urea nitrogen (BUN) of 26 mg/dL and serum creatinine of 2.35 mg/dL

A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client presentation increases the likelihood of a cardiovascular disorder?

clubbing of fingers

A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply.

creatine kinase (CK) troponin T and troponin I myoglobin

The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:

decreased blood flow.

The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an aortic aneurysm. What is a priority assessment for this client?

decreased urinary output

Which signs and symptoms accompany a diagnosis of pericarditis?

fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

The nurse is monitoring a client postoperatively after a permanent pacemaker insertion. Which finding would be most concerning to the nurse?

heart rate of 48 beats/minute

In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload?

hemorrhage, sepsis, and anaphylaxis

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

heparin sodium

A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume?

leaning forward while sitting

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.)

nail bed color. skin temperature. pain in extremity.

A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply.

orthopnea cough crackles

A client has been diagnosed with peripheral arterial occlusive disease. In order to promote circulation to the extremities, the nurse should instruct the client to:

participate in a regular walking program.

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect?

pericardial tamponade

A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:

showing the location of the obstruction and the collateral circulation.

The nurse is caring for an older adult man who walks 2 miles every morning. The nurse notes that during his morning walk, he called his child and stated that he thought that he was having a heart attack. Which symptom, identified by the client, is the most common and consistent with that of a heart attack (myocardial infarction)?

sternal pain

A client was transferring a load of fire wood from their front driveway to the backyard woodpile at 10 a.m.,when the client experienced a heaviness in their chest and dyspnea. The client stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., the client's spouse took them to the emergency department. Around 2:30 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician?

sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry

A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to:

weigh daily.

The nurse instructs a client on the use of transdermal nitroglycerin 0.2 mg/hour patch for angina pectoris. Which client statement indicates that teaching was effective?

"I should report any skin irritation to the healthcare provider."

The nurse is evaluating client understanding of discharge teaching about Prinzmetal's variant angina (PVA). Which statement by the client requires further instruction?

"I will take prophylactic beta blockers."

A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?

"I'll keep a log of each time my ICD discharges."

A client presents with a heart rate of 30 beats/min. The nurse notes a pacemaker in the client's right upper chest wall. What is the nurse's priority action?

Assess the blood pressure.

During a home visit, the nurse assesses a client who is taking hydrochlorothiazide and lisinopril for the treatment of hypertension. Which finding would indicate the nurse should inform the health care provider of a possible need to change medication therapy?

Client has a persistent cough.

A nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that they think they are going to die before a donor heart is found. The client also tells the nurse that they have not been attending a church but wants to talk with a priest. What action should the nurse take?

Contact the clergy member who is assigned to the transplant team.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating?

Eat food on only half of the plate.

The client has had hypertension for 20 years. The nurse should assess the client for?

Renal insufficiency and failure.

The plan of care for a client with hypertension taking propranolol hydrochloride should include:

instructing the client to notify the health care provider of irregular or slowed pulse rate.

During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the nurse palpates the radial pulse and notices which signs?

irregular rhythm with pulse rate greater than 100 bpm

A client with heart failure is receiving furosemide, 40 mg I.V. The physician orders [40 mEq (40 mmol/L)] of potassium chloride in 100 ml of dextrose 5% in water to infuse over 4 hours. The client's most recent serum potassium level is [3.0 mEq/L (3.0 mmol/L)]. At what infusion rate should the nurse set the I.V. pump?

25 ml/hour

A newly admitted client reports taking digoxin and warfarin. Which statement would the nurse include in the discharge instructions?

"Notify your healthcare provider if you experiences visual changes."

To prevent pulmonary emboli in a client who has had abdominal surgery, what should the nurse do?

Have the client perform leg exercises every hour while awake.

A client is started on digoxin. The health care provider (HCP) prescribes IV push doses of 0.5 mg now, 0.25 mg in 8 hr., and another 0.25 mg in another 8 hr. The client has a 1,000 mL bag of normal saline infusing at 25 mL/hr. What action should the nurse perform?

Administer each dose of medication over 5 minutes via IV push.

A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. What other sign should the nurse assess next?

digoxin toxicity.

Two days after a myocardial infarction (MI), a client's temperature is elevated. The nurse understands which response to be most likely related to the infarction?

tissue necrosis

The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client who is inquiring about the purpose of the new diet?

to reduce the metabolic workload of digestion

The nurse is assessing a client with heart failure whose blood pressure and weight are being monitored remotely. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. What should the nurse ask the client first?

"Are you having shortness of breath?"

The nurse should give which discharge instructions about thermal injury to a client with peripheral vascular disease? Select all that apply.

"Avoid sunburn during the summer." "Wear extra socks in the winter." "Choose loose, soft, cotton socks."

Which is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)?

The client can perform personal self-care activities without pain

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include?

"Client will verbalize the intention to stop smoking."

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)?

Identify the time of onset of the stroke.

A client in the emergency department reported vomiting and diarrhea for the previous 24 hours. The client's blood pressure is 90/60 mm Hg, respiration is 20 breaths per minute, heart rate is 92 beats per minute, and temperature is 37.5° C (99.5° F). Which intervention will the nurse perform first?

Assess for dehydration.

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

Assess respiratory status.

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor exhibits the following. Which interventions would the nurse do first?

Assess the client's airway, breathing, and circulation.

The nurse observes a sudden dampening of the arterial waveform. What is the priority action by the nurse?

Assess the client's blood pressure.

A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. What should the nurse do first?

Assess the oxygen saturation.

A client is recovering from coronary artery bypass graft (CABG) surgery and begins to experience chest pain, shortness of breath, and tachycardia. Further assessment reveals a widened QRS complex and an elevated ST segment. Which nursing diagnosis takes highest priority at this time?

Decreased cardiac output related to depressed myocardial function

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

history of aortic valve replacement

An older adult had a myocardial infarction (MI) 4 days ago. At 0930, the client's blood pressure is 102/64 mm Hg. After reviewing the client's progress notes (see chart), what should the nurse do first?

Notify the health care provider (HCP).

The nurse is evaluating the therapeutic goal of a client with history of cardiac dysrhythmias and newly completed radiofrequency catheter ablation. Which client-centered goal is most appropriate?

The client will have a regular heart rhythm from destruction of errant tissue of the heart.

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. What should the nurse do first?

Notify the health care provider (HCP).

A client receiving digoxin has a serum magnesium level of 0.9 mg/dL (0.57 mmol/L). What is the nurse's best action?

Notify the healthcare provider.

The client asks the nurse, "Why won't the health care provider tell me exactly how much of my leg he is going to take off? Don't you think I should know that?" On which information should the nurse base the response?

the adequacy of the blood supply to the tissues

A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. What is the nurse's primary goal at this time?

Prepare the client for emergency surgery.

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT)

A client is receiving digoxin, and the pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should do what first?

Withhold the digoxin.

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse?

a urinary output of 50 mL in the past 3 hours

The nurse is assessing a client with an atrial septal defect (ASD). Which finding requires immediate nursing intervention?

client having an uneven smile and facial droop

A client has peripheral artery disease of both lower extremities. The client tells the nurse, "I've really tried to manage my condition well." Which example indicates the client is using appropriate care management strategies?

The client walks slowly but steadily for 30 minutes twice a day.

A nurse is planning care for a client who has heart failure. Which goal is appropriate for a client with excess fluid volume?

Serum osmolality will be within normal limits.

A group has asked the nurse to discuss how lifestyle factors affect heart health. Which statements by members of the group would indicate that the teaching was effective? Select all that apply

"Gradually increasing my exercise levels will help enhance circulation through the heart." "Walking is excellent exercise to strengthen my heart." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." Correct response: "Gradually increasing my exercise levels will help enhance circulation through the heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "Walking is excellent exercise to strengthen my heart."

The nurse has been instructing the client about how to prepare meals that are low in fat. Which of these comments would indicate the client needs additional teaching?

"I will eat more liver with onions."

A client takes isosorbide dinitrate as an antianginal medication. Which statement indicates that the client understands the adverse effects of the drug?

"I'll need to change positions slowly so I won't get dizzy."

The nurse is teaching a client about actions to control manifestations of left-sided heart failure. Which statement by the client indicates appropriate understanding?

"If I have trouble breathing, I will sit in my recliner with my head up."

What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine?

"Morphine decreases the heart's need for oxygen and also makes your heart not work as hard."

A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client?

"PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter."

The client with heart failure asks the nurse about the reason for taking enalapril maleate. The nurse should tell the client:

"This drug will dilate your blood vessels and lower your blood pressure."

A client is to have sclerotherapy to treat varicose veins. What information about the procedure should the nurse include in the teaching plan for this client?

It causes the veins to fade and disappear.

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

arterial blood gas (ABG) findings

When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum?

2 in (5 cm)

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to safely remove the femoral sheath when the partial thromboplastin time (PTT) is:

50 seconds or less.

A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assess the attendee as being unresponsive. Indicate how the nurse would respond by placing the following actions in chronological order. All options must be used.

Appoint a person to call 911. Perform chest compressions. Perform a head tilt-chin lift maneuver. Check for normal breathing. Deliver two rescue breaths. Check for a pulse.

A client with stage IV heart failure documents in an advance directive that no ventilatory support should be provided. What should the nurse do when the client begins experiencing severe dyspnea?

Administer oxygen, morphine, and a bronchodilator for comfort.

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal?

B-type natriuretic peptide (BNP)

A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the client is admitted to the coronary care unit?

Begin telemetry monitoring.

A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal?

Bupropion.

Which of the following explains the influence of aging on the development of peripheral vascular disease?

Increased resistance.

A client is admitted with shortness of breath, a brain natriuretic peptide (BNP) level of 615 pg/mL, and pedal edema. Which actions should the nurse take next? Select all that apply.

Initiate I.V. diuretic therapy. Give oxygen by mask

A nurse is assessing a client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. After determining that other vital signs are normal, what should the nurse do first?

Notify the health care provider (HCP).

The nurse teaches a client with heart failure to take oral furosemide in the morning. What is the expected outcome for taking this drug in the morning? The client will:

Obtain more sleep.

An older adult is admitted to the hospital with sudden onset of severe pain in the back, flank, and abdomen. The client reports feeling weak; the blood pressure is 68/31 mm Hg. There has been no urine output. Bilateral leg pulses are weak, although bruit and pulsation are noted at the umbilicus. What should the nurse do first?

Start an IV infusion.

While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. What should the nurse do next?

Stop and assess the client further.

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. What should the nurse instruct the client to do?

Take a nitroglycerin tablet before climbing the stairs.

A nurse is caring for a client with advanced heart failure. The client can't care for themself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses their desire for "nature to take its course." The client's family is pleading with the client to have a feeding tube inserted. What is the most appropriate action for the nurse to take?

Talk with the client's family about the client's right to decide for themself.

A visiting nurse is teaching a client with heart failure about taking their medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene?

Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications.

The nurse is preparing a teaching plan for a client who is being discharged after being admitted for chest pain. The client has had one previous myocardial infarction 2 years ago and has been taking simvastatin 40 mg for the last 2 years. After reviewing the lab results for the client's cholesterol levels (see chart), what should the nurse do?

Tell the client that the cholesterol levels are within normal limits.

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain.

A client with atrial fibrillation has been receiving warfarin. The INR is 4.5. What is the next action the nurse should take?

Withhold the next scheduled dose.

A nurse is caring for 4 clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?

a client 4 days postoperative after mitral valve replacement

Which assessment finding supports the administration of protamine sulfate?

aPTT 3.5-5 times normal

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

acute pulmonary edema.

The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The client has understood the instruction when the client identifies which potential complications? Select all that apply.

becoming increasingly short of breath at rest weight gain of 2 lb (0.9 kg) or more in 1 day having to sleep sitting up in a reclining chair

A client is taking spironolactone to control hypertension. The client's serum potassium level is [6 mEq/L (56mmol/L)]. For this client, the nurse's priority should be to assess their

electrocardiogram (ECG) results.

Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's:

electrocardiogram (ECG).

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

respiratory alkalosis

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. How should the nurse document these findings?

heart rate irregular with S3

The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance?

hyperkalemia

Which activity is least effective in preventing sensory deprivation during a client's stay in the cardiac care unit?

keeping the door closed to provide privacy

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?

potassium

A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review?

reducing cholesterol levels, increasing activity levels progressively, and coping strategies

The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye?

retina

A client is admitted with chest pain, fever, and joint pain 4 weeks after experiencing an acute inferior wall myocardial infarction. Which laboratory value should the nurse address?

sedimentation rate (ESR) 49 mm/hr

A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching?

turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation

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

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

ventricular depolarization.

A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action?

weight gain of 2.5 kg (5.5 lb) in 24 hours

A client with chest pain doesn't respond to nitroglycerin. When the client is admitted to the emergency department, the healthcare team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

wthin 6 hours

The nurse is teaching a client how to apply nitroglycerin topical ointment. Which statement indicates that the client needs additional clarification of the instructions?

"I'll carefully massage the ointment into the skin."

A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client makes which statement?

"I'll try to lose weight by following a reduced-calorie, balanced diet."

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris?

"The pain occurred while I was mowing the lawn."

A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). To determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask?

"What time did your chest pain start?"

A client is receiving cilostazol for intermittent claudication. What should the nurse ask the client to determine the effectiveness of the drug?

"Do you have less pain in the legs?"

A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client?

"During the procedure, the health care provider will insert a special wire used to increase the heart rate and produce the irregular beats that caused your signs and symptoms."

The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin. The client has had 2 previous episodes of coronary artery disease. At the onset of chest pain, what should the client do?

Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective.

A nurse is teaching a client how to take nitroglycerin to treat angina pectoris. What should the nurse include in the instructions?

Call emergency medical services immediately if chest pain does not subside within 15 minutes.

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:

Dependent edema.

The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch, and pedal pulses are palpable +1. What should the nurse instruct the client to do?

Seek consultation from the health care provider.

Which client is at greatest risk for coronary artery disease?

a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L)

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. During admission, what should the nurse assess first?

blood pressure