Cardiovascular Disorders - PassPoint NCLEX

A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority? A client's cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions. A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. A client's monitor shows frequent paced beats with capture. A client's monitor shows sinus tachycardia with frequent premature atrial contractions (PACs).

A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. 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, 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.

When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum? 0.5 in (1 cm) 1 in (2.5 cm) 1.5 in (4 cm) 2 in (5 cm)

2 in (5 cm)

A middle-aged man collapses in the emergency department waiting room. What should the nurse do first? Ask the client to state his name. Perform the chin-tilt to open the victim's airway. Feel for any air movement from the victim's nose or mouth. Watch the victim's chest for respirations.

Ask the client to state his name. Calling the victim's name and gently shaking the victim is used to establish unresponsiveness. The head-tilt, chin-lift maneuver is used to open the victim's airway. Feeling for any air movement from the victim's nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victim's chest for respirations to see if the victim is breathing.

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 skin breakdown serum potassium level urine output

blood pressure

A fourth heart sound (S4) indicates a dilated aorta. normally functioning heart. decreased myocardial contractility. failure of the ventricle to eject all blood during systole.

failure of the ventricle to eject all blood during systole.

A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? the client with a history of cardioversion for sustained ventricular tachycardia 2 days ago the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block the client with a history of heart failure who has bibasilar crackles and pitting edema in both feet the client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday

the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block)

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." "PTCA involves cutting away blockages with a special catheter." "PTCA involves passing a catheter through the coronary arteries to find blocked arteries." "PTCA involves inserting grafts to divert blood from blocked coronary arteries."

"PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery.

A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take? Assess the client's airway, breathing, pulses, and level of consciousness. Defibrillate the client. Begin cardiopulmonary resuscitation (CPR). Apply the external pacemaker.

Assess the client's airway, breathing, pulses, and level of consciousness. If the client is experiencing ventricular tachycardia, the priority for the nurse is to assess the client's airway, breathing, and level of consciousness before any further action is taken.

A client, hospitalized with heart failure, is receiving digoxin and furosemide intravenously and now has continuous ringing in the ears. What is the appropriate action for the nurse to take at this time? Obtain a digoxin level to check for toxicity. Note the observation in the medical record and plan to reassess in 2 hours. Ask the client about taking aspirin in addition to other medications. Discontinue the furosemide and notify the health care provider (HCP).

Discontinue the furosemide and notify the health care provider (HCP). The nurse should recognize the ringing in the ears, or tinnitus, as a sign of ototoxicity probably caused by the furosemide. The appropriate action is for the nurse to stop the furosemide and notify the HCP. If the drug is stopped soon enough, permanent hearing loss can be avoided, and the tinnitus should subside. The nurse should note the observation in the medical record but should not delay action. Tinnitus is not a symptom of digoxin toxicity. Aspirin can cause tinnitus, but the nurse should first investigate the obvious cause of tinnitus, which in this case is the furosemide.

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? Report the findings to the charge nurse for documentation follow up with the previous shift's nurse. Document the findings as the only action, as this is expected in clients with lung cancer. Notify the physician of the change in client status. Call radiology for an X-ray to confirm findings.

Notify the physician of the change in client status. Pleural effusion is a common complication of lung cancer. Fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Documentation of abnormal findings without any follow-up is an error in the nursing process. Ordering an X-ray is not an independent nursing action.

The plan of care for a client with hypertension taking propranolol hydrochloride should include: instructing the client to discontinue the drug if nausea occurs. monitoring blood pressure every week and adjusting the medication dose accordingly. measuring partial thromboplastin time weekly to evaluate blood clotting status. instructing the client to notify the health care provider of irregular or slowed pulse rate.

instructing the client to notify the health care provider of irregular or slowed pulse rate. Propranolol hydrochloride is a beta-adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other arrhythmias.

The nurse is teaching a group of women about risk for varicose veins. Which client is at risk for varicose veins? a client who has had a cerebrovascular accident a client who has had anemia a client who has had thrombophlebitis a client who has had transient ischemic attacks

a client who has had thrombophlebitis Secondary varicosities can result from previous thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebrovascular accident, anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins.

A client with a ventricular dysrhythmia is receiving intravenous lidocaine. For which assessment finding should the nurse suspect the client is experiencing toxicity from the medication? nausea and vomiting pupillary changes confusion and restlessness hypertension

confusion and restlessness Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine or tocainide — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.

The nurse is monitoring a client postoperatively after a permanent pacemaker insertion. Which finding would be most concerning to the nurse? urine output of 30 mL over 1 hour heart rate of 48 beats/minute blood pressure of 160/91 mm Hg reports of left chest soreness

heart rate of 48 beats/minute The client experiencing bradycardia would be the most serious report postoperatively because it likely indicates pacemaker malfunction. The blood pressure, while elevated, is not at a dangerous level at this time and only needs to be monitored. The urine output is normal over 1 hour and would be monitored and gauged against the client's intake. The client would be expected to have soreness in the left chest and should be given pain medication as needed.

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort? brown discoloration of the skin with edema in the lower left leg dark, protruding veins of both legs that are uncomfortable when standing absence of pain or swelling when the client dorsiflexes the left foot red, warm, palpable linear cord along the vein that is painful on palpation

red, warm, palpable linear cord along the vein that is painful on palpation

The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply. serum bilirubin serum troponin serum myoglobin urinalysis electroencephalogram 24-hour creatinine clearance

serum troponin serum myoglobin