Chapter 35 - Concepts of Care for Patients with Acute Coronary Syndromes
A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all in patients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."
A
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the clients blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.
A
A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assess respiratory status. b. Monitor electrolyte levels. c. Administer intravenous fluids. d. Insert a Foley catheter.
A
A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer furosemide (Lasix) first.
A
A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"
A
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the client's vital signs. d. Obtain consent for a central line.
A
A client is to receive a dopamine infusion. What does the nurse do to prepare for this infusion? A. gather central line supplies B. mark the client's pedal pulses C. monitor the clients vital signs D. ensure an accurate weight is charted
A
A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? a. "Please come into the clinic for an evaluation." b. "Increase your fluid intake during waking hours." c. "Use an over-the-counter cough suppressant." d. "Sleep on two pillows to facilitate postnasal drainage."
A
A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action? a. Administer the Vasotec. b. Recheck the blood pressure. c. Hold the Vasotec d. Notify the health care provider.
A
A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction.
A
A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."
A
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems
A
A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness."
A
After receiving change-of-shift report about these four clients, which client should the nurse assess first? a. The 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset, frequent premature ventricular complexes b. The 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% c. The 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths d. The 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, rate 104
A
An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? a. Echocardiography b. Chest x-ray c. T4 and thyroid-stimulating hormone (TSH) d. Arterial blood gas
A
An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? a. "Would you like to talk about this more?" b. "You're lucky to have such a devoted daughter." c. "You must feel as though you are a burden." d. "Would you like an antidepressant medication?"
A
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.
A
How soon does the nurse expect anginal pain to begin subsiding after administering sublingual nitroglycerin to a client with chronic stable angina? A. 1-2 minutes B. 5-6 minutes C. 10-12 minutes D. 15-20 minutes
A
How would the critical care nurse assess for postoperative bleeding in a client who just had CABG surgery? A. Measure mediastinal and pleural chest tube drainage at least once an hour and report drainage amount over 150 mL/hr to the surgeon. B. Measure mediastinal and pleural chest tube drainage at least once a shift and report drainage amount over 50 mL/hr to the surgeon. C. Assess the sternal dressing for bleeding every 4 hours, then reinforce with sterile gauze as needed and report the appropriate amount of bleeding to the surgeon. D. Assess the vein donor site every 4 hours and report the amount of serous drainage as well as pain to the surgeon.
A
The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.
A
The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching? a. "I should avoid grilling hamburgers." b. "I must cut out bacon and canned foods." c. "I shouldn't put the salt shaker on the table anymore." d. "I should avoid lunch meats but may cook my own turkey."
A
The nurse evaluates diagnostic results for a client who has chest pain. Which laboratory test is most specific for acute coronary syndromes? a. Troponin markers b. Serum lactate dehydrogenase (LDH) c. Serum myoglobin d. Creatine kinase (CK)-MB isoenzyme
A
The nurse is administering thrombolytic therapy to a client who had a myocardial infarction. Which intervention does the nurse implement to reduce the risk of complications in this client? a. Administer prescribed heparin. b. Apply ice to the injection site. c. Place the client in Trendelenburg position. d. Instruct the client to take slow deep breaths.
A
The nurse is assessing a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) and is ordered to receive an IV infusion of abciximab (ReoPro). Which clinical manifestation does the nurse monitor for in this client? a. Bleeding b. Joint pain c. Pedal edema d. Excessive thirst
A
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes cigarettes daily d. Older man who has had a myocardial infarction
A
The nurse is caring for a client who had a myocardial infarction. The client develops increased pulmonary congestion; an increase in heart rate from 80 to 102 beats/min; and cold, clammy skin. Which action does the nurse implement before notifying the health care provider? a. Administer oxygen. b. Increase the IV flow rate. c. Place the client in supine position. d. Prepare the client for surgery.
A
The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on the left side
A
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure? a. Ibuprofen (Motrin) b. Hydrochlorothiazide (HydroDIURIL) c. NPH Insulin d. Levothyroxine (Synthroid)
A
The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate
A
The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation
A
The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching? a. "I will call the provider if I have a cough lasting 3 or more days." b. "I will report to the provider weight loss of 2 to 3 pounds in a day." c. "I will try walking for 1 hour each day." d. "I should expect occasional chest pain."
A
The nurse is teaching a client prescribed sublingual nitroglycerin for chest pain. Which statement indicates that the client needs further teaching? a. "I carry my medicine around in a clear plastic bag so that I can get to it easily if I have chest pain." b. "Even if I have not used any of the nitroglycerin from one refill, I get another refill every 3 months." c. "If I still have chest pain after I have taken 3 nitroglycerin tablets, I will go to the hospital." d. "When my nitroglycerin tablet tingles under my tongue, I know that it is strong enough to work."
A
The nurse is teaching a client who is prescribed a calcium channel blocking agent after a percutaneous transluminal coronary angioplasty (PTCA). Which instruction does the nurse include in this client's teaching? a. "Change position slowly." b. "Avoid crossing your legs." c. "Weigh yourself daily." d. "Decrease salt intake."
A
What priority question would the nurse ask before administering SL nitroglycerin to a middle-aged male client with client pain? A. "Have you taken a medication for erectile dysfunction within the past 24 to 48 hours?" B. "Do you have a family history of heart disease, especially parents and grandparents?" C. "Have you experienced any other symptoms with your chest pain?" D. "What were you doing when the chest pain started?"
A
Which finding would the nurse expect when a client experiences a non-ST-segment elevation MI (NSTEMI)? A. ST depression and T-wave inversion on a 12-lead ECG B. Cardiac dysrhythmias C. Immediate elevation of troponin levels D. ST elevation in two contiguous leads on a 12-lead ECG
A
Which manifestation would the nurse expect with a client labeled class I on the Killip scale for heart failure? A. Clear lung sounds and absence of S3 B. Crackles in the lower half of the lung fields and possible S3 C. Crackles more than halfway up the lung fields and frothy sputum D. Systolic blood pressure less than 90 mm Hg and oliguria
A
Which statement by a client indicates to the nurse correct understanding of resuming sexual activity in the presence of angina? A. "When I can climb two flights of stairs, it is safe to resume sexual activity." B. "It is best to resume sexual activity in the evening before I go to sleep." C. "If I am unable to walk at least a mile, it is unsafe for me to resume sexual activity." D. "I will discuss alternative methods with my partner as I will no longer be able to resume my previous level of sexual activity."
A
A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the client's sheets. c. Put on a pair of gloves. d. Assess blood pressure.
A/C
Which findings would the nurse expect when assessing a client with chronic stable angina? Select all the apply. A. Chest discomfort occurs in a pattern that is familiar to the client B. Chest discomfort that occurs with moderate to prolonged exertion C. Frequency, duration, and intensity of symptoms remain the same over several months D. Results in moderate limitation of activity E. Usually treated with rest and nitroglycerin (NTG) F. Pain lasts less than 15 minutes
ABCDEF
A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking
ABCE
Which statements about coronary artery disease and women are accurate? Select all that apply. A. Postmenopausal women in their 70s have the same incidence of myocardial infarction (MI) as men. B. Women have smaller coronary arteries and frequently have plaque that breaks off and travels into the small vessels to form an embolus. C. The older a woman is the more likely she is to have coronary artery disease. D. More men than women die within a year after a MI. E. Women whose parents had CAD are more susceptible to the disease. F. Many women experience atypical angina as indigestion, pain between shoulders, aching jaw, and a choking sensation.
ABCEF
or which manifestations would the nurse monitor when providing care for a client prescribed beta-blocker therapy? Select all that apply. A. Depression B. Bradycardia C. Decreased level of consciousness D. Increased urine output E. Crackles or wheezes in the lungs F. Chest discomfort
ABCEF
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause
ABDE
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause
ABDE
Which alternative therapies may be helpful in reducing a client's anxiety about progressive activity postoperatively and during rehabilitation? Select all that apply. A. Guided imagery B. Progressive muscle relaxation C. Acupuncture D. Music therapy E. Pet therapy F. Herbal remedies
ABDE
Which signs and symptoms indicate to the nurse that a client with a myocardial infarction and heart failure is going into cardiogenic shock? Select all that apply. A. Cold, clammy skin with poor peripheral pulses B. Pulmonary congestion and tachypnea C. Bradycardia and hypertension D. Urine output less than 0.5 to 1 mL/kg/hr E. Agitation, restlessness, or confusion F. Systolic BP less than 100 mm Hg
ABDE
Which statements about the use of thrombolytic agents for a client with an acute myocardial infarction are accurate? Select all that apply. A. Clients who cannot receive a thrombolytic agent must be carefully monitored before, during, and after the drug is given. B. A client who has received a thrombolytic agent must be carefully monitored before, during, and after the drug is given. C. Thrombolytic therapy is indicated for chest pain of less than 15 minutes duration that is relieved by nitroglycerin. D. The client must be assessed for absolute and relative contraindications before a thrombolytic agent is administered. E. Monitor for bleeding which is a major risk when a client receives thrombolytic therapy. F. Indications that the clot has been dissolved and the artery reperfused include sudden onset of ventricular dysrhythmias.
ABDEF
The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply. a. Chest discomfort or pain b. Tachycardia c. Expectorates thick, yellow sputum d. Sleeps on back without a pillow e. Shortness of breath with exertion
ABE
The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. S3/S4 summation gallop f. Cough worsens at night
ABEF
The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria
ABEF
Which are characteristics the nurse would expect to find in a client with unstable angina (USA)? Select all that apply. A. Chest pain occurs at rest or with exertion B. Pain causes severe limitation of activities C. Includes chronic stable angina, vasospastic angina, and new-onset angina D. Presents with ECG changes and elevation of troponin levels E. Ischemia does not cause myocardial damage or cell death F. The pain or pressure is poorly relieved by nitroglycerin
ABEF
A nurse is studying hemodynamic monitoring. Which measurements are correctly matched with the physiologic cause? (Select all that apply.) a. Right atrial pressure 12 mm Hg: right ventricular failure b. Right atrial pressure 4 mm Hg: hypovolemia c. Pulmonary artery pressure 20/10 mm Hg: normal finding d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction
ACDE
Which absolute contraindications would the nurse assess for when a client is being considered for thrombolytic therapy? Select all that apply. A. Any prior intracranial hemorrhage B. History of chronic, severe, poorly controlled hypertension C. Suspected aortic dissection D. Known malignant intracranial neoplasm (primary or metastatic) E. Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg) F. Active bleeding or bleeding diathesis (excluding menses)
ACDF
Which clients are potential candidates for coronary artery bypass graft (CABG) surgery? Select all that apply. A. Client with angina and greater than 50% occlusion of the left main coronary artery that cannot be stented B. Client with unstable angina with moderate one-vessel disease appropriate for stenting C. Client with valvular disease D. Client with coronary vessels unsuitable for percutaneous coronary intervention (PCI) E. Client with acute myocardial infarction (MI) that is responding to medical therapy F. Client with ischemia or impending MI after angiography or PCI
ACDF
Which essential preoperative teaching would the nurse provide to a client scheduled for CABG surgery using the traditional procedure? Select all that apply. A. There will be a sternal incision. B. Coughing will be avoided to keep stress off of the sternal incision. C. There will be as many as three chest tubes in place after the surgery. D. An indwelling urinary catheter will be in place to drain urine. E. You will be on bedrest for up to 48 hours after the surgery. F. An endotracheal tube will prevent talking immediately after surgery.
ACDF
A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the commode. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse.e. Take and record a full set of vital signs per hospital protocol.
ACE
A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.
ACE
Which essential points would the nurse include when teaching a client with coronary artery disease how to manage activity at home? Select all that apply. A. Begin by walking the same distance at home as in the hospital (usually 400 feet) three times each day. B. Check your pulse before and after you exercise. C. Always carry a bottle of nitroglycerin with you. D. Stop your activity if your pulse increases by 10 beats/min. E. Exercise outdoors when the weather is pleasant. F. Avoid straining (lifting, push-ups, pull-ups, and straining at bowel movements).
ACEF
Which are post-administration nursing responsibilites when caring for a client who received thrombolytic therapy? Select all that apply. A. Observe all IV sites for bleeding and patency. B. Document the client's emotional reaction to the thrombolytic therapy. C. Monitor white blood cells (WBC) count and differential. D. Test stool, urine, and emesis for occult blood. E. Monitor clotting study values. F. Observe for signs of internal bleeding (e.g., blood pressure)
ADEF
Which indicators of metabolic syndrome would the nurse expect in a client with heart failure? Select all that apply. A. Blood pressure of 130/86 mm Hg while taking a beta blocker B. Large waist of 35 inches (88 cm) or greater for men C. HDL-C greater than 40 mg/dL for men D. Increased fasting glucose of 100 mg/dL or higher E. Increased level of triglycerides of 150 mg/dL or higher F. Decreased LDL-C of less than 50 mg/dL for women
ADEF
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler's position.
B
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.
B
A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.
B
A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."
B
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.
B
A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."
B
A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."
B
A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription? a. Serum sodium level of 135 mEq/L b. Serum potassium level of 2.8 mEq/L c. Serum creatinine of 1.0 mg/dL d. Serum magnesium level of 1.9 mEq/L
B
A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regularly gallop rhythm d. Coarse crackles in bilateral lung bases
B
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? a. Increase in stroke volume b. Decrease in tissue perfusion c. Increase in oxygen saturation d. Decrease in arterial vasoconstriction
B
A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home
B
A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L
B
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking
B
A nurse is in charge of the coronary intensive care unit. Which client would the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64mm Hg c. Client who is 1-day post percutaneous coronary intervention, going home this morning d. Client who is 2-day post coronary artery bypass graft, who became dizzy thismorning while walking
B
After administering SL nitroglycerin to a client whose baseline blood pressure is 130/80 mm Hg, for which finding would the nurse immediately notify the health care provider? A. Client reports a headache. B. Systolic pressure is 90 mm Hg. C. Anginal pain is somewhat relieved. D. Heart rate is 92 beats/min.
B
An alert and oriented client comes to the walk-in clinic with left-sided chest pain, mild shortness of breath, and diaphoresis. What is the nurse's first priority action? A. Obtain a complete cardiac history for the client. B. Place the client in semi-Fowler position with supplemental oxygen. C. Instruct the client to go immediately to the nearest full-service hospital. D. Immediately alert the health care provider and establish IV access.
B
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? a. Ejection fraction is 25%. b. Client states that she is able to sleep on one pillow. c. Client was hospitalized five times last year with pulmonary edema. d. Client reports that she experiences palpitations.
B
The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication? a. The client's ability to understand medication teaching b. The risk for hypotension c. The potential for bradycardia d. Liver function tests (LFTs)
B
The client who has been admitted for the third time this year for cardiac failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? a. Calls the family to lift the client's spirits b. Considers further assessment for depression c. Sedates the client to decrease myocardial oxygen demand d. Tells the client that things will get better
B
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.
B
The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action should the nurse take first? a. Assess the client for peripheral edema. b. Listen to the client's posterior breath sounds. c. Notify the physician about the client's weight gain. d. Remind the client about dietary sodium restrictions.
B
The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia.
B
The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."
B
The nurse is assessing a client who has a history of stable angina. The client describes a recent increase in the number of attacks and in the intensity of the pain. Which question does the nurse ask to assess the client's change in condition? a. "How many cigarettes do you smoke daily?" b. "Do you have pain when you are resting?" c. "Do you have abdominal pain or nausea?" d. "How frequently are you having chest pain?"
B
The nurse is assessing a client who has a serum potassium level of 4.5 mEq/L after coronary artery bypass graft (CABG) surgery. Which action does the nurse take? a. Notify the health care provider. b. Document the finding. c. Administer prescribed diuretics. d. Administer prescribed potassium replacements.
B
The nurse is assessing a client who is 6 hours postoperative from coronary artery bypass graft surgery. The client's mediastinal tubes are not draining. Which action does the nurse implement at this time? a. Replace the drainage tubing. b. Check for kinks in the tubing. c. Irrigate the tubing with normal saline. d. Document the finding.
B
The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"
B
The nurse is assisting a client to walk in the hall on the third day after a myocardial infarction. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity? a. Facial flushing b. Onset of chest pain c. Heart rate increase of 10 beats/min at completion of the activity d. Systolic blood pressure increase of 10 mm Hg at completion of the activity
B
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.
B
The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness
B
The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education? a. "I will be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K, like spinach." d. "I will use an electric razor instead of a straight razor to shave."
B
The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."
B
The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina? a. Chest discomfort at rest and inability to tolerate mowing the lawn b. Chest discomfort when mowing the lawn and subsiding with rest c. Indigestion and a choking sensation when mowing the lawn d. Jaw pain that radiates to the shoulder after mowing the lawn
B
The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.
B
The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality? a. Dobutamine (Dobutrex) b. Carvedilol (Coreg) c. Digoxin (Lanoxin) d. Bumetamide (Bumex)
B
The nurse would teach a client to seek treatment for symptoms of myocardial infarction (MI) immediately rather than delay, because physical changes occurs in how many hours after an MI? A. 3 hours B. 6 hours C. 12 hours D. 24 hours
B
What is the best action for the home health nurse to take when visiting a new client with CAD who is experiencing new-onset chest pain and shortness or breath? A. Instruct the client to rest quietly and take slow, deep breaths. B. Have the client chew a 325-mg aspirin tablet and call 911. C. Apply supplemental home oxygen until the symptoms subside. D. Administer a sublingual nitroglycerin tablet and have the family take the client to the emergency room.
B
Which of these clients is best to assign to an LPN/LVN working on the telemetry unit? a. A client with heart failure who is receiving dobutamine (Dobutrex) b. A client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea c. A client with pericarditis who has a paradoxical pulse and distended jugular veins d. A client with rheumatic fever who has a new systolic murmur
B
Which procedure has shown promise for managing clients with cardiogenic shock? A. Percutaneous ventricular assistive device B. Immediate reperfusion C. Intra-aortic balloon pump D. Minimally invasive bypass surgery
B
Which procedure would the nurse expect to be recommended for a client with discrete, proximal, noncalcified blockage in one coronary artery? A. Minimally invasive direct coronary artery bypass (MIDCAB) B. Percutaneous coronary intervention (PCI) C. Immediate thrombolytic reperfusion therapy D. Exercise tolerance test (stress test) on a treadmill
B
Which statement by the client who had CABG surgery indicates to the nurse that his or her pain is related to the sternotomy and is not anginal in origin? A. "The pain goes down my arm and sometimes into my jaw." B. "My pain increases when I cough or take a deep breath." C. "The nitroglycerin helped to relieve the pain." D. "I feel nausea and shortness of breath with the pain."
B
Which task would the nurse delegate to the assistive personnel (AP) when caring for a client in phase 1 of cardiac rehabilitation? A. Assist the client to ambulate 400 feet four times a day. B. Assist the client with ambulation to the bathroom. C. Assess the client's vital signs and fatigue level with each increase in activity. D. Teach the client to notify the health care provider for episodes of chest pain.
B
Which type of dysrhythmia would the nurse expect to monitor for when a client experiences an inferior wall myocardial infarction (IWMI)? A. Premature ventricular complexes (PVCs) B. Bradycardia with second-degree heart block C. Supraventricular tachycardia D. Atrial fibrillation
B
While evaluating a client's electrocardiogram (ECG) before surgery, the preoperative nurse identifies large, wide Q waves. What is the nurse's best interpretation of this finding? a. An acute myocardial infarction is occurring. b. The client had a myocardial infarction in the past. c. The ventricles are enlarged and failing. d. The ECG is a common variation of normal sinus rhythm.
B
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."
B/C
A client with chronic stable angina now has chest pressure, cool and clammy skin, blood pressure 150/90 mm Hg, heart rate 100 beats/min, and respiratory rate 32 breaths/min. What are the priorities of collaborative care for this client? Select all that apply. A. Maintain NPO status B. Relieve chest pain C. Improve coronary artery perfusion D. Draw troponin blood samples E. Improve myocardial oxygenation F. Relieve nausea
BCDE
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress
BCDE
Which observation would the nurse expect when a client develops mediastinitis after CABG surgery? Select all that apply. A. Anginal-type chest pain B. Fever continuing beyond the first 4 days after surgery C. Bogginess of the sternum D. Redness and drainage from the suture site E. Induration or swelling at the suture site F. Decreased white blood cell count
BCDE
Which priority problems may be considered for the client with heart failure? Select all that apply. a. Decreased fluid volume related to compromised regulatory mechanism b. Impaired Physical Mobility related to limited cardiovascular endurance c. Impaired Gas Exchange related to ventilation-perfusion imbalance d. Potential for pulmonary edema e. Risk for Ineffective renal Perfusion related to hypervolemia
BCDE
Which postprocedure medications would the nurse teach about, before discharge, to a client who had a percutaneous coronary intervention (PCI)? Select all that apply. A. Furosemide B. Clopidogrel C. Metoprolol D. Isosorbide dinitrate E. Docusate F. Aspirin
BCDF
The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. a. Hypokalemia b. Sinus bradycardia c. Fatigue d. Serum digoxin level of 1.5 e. Anorexia
BCE
Which interventions would the nurse perform to protect a client from a sternal wound infection after CABG surgery? Select all that apply. A. Shave the client's body from neck to knees. B. Instruct the client to shower with 4% chlorhexidine gluconate. C. Prepare the surgical site by clipping hair when applying chlorhexidine with isopropyl alcohol (0.5% or 2%). D. Collect and send urine and sputum samples to the laboratory for culture and sensitivity. E. Administer IV antibiotics 1 hours prior to the surgical procedure. F. Wear gloves, a gown, and a mask while preparing the client for surgery.
BCE
About which associated symptoms would the nurse ask a client with a history of intermittent episodes of chest pain? Select all that apply. A. Diarrhea B. Nausea C. Shortness of breath D. Joint pain E. Dizziness F. Diaphoresis
BCEF
Prior to discharge a client who had an acute myocardial infarction and coronary artery bypass graft asks the nurse about sexual activity. What information does the nurse provide? Select all that apply A. you will need to wait at least 6 weeks before intercourse B. your usual sexual activity is not likely to damage your heart. C. start having sex when you are most rested like in the morning D. when you can climb up four flights of stairs you can tolerate having sex E. don't eat for three hours before engaging in sexual activity F. Use a comfortable position that doesn't stress your incision
BCF
Which advantages would the nurse teach a client about with regard to robotic heart surgery? Select all that apply. A. Shorter surgical time than traditional CABG surgery B. Shorter hospital stay of just 2 to 3 days C. Decreased pain due to smaller incisions D. Shorter time on the heart-lung bypass machine E. Chest tubes are never needed F. Ability to reach otherwise inaccessible blockage sites
BCF
What diagnostic tests would the nurse obtain to determine whether a client admitted with acute-onset chest pain and dyspnea had experienced a myocardial infarction (MI)? Select all that apply. A. C-reactive protein B. 12-lead ECG C. Chest x-ray D. Serial troponins T and I E. Lipid profile F. Exercise stress test
BD
A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.
BDE
Which essential points would the nurse include when teaching a client with angina about nitroglycerin tablets? Select all that apply. A. If one tablet does not relieve the chest pain after 5 minutes, put two pills under your tongue. B. Keep your nitroglycerin pills with you at all times. C. The prescription should last about 7 to 8 months before a refill is needed. D. You can tell the tablets are active when you feel a tingling after placing one under your tongue. E. Keep the tablets in a glass, light-resistant container. F. If no immediate pain relief occurs, just wait because the drug will eventually take effect.
BDE
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours
C
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.
C
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation
C
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.
C
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)
C
A client who is post percutaneous transluminal coronary angioplasty (PTCA) reports severe chest pain. Which action does the nurse take first? a. Administer the prescribed IV morphine. b. Administer the prescribed sublingual nitroglycerin. c. Assess the client's vital signs and notify the health care provider. d. Perform an immediate 12-lead ECG.
C
A client who presented with an acute myocardial infarction is prescribed thrombolytic therapy. The client had a stroke 1 month ago. Which action does the nurse take? a. Administer the medication as prescribed. b. Perform a CT scan before administering the medication. c. Contact the health care provider to discontinue the prescribed therapy. d. Administer the therapy with a normal saline bolus.
C
A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." what is the nurse's best response? a. this is a routine surgery and the risk of death is very low b. would you like to speak with a chaplain prior to surgery C. tell me more about your concerns about the surgery D. what support systems do you have to assist you
C
Because many sudden cardiac arrest victims die before reaching the hospital, which priority teaching point would the nurse be sure to include in a community presentation about heart disease? A. The importance of controlling alcohol consumption and smoking cessation. B. Modifying risk factors and blood pressure medication compliance C. How to operate an automatic external defibrillator (AED) in the workplace D. Recognizing unstable angina and when to call for help
C
Eight hours after presentation to the emergency department with reports of substernal chest pain, a client's laboratory results demonstrate myoglobin levels of 55 ng/mL. What does the nurse do next? a. Prepare the client for an emergency coronary bypass graft surgery. b. Administer nitroglycerin to prevent further myocardial cell death. c. Assess the client to identify another potential cause of the chest pain. d. Provide client education related to complications of myocardial infarctions.
C
For which complication does the nurse monitor when a client with chronic stable angina (CSA) is prescribed a calcium channel blocker? A. Tachycardia B. Wheezes and crackles C. Hypotension D. Forgetfulness
C
In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis? a. Serum potassium level of 3.2 mEq/L b. Ejection fraction of 60% c. B-type natriuretic peptide (BNP) of 760 ng/dL d. Chest x-ray report showing right middle lobe consolidation
C
The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? a. "How does this make you feel?" b. "This can be caused by taking performance-enhancing drugs." c. "This may be caused by a genetic trait." d. "Just imagine how bad it would be if you weren't in good shape."
C
The community health nurse assesses clients at a health fair. Which statement assists the nurse to identify modifiable risk factors in clients with coronary artery disease? a. "Would you please state your full name and birth date?" b. "Have you ever had an exercise tolerance stress test?" c. "In what activities do you participate on a daily basis?" d. "Does anyone in your family have a history of heart disease?"
C
The emergency department nurse is assessing an 82-year-old client for a potential myocardial infarction. Which clinical manifestation does the nurse monitor for? a. Pain on inspiration b. Posterior wall chest pain c. Disorientation or confusion d. Numbness and tingling of the arm
C
The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, pink, frothy sputum, and crackles throughout the lung fields. Which prescription should the nurse carry out first? a. Enalapril b. Heparin c. Furosemide d. I & O
C
The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? a. "I have been drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."
C
The nurse is assessing a client who has left ventricular failure secondary to a myocardial infarction. Which clinical manifestation of poor organ perfusion does the nurse monitor for in this client? a. Headache b. Hypertension c. Urine output of less than 30 mL/hr d. Heart rate of 55 to 60 beats/min
C
The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? a. Friction rub auscultated at the left lower sternal border b. Pain aggravated by breathing, coughing, and swallowing c. Splinter hemorrhages d. Thickening of the endocardium
C
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic pressure
C
The nurse is caring for an 80-year-old client who has had coronary artery bypass graft surgery. Which assessment does the nurse prioritize for this client? a. Skin b. Otoscopic c. Mental status d. Gastrointestinal
C
The nurse is planning discharge education for a client after coronary artery bypass graft surgery. Which instruction does the nurse include in this client's teaching? A. "Remember to drink at least 3 liters of fluid daily." b. "You should abstain from sexual activity for 6 months." c. "Take your pulse before, midway through, and after exercising." d. "Stop taking your antihyperlipidemic medication at this time."
C
The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have only two alcoholic drinks daily."
C
The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures. b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure. c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes. d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.
C
The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease? a. "Rest is the best medicine at this time. Do not start an exercise program." b. "You are a man; therefore there is nothing you can do to minimize your risks." c. "You should talk to your provider about medications to help you quit smoking." d. "Decreasing the carbohydrates in your diet will help you lose weight."
C
The provider requests the nurse start an infusion of an milrinone on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."
C
The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? a. Decrease in oxygen saturation from 98% to 95% b. Respiratory rate change from 22 to 28 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Increase in heart rate from 86 to 100 beats/min
C
What is the nurse's next action 5 minutes after administering a sublingual (SL) nitroglycerin tablet to a client with chest pain? A. Apply oxygen at 2 to 4 L by nasal cannula. B. Administer morphine sulfate IV push. C. Recheck pain intensity and vital signs. D. Notify the health care provider and give a chewable aspirin.
C
What priority action will the nurse take when providing care for a client with chest pain being treated with IV nitroglycerin? A. Restrict the client to bedrest with use of a bedpan. B. Elevated the head of the bed to 90 degrees. C. Monitor blood pressure continuously. D. Increase the dose rapidly to achieve pain relief.
C
When caring for a client who has undergone a partial left ventriculectomy, which of these new-onset clinical manifestations indicates the need for immediate action by the nurse? a. Chest pain with movement b. Fatigue after ambulation c. Muffled heart sounds d. Bi-basilar fine crackles
C
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? a. Auscultation of crackles b. Pedal edema c. Weight loss of 6 pounds since the last visit d. Reports sucking on ice chips all day for dry mouth
C
Which diagnostic test is performed after a client's acute stage of an unstable angina episode to determine if there are cardiac changes that are consistent with ischemia? A. Electrocardiogram B. Echocardiography C. Exercise tolerance test D. Chest CT scan
C
Which drug therapy would the nurse expect to be prescribed for a client with acute coronary syndrome (ACS) to decrease the risk of recurrent myocardial infarction, stroke, and mortality? A. Anti-inflammatory drug B. Central vasodilator C. High-intensity statin therapy D. Anticoagulant therapy
C
Which finding most strongly indicates left heart failure in a client when the nurse auscultates heart sounds? A. Murmur B. Split S1 and S2 C. S3 gallop D. Pericardial friction rub
C
Which finding prompts the nurse to immediately contact the surgeon for a client who had a minimally invasive direct coronary artery bypass (MIDCAB)? A. Client has difficulty with coughing and deep breathing. B. Client has acute incisional pain. C. Client has ECG changes including Q waves and ST-segment and T-wave changes in leads V2 to V6. D. Client has chest tube drainage of 80 mL/hr.
C
Which nursing assessment is specific to a client who had CABG surgery with the radial artery used as the graft? A. Check the fingertips, hand, and arm for sensation and mobility once a shift. B. Take blood pressure every hour on the unaffected arm to use a leg cuff on the legs. C. Assess hand color, temperature, ulnar pulse, and capillary refill every hour initially. D. Assess for and document expected edema, bleeding, and swelling at the donor site.
C
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? a. Client ambulates around the nursing unit with a walker. b. The nurse monitors the client's pulse and blood pressure frequently. c. The nurse obtains a bedside commode before administering furosemide. d. The nurse returns the client to bed when he becomes tachycardic.
C
Which of these nursing actions should the nurse delegate to a nursing assistant working on the medical unit? a. Determine the usual alcohol intake for a client with cardiomyopathy. b. Monitor the pain level for a client with acute pericarditis. c. Obtain daily weights for several clients with class IV heart failure. d. Check for peripheral edema in a client with endocarditis.
C
A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective? a. The client has a diuresis of 400 mL in 24 hours. b. The client's blood pressure is 122/84 mm Hg. c. The client has an apical pulse of 82 beats/min. d. The client's weight decreases by 2.5 kg.
D
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed.
D
A client has progressed to Killip class III heart failure after a myocardial infarction. What does the nurse anticipate the client's care to include? a. Diuretics b. Nitrates c. Clopidogrel d. Dobutamine
D
A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.
D
A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? a. Cough b. Headache c. Pulse of 62 beats/min d. Potassium of 2.9 mEq/L
D
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.
D
A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."
D
A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." What is the nurse's best response? a. "Would you like to speak with a priest or chaplain?" b. "I will consult a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?
D
A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.) a. Assess for further chest pain. b. Call the Rapid Response Team. c. Have the client sit upright. d. Listen to the clients lung sound
D
Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance with prescribed home therapy. Which laboratory test confirms the nurse's suspicions? a. B-type natriuretic peptide (BNP) 90 pg/mL b. Serum electrolytes c. Hemoglobin and hematocrit d. Digoxin level of 0.2 ng/dL
D
Following CABG surgery, a client's body temperature is below 96.8 degree F. What measures would the nurse take to rewarm the client? A. Infuse warm IV fluids. B. Do not rewarm because cold cardioplegia is protective. C. Place the client in a warm fluid bath. D. Use lights and thermal blankets to slowly warm the client.
D
The client who just started taking isosorbide dinitrate (Isordil) reports a headache. What is the nurse's best action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Isordil. c. Instruct the client to drink water. d. Administer PRN acetaminophen.
D
The nurse assesses a client who has received thrombolytic therapy after having a myocardial infarction. Which clinical manifestation indicates to the nurse that reperfusion has been successful? a. ST-segment depression b. Cessation of diaphoresis c. Sudden onset of pleuritic chest pain d. Onset of ventricular dysrhythmias
D
The nurse is assessing a client who had percutaneous transluminal coronary angioplasty (PTCA) 1 hour ago. Which complication does the nurse monitor for? a. Hypertensive crisis b. Hyperkalemia c. Infection d. Bleeding
D
The nurse is assessing a client who has been prescribed a nonselective beta-blocking agent. Which adverse effect does the nurse monitor for in this client? a. Headache b. Postural hypotension c. Nonproductive cough d. Wheezing
D
The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? a. Determines the client's physical limitations b. Encourages alternate rest and activity periods c. Monitors and documents heart rate, rhythm, and pulses d. Positions the client to alleviate dyspnea
D
The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about? a. Family history of coronary artery disease b. Recent travel to Third World countries c. Pet ownership, especially cats with litter boxes d. History of a systemic infection within the past month
D
The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.
D
The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, "The pain has not gotten any better." What does the nurse do next? a. Place the client in a semi-Fowler's position. b. Administer intravenous nitroglycerin. c. Begin supplemental oxygen at 2 L/min. d. Notify the health care provider.
D
The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."
D
When would the nurse be sure to hold a beta blocker drug and notify the health care provider? A. When a client states he or she woke up with a headache. B. When a client's respiratory rate is 26 breaths/min on room air. C. When a client is scheduled for a chest x-ray. D. When a client's heart rate is less than 50 beats/min and SBP is less than 100 mm Hg.
D
Which assessment would the nurse perform to help prevent harm from graft collapse after CABG surgery? A. Assess for motion and sensation in the donor extremity. B. Observe for generalized hypothermia. C. Auscultate lungs for crackles or wheezes. D. Monitor blood pressure for hypotension.
D
Which client does the nurse expect to have the highest risk for death related to damage to the left ventricle? A. Client with an inferior wall MI (IWMI) B. Client with lateral wall MI (LWMI) C. Client with a posterior wall MI (PWMI) D. Client with an arterior wall MI (AWMI)
D
Which early reaction is most common in clients with chest discomfort associated with unstable angina or myocardial infarction (MI)? A. Depression B. Anger C. Fear D. Denial
D
he nurse prepares to administer digoxin to a client with heart failure and notes the following information:Temperature: 99.8Pulse: 48 and irregular Respirations: 20 Potassium level: 3.2 mEq/L. What action does the nurse take? a. Give digoxin; reassess the heart rate in 30 minutes. b. Give the digoxin; document assessment findings in the medical record. c. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. d. Hold the digoxin, and obtain a prescription for a potassium supplement.
D
