Elsevier Cardiovascular, Hematologic, and Lymphatic Systems EAQ

During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions. 1. Elevate the head of the bed to 45 degrees 2. Apply oxygen via nasal cannula 3. Reduce the flow rate of the transfusion 4. Administer furosemide (Lasix) per provider prescription 5.Document findings in the client record

1, 2, 3, 4, 5 These symptoms represent circulatory overload. First, the nurse's priority is to facilitate gas exchange by elevating the head of the bed, then applying oxygen. Next, the transfusion rate should be slowed to reduce further circulatory overload and client compromise, followed by the administration of a diuretic to reduce circulating volume. Lastly, the findings and interventions should be documented accordingly.

A nurse is caring for a client immediately following a transesophageal echocardiogram (TEE). Which of the following assessments are appropriate for this client? (Select all that apply.) A. Assess for return of gag reflex. B. Assess groin for hematoma or bleeding. C. Monitor vital signs and oxygen saturation. D. Position client supine with head of bed flat. E. Assess lower extremities for circulatory compromise.

A & C The client undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anaesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for gag reflex return before allowing the client to eat or drink. Vital signs and oxygen saturation are also important assessment parameters resulting from the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels. Therefore it is not necessary to monitor the client's groin or lower extremities in relation to this procedure.

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected. A test for the human immunodeficiency virus (HIV) is performed and acute retroviral syndrome is diagnosed. Which clinical responses are associated most commonly with this syndrome? Select all that apply. A. Malaise B. Confusion C. Constipation D. Swollen lymph glands E. Oropharyngeal candidiasis

A & D Development of HIV-specific antibodies (seroconversion) is accompanied by a flu-like syndrome called acute retroviral syndrome. This syndrome includes malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle/joint pain, or a diffuse rash. It occurs 1 to 3 weeks after infection and may continue for several months. Acute retroviral syndrome over time is followed by the early-chronic, intermediate-chronic, and late-chronic stages of HIV infection. Development of HIV-specific antibodies, accompanied by flu-like syndrome, includes swollen lymph glands. Confusion is associated with the intermediate-chronic and late-chronic stages of HIV infection when the individual develops AIDS-dementia complex or an opportunistic infection that affects the neurologic system. Diarrhea, not constipation, is associated with this syndrome. Oropharyngeal candidiasis occurs during the intermediate-chronic stage of HIV infection.

The nurse is providing nutritional counselling for clients at risk for coronary artery disease (CAD). Which of the following foods would the nurse encourage clients to include in their diet? (Select all that apply.) A. Tofu B. Walnuts C. Tuna fish D. Whole milk E. Orange juice

A, B, C Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with coronary artery disease (CAD) when consumed regularly.

A client admitted with heart failure (HF) appears very anxious and complains of shortness of breath. Which of the following nursing actions would be appropriate to alleviate this client's anxiety? (Select all that apply.) A. Position client in a semi-Fowler's position. B. Administer ordered morphine sulphate. C. Position client on left side with head of bed flat. D. Instruct client on the use of relaxation techniques. E. Use a calm, reassuring approach while talking to client.

A, B, D, E Morphine sulphate reduces anxiety and may assist in reducing dyspnea. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety. The client should be positioned in semi-Fowler's position to improve ventilation.

Which of the following cardiovascular effects of aging should the nurse anticipate when providing care for older adults? (Select all that apply.) A. Arterial stiffening B. Increased blood pressure C. Increased amplitude of QRS complex D. Decreased maximal heart rate E. Increased recovery time from activity

A, B, D, E Well-documented cardiovascular effects of the aging process include arterial stiffening, possible increased blood pressure, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease with age. Amplitude of QRS complex decreases rather than increase.

The nurse is caring for a client newly diagnosed with heart failure (HF). The client is to receive a first dose of digoxin 0.125 mg IV push. An ampule containing 0.25 mg/mL is available. How many millilitres should the nurse draw up to administer the dose? A. 0.5 mL B. 0.6 mL C. 1.2 mL D. 1.4 mL

A. 0.5 mL 0.125 mg (dose desired) ÷ 0.25 mg/mL (dose available) = 0.5 mL.

The nurse is completing an assessment on a couple seeking genetic counseling for sickle cell anemia. Both prospective parents carry sickle cell traits. The nurse recognizes that the couple has what chance of having a child who develops the disease? A. 25% B. 50% C. 75% D. 100%

A. 25% Sickle cell is an autosomal recessive genetic disorder. If both individuals have sickle cell traits, there is a 25% chance they will produce a child with the disease. Other options, such as 50%, 75%, and 100%, are not plausible. However, the children do have a 50% chance of being carriers.

Which of the following individuals would the nurse identify as having the highest risk for coronary artery disease (CAD)? A. A 45-year-old depressed male with a high-stress job B. A 60-year-old male with below-normal homocysteine levels C. A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels D. A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

A. A 45-year-old depressed male with a high-stress job Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the client with two risk factors is at greatest risk for developing CAD.

A client with hypertension has received a prescription for metoprolol. Which information should the nurse include when teaching this client about metoprolol? A. Do not abruptly discontinue the medication. B. Consume alcoholic beverages in moderation. C. Report a heart rate of less than 70 beats per minute. D. Increase the medication dosage if chest pain occurs.

A. Do not abruptly discontinue the medication. Abrupt discontinuation of metoprolol may cause rebound hypertension and an acute myocardial infarction. Alcohol is contraindicated for clients taking beta-adrenergic blockers such as metoprolol. Clients should never increase medications without medical direction. The pulse rate can go lower than 70 beats per minute as long as the client feels well and is not dizzy.

The nurse is teaching a client with hypertension that uncontrolled hypertension may damage organs in the body. Which of the following mechanisms is the primary reason? A. Hypertension promotes atherosclerosis and damage to the walls of the arteries. B. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. C. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. D. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.

A. Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

The nurse is providing care for a client who has decreased cardiac output related to heart failure. Which of the following information is true related to cardiac output? A. It is calculated by multiplying the client's stroke volume by the heart rate. B. It is the average amount of blood ejected during one complete cardiac cycle. C. It is determined by measuring the electrical activity of the heart and the client's heart rate. D. It is the client's average resting heart rate multiplied by the client's mean arterial blood pressure.

A. It is calculated by multiplying the client's stroke volume by the heart rate. Cardiac output is determined by multiplying the client's stroke volume (SV) by heart rate (HR), thus identifying how much blood is pumped by the heart over a one-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.

The nurse is planning emergent care for a client with a suspected myocardial infarction (MI). Which of the following actions should the nurse include in the emergency care for this client? A. Oxygen, nitroglycerin, acetylsalisylic acid, and morphine sulphate B. Oxygen, furosemide, nitroglycerin, and meperidine C. Acetylsalisylic acid, nitroprusside, dopamine, and oxygen D. Nitroglycerin, lorazepam, oxygen, and warfarin

A. Oxygen, nitroglycerin, acetylsalisylic acid, and morphine sulphate (M.O.N.A) Emergency care of the client with chest pain includes the administration of oxygen, nitroglycerin, Aspirin, and morphine sulphate. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation.

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? A. Pain subsides as a result of arteriole and venous dilation. B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves as a response to increased collateral circulation.

A. Pain subsides as a result of arteriole and venous dilation. Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain. An increased pulse rate does not indicate effectiveness; it is a side effect of nitroglycerin. The tingling indicates that the medication is fresh; relief of pain is the only indicator of effectiveness. Nitroglycerin does not promote the formation of new blood vessels.

The nurse is caring for a client with hypertension who is scheduled to receive a dose of atenolol. The nurse should withhold the dose and consult the primary care provider for which of the following vital signs were taken just before administration? A. Pulse 48 beats/minute B. Respirations 24 breaths/minute C. Blood pressure 118/74 mm Hg D. Oxygen saturation 93%

A. Pulse 48 beats/minute Because atenolol is a α1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the prescriber for parameters regarding pulse rate limits.

A client with a recent diagnosis of heart failure (HF) has been prescribed furosemide in an effort to accomplish which of the following outcomes? A. Reduce preload B. Decrease afterload C. Increase contractility D. Promote vasodilation

A. Reduce preload Diuretics such as furosemide are used in the treatment of heart failure (HF) to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence contractility, afterload, or vessel tone.

The community health nurse is planning health-promotion teaching targeted at preventing coronary artery disease (CAD). Which of the following individuals would the nurse select as the highest priority for this intervention? A. White male B. South Asian female C. Black male D. Indigenous female

A. White male The incidence of coronary artery disease (CAD) and myocardial infarction (MI) is highest among White, middle-aged men.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Select all that apply. A. Cyanosis B. Backache C. Shivering D. Bradycardia E. Hypertension

B & C Mismatched blood cells are attacked by antibodies, and the hemoglobin released from ruptured erythrocytes plugs the kidney tubules; this kidney involvement results in backache. Shivering occurs as part of the inflammatory response associated with a transfusion reaction. Cyanosis is not commonly associated with a transfusion reaction. Tachycardia, not bradycardia, is associated with a transfusion reaction. Hypotension, not hypertension, is associated with a transfusion reaction.

The nurse is assessing a client with symptoms of chest pain. Which of the following clinical manifestations are associated with myocardial infarction (MI)? (Select all that apply.) A. Flushing B. Ashen skin C. Diaphoresis D. Nausea and vomiting E. S3 or S4 heart sounds

B, C, D, E During the initial phase of a myocardial infarction (MI), catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The client's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting centre by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

The nurse is teaching a client with chronic stable angina about nitroglycerin. Which of the following client statements indicates that further teaching is required? A. "I will replace my nitroglycerin supply every six months." B. "I can take up to five tablets every three minutes for relief of my chest pain." C. "I will take acetaminophen to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B. "I can take up to five tablets every three minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the client should be instructed to activate the emergency medical services (EMS) system.

A nurse is auscultating a client's heart. Where should the nurse listen to hear S1 the loudest? A. Base of the heart B. Apex of the heart C. Left lateral border D. Right lateral border

B. Apex of the heart The first heart sound is produced by closure of the mitral and tricuspid valves; it is best heard at the apex of the heart. The base of the heart is where the second heart sound (S2) is best heard; S2 is produced by closure of the aortic and pulmonic valves. Left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. Right lateral border covers a large area; the only auscultatory area near it is the aortic area.

A primary healthcare provider prescribes atenolol 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to include in the discharge teaching plan for this client? A. Drink alcoholic beverages in moderation. B. Avoid abruptly discontinuing the medication. C. Increase the medication if chest pain develops. D. Report a pulse rate less than 70 beats per minute.

B. Avoid abruptly discontinuing the medication. An abrupt discontinuation of atenolol may cause an acute myocardial infarction. Alcohol is contraindicated for clients taking atenolol because it can cause additive hypotension. Clients should never increase medications without a healthcare provider's direction. The pulse rate can go much lower as long as the client feels well and is not dizzy.

The nurse is caring for a client admitted with a history of hypertension. The client's medication history includes hydrochlorothiazide daily for the past 10 years. Which of the following parameters would indicate the optimal intended effect of this drug therapy? A. Weight loss of 1 kg B. Blood pressure 128/86 C. Absence of ankle edema D. Output of 600 mL per shift

B. Blood pressure 128/86 Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Since the client has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

A healthcare provider prescribes morphine for a client being treated for myocardial infarction. What physiologic response will occur if the client experiences the intended therapeutic effect of morphine? A. Increased respiratory rate B. Decreased workload of the heart C. Reduced size of the clot blocking the coronary artery D. Diminished metabolites within the ischemic heart muscle

B. Decreased workload of the heart Morphine reduces pain and anxiety. This limits the response of the sympathetic nervous system, ultimately decreasing cardiac preload and the workload of the heart. Reduced respiratory rate is a side effect of morphine; it is not the intended therapeutic effect for a client being treated for myocardial infarction. Decreasing the size of the clot blocking the coronary artery is the action of antithrombolytic therapy. Decreasing metabolites within the ischemic heart muscle is not the action of morphine.

The nurse is providing teaching to a client recovering from a myocardial infarction (MI). Which of the following actions should the nurse take regarding the resumption of sexual activity? A. Delegated to the primary care provider B. Discussed along with other physical activities C. Avoided because it is embarrassing to the client D. Accomplished by providing the client with written material

B. Discussed along with other physical activities Although some nurses may not feel comfortable discussing sexual activity with clients, it is a necessary component of client teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the client with written material is appropriate, it should not replace a verbal dialogue that can address the individual client's questions and concerns.

A client with a diagnosis of heart failure (HF) has been started on a nitroglycerin patch by his primary care provider. Which of the following should the nurse teach the client to avoid? A. High-potassium foods B. Drugs to treat erectile dysfunction C. Over-the-counter H2-receptor blockers D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

B. Drugs to treat erectile dysfunction The use of erectile dysfunction drugs concurrent with nitrates creates a risk of severe hypotension. Nonsteroidal anti-inflammatory drugs (NSAIDs), H2-receptor blockers, and highpotassium foods do not pose a risk in combination with nitrates.

A client receiving 0.9% normal saline (NS) intravenously at keep vein open (KVO) complains of pain at the insertion site. The nurse notes that there is erythema and edema present at the access site. Based on the phlebitis scale, how should the nurse properly document the phlebitis? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

B. Grade 2 According to the phlebitis scale, grade 2 presents as pain at the access site with erythema or edema. Grade 1 presents as erythema with or without pain. Grade 3 presents as pain at the access site with erythema or edema, streak formation, and palpable cord. Grade 4 presents as pain at the access site with erythema or edema, streak formation, palpable cord more than one inch long, and purulent drainage.

A nurse in the emergency department is assigned a recently admitted client. The nurse reviews the client's progress notes, obtains the vital signs, and performs a physical assessment. Which intervention should the nurse anticipate the primary healthcare provider will prescribe initially? Check this photo link for choices: https://bit.ly/3JzmSjL A. Pain medication B. Intravenous fluids C. Multiple antibiotics D. Packed red blood cell

B. Intravenous fluids The client probably is experiencing hypovolemic shock, as evidenced by the vital signs (elevated pulse and respirations and low blood pressure). Intravenous fluids will help correct the hypovolemia. Analgesics should not be administered until after the client is assessed fully, particularly for a head injury. Antibiotics may be prescribed eventually, but this is not the initial intervention. Packed red blood cells eventually may be administered, but this depends on an additional physical assessment and hematologic laboratory tests.

The nurse is admitting a client who is scheduled to undergo a cardiac catheterization. Which of the following allergies is most important for the nurse to assess before this procedure? A. Iron B. Iodine C. Aspirin D. Penicillin

B. Iodine The health care provider usually will use an iodine-based contrast to perform this procedure. Therefore it is imperative to know whether or not the client is allergic to iodine or shellfish.

Before a femoral arteriogram is started, what should the nurse teach the client regarding the procedure? A. Radioactive dye will be injected into the femoral vein B. Local anesthesia will be used to decrease pain at the site C. Contrast media will be injected into a small vessel of the foot D. Medication will be administered intravenously to induce sleep

B. Local anesthesia will be used to decrease pain at the site Teaching the client that local anesthesia will be used to decrease any pain at the site reassures the client and allays fears of pain. The contrast medium used is not radioactive. The femoral artery is used for contrast media. The client will be awake during the procedure.

A client with a history of type 1 diabetes is diagnosed with heart failure. Digoxin is prescribed. What is an important nursing action associated with this drug? A. Administer the digoxin 1 hour after the client's morning insulin B. Monitor the client for atrial fibrillation and first-degree heart block C. Administer the medication with 8 ounces (240 mL) of orange juice D. Withhold the medication if the apical pulse rate is greater than 60 beats/min

B. Monitor the client for atrial fibrillation and first-degree heart block The speed of conduction is decreased when digoxin is given, and this can result in premature beats, atrial fibrillation, and first-degree heart block. Digoxin does not deplete potassium and therefore orange juice does not need to be given; orange juice is high in calories and needs to be calculated in the diet. Insulin and digoxin can be given at the same time. The purpose of the drug is to reduce a rapid heart rate and therefore should be administered; it should be withheld when the client's heart rate decreases below a parameter set by the healthcare provider (e.g., 60 beats/min).

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? A. Prepare for blood transfusions. B. Notify the surgeon immediately. C. Make the client nothing by mouth (NPO). D. Administer the prescribed preoperative sedative.

B. Notify the surgeon immediately. Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms of shock.

The nurse is caring for a client with heart failure who is prescribed furosemide. Which of the following problems should the nurse monitor in the client? A. Hyperkalemia B. Ototoxicity C. Bradycardia D. Paroxysmal nocturnal dyspnea

B. Ototoxicity Problems in using loop diuretics include reduction in serum potassium levels, ototoxicity, and possible allergic reaction in the client who is sensitive to sulpha-type drugs.

The nurse is examining the ECG of a client who has just been admitted with a suspected MI. Which of the following ECG changes is most indicative of prolonged or complete coronary occlusion? A. Sinus tachycardia B. Pathological Q wave C. Fibrillatory P waves D. Prolonged PR interval

B. Pathological Q wave The presence of a pathological Q wave, as often accompanies ST-segment- elevation myocardial infarction (STEMI), is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

The nurse is teaching a client about dietary management of stage 1 hypertension. Which of the following instructions is best to include in the teaching plan? A. Restrict all caffeine. B. Restrict sodium intake. C. Increase protein intake. D. Use calcium supplements.

B. Restrict sodium intake. The client should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention.

The nurse is providing dietary instruction to a client with hypertension. Which of the following foods should the nurse advise the client to avoid? A. Broiled fish B. Roasted duck C. Roasted turkey D. Baked chicken breast

B. Roasted duck Roasted duck is high in fat, which should be avoided by the client with hypertension. The other meats are lower in fat and are therefore acceptable in the diet.

The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS; then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the primary healthcare provider. Which rhythm does the nurse share with the provider? A. First degree atrioventricular (AV) block B. Second degree AV block Mobitz I (Wenckebach) C. Second degree AV block Mobitz II D. Third degree AV block (complete heart block)

B. Second degree AV block Mobitz I (Wenckebach) Also called Mobitz I or Wenckebach heart block, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. Which information should the nurse share with the client? A. Choose only familiar sexual positions. B. Select familiar settings for sexual activity. C. Return to regular sexual activity in four to six weeks. D. Depending upon your preference, take a hot or cold shower after intercourse.

B. Select familiar settings for sexual activity. An unfamiliar environment increases stress, which increases cardiac workload. It is advantageous to experiment with positions and find one that is relaxing and permits unrestricted breathing. It is generally safe to resume sexual activity 7 to 10 days after an uncomplicated MI. However, some physicians believe that the client should decide when ready to resume sex. Hot or cold showers should be avoided just before and after intercourse.

The nurse is caring for a client with heart failure who is taking spironolactone. Which of the following laboratory results should the nurse monitor? A. pH B. Serum potassium C. Serum sodium D. Creatinine

B. Serum potassium Serum potassium levels need to be monitored during treatment because of the potential for hyperkalemia.

During a cardiovascular assessment, a nurse auscultates a client's heart and hears these sounds. How does the nurse document these sounds on the client's assessment report? A. Cardiac murmurs B. Third heart sound (S3) C. Second heart sound (S2) D. Pericardial friction rubs

B. Third heart sound (S3) The third heart sound (S3) is a low-intensity vibration of the ventricular walls; it sounds like a gallop. It is associated with decreased compliance of the ventricles during filling. Cardiac murmurs are turbulent sounds that occur between normal heart sounds. The second heart sound (S2) is a short, high-pitched sound heard at the base of the heart at the end of ventricular systole. Pericardial friction rubs are high-pitched, scratchy sounds that may be transient or intermittent. They are associated with pericarditis.

The nurse is admitting a client to the emergency room who has symptoms of chest pain. Which of the following components of subsequent blood work is most clearly indicative of a myocardial infarction (MI)? A. CK-MB B. Troponin C. Myoglobin D. C-reactive protein

B. Troponin Troponin is the biomarker of choice in the diagnosis of myocardial infarction (MI), with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.

The nurse is auscultating a client's heart and assesses the presence of a murmur. Which of the following physiological changes has occurred to result in a heart murmur? A. Increased viscosity of the client's blood B. Turbulent blood flow across a heart valve C. Friction between the heart and the myocardium D. A deficit in heart conductivity that impairs normal contractility

B. Turbulent blood flow across a heart valve Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.

Valsartan, an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply. A. Constipation B. Hypokalemia C. Irregular pulse rate D. Change in visual acuity E. Orthostatic hypotension

C & E Dysrhythmias, including second-degree heart block, are cardiovascular side effects of valsartan. It also may precipitate angina pectoris, myocardial infarction, and brain attack (cerebrovascular accident, CVA). Angiotensin II receptor antagonists, such as valsartan, block vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle, thus reducing the blood pressure; dizziness, orthostatic hypotension, and excessive hypotension may occur. Diarrhea, not constipation, may occur with valsartan. Hyperkalemia, not hypokalemia, may occur with valsartan. Valsartan does not cause altered visual acuity.

The nurse is caring for a postoperative client who underwent coronary artery bypass graft (CABG) surgery. Which of the following common complication should the nurse monitor in the client? A. Dehydration B. Paralytic ileus C. Atrial dysrhythmias D. Acute respiratory distress syndrome

C. Atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first three days following CABG surgery. Although the other complications could occur, they are not common complications.

Which of the following is the priority nursing assessment of a client who is hemodynamically unstable and is receiving milrinone to treat heart failure? A. Urine output B. Lung sounds C. Blood pressure D. Respiratory rate

C. Blood pressure Milrinone has been linked to more frequent atrial arrhythmias, increased hypotension and worsening HF so the priority nursing assessment is blood pressure.

The nurse is caring for a client admitted with emphysema, angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the client carefully. Which of the following adverse effects is this client at risk for given the client's health history? A. Hypocapnia B. Tachycardia C. Bronchospasm D. Nausea and vomiting

C. Bronchospasm Atenolol is a cardioselective α1-adrenergic blocker that reduces blood pressure and could affect the α2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective α-blockers than nonselective α-blockers, atenolol should be used cautiously in clients with chronic obstructive pulmonary disorder (COPD).

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms are most likely to be associated with this disorder? A. General blanching of skin B. Easy fatigue of extremities C. Burning pain after exposure to cold D. Presence of Homans sign when ambulating

C. Burning pain after exposure to cold Thromboangiitis obliterans is characterized by vascular inflammation in the hands and feet, leading to thrombus formation. As a result of impaired circulation, burning pain and intermittent claudication occur. General blanching of the skin, easy fatigue of extremities, and presence of Homans sign when ambulating are not related to thromboangiitis obliterans.

When caring for a client who has hyponatremia, the nurse would monitor for which symptom? A. Increased urine output B. Deep rapid respirations C. Change in level of consciousness D. Distended neck veins

C. Change in level of consciousness A normal sodium level is between 135 and 145 mEq/L (135 and 145 mmol/L) of sodium. As sodium levels drop below 140 mEq/L, symptoms reflect cellular over-hydration which results from water movement from the relatively hypotonic serum into cells. Symptoms affect primarily the central nervous system (CNS) and musculoskeletal systems. CNS effects range from headache, fatigue and anorexia to lethargy, confusion, disorientation, agitation, vomiting, seizures, and coma. Musculoskeletal symptoms may include cramps and weakness. Vital signs will reflect an increased, weak, thready pulse, shallow respirations, and a low urine output.

A client with a history of occasional pain in the left foot when walking now has pain at rest. The left foot is cyanotic, numb, and painful. The suspected cause is arteriosclerosis. Which information will the nurse share with the client to help decrease the pain? A. Keep the left foot cool B. Cross legs with the left one on top C. Comply with the prescribed exercise program D. Keep the foot elevated at a 30-degree angle

C. Comply with the prescribed exercise program An exercise/rest program helps develop collateral circulation, which improves well-being and enables clients to increase their ability to walk longer distances. A cool environment favors constriction of peripheral blood vessels and further decreases arterial flow. Crossing the legs increases local pressure, which tends to occlude blood vessels. Elevation slows inflow of arterial blood, leading to further oxygen deprivation and pain.

The nurse is assessing the cardiovascular status of a client and performs auscultation. Which of the following practices should the nurse implement into the assessment during auscultation? A. Position the client supine. B. Ask the client to hold his or her breath. C. Palpate the radial pulse while auscultating the apical pulse. D. Use the bell of the stethoscope when auscultating S1 and S2.

C. Palpate the radial pulse while auscultating the apical pulse. In order to detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. The diaphragm is more appropriate than the bell when auscultating S1 and S2. A sitting or side-lying position is most appropriate for cardiac auscultation. It is not necessary to ask the client to hold his or her breath during cardiac auscultation.

The nurse is caring for a client admitted with poorly controlled hypertension. Which of the following laboratory test results would indicate the presence of target organ damage secondary to the primary diagnosis? A. Blood urea nitrogen (BUN) of 5.36 mmol/L B. Serum uric acid of 0.20 mmol/L C. Serum creatinine of 145 mcmol/L D. Serum potassium of 3.5 mmol/L

C. Serum creatinine of 145 mcmol/L The normal serum creatinine level is 15.3-76.3 mcmol/L. This elevated level indicates target organ damage to the kidneys.

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? A. To prevent dyspnea B. To prevent cyanosis C. To increase oxygen concentration to heart cells D. To increase oxygen tension in the circulating blood

C. To increase oxygen concentration to heart cells Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.

The nurse is reviewing medication instructions with a client who has hypertension and is being discharged. Which of the following statements would be best for the nurse to make when discussing metolazone? A. "A fast heart rate is an adverse effect to watch for while taking metolazone." B. "Stop the drug and notify your doctor if you experience any nausea or vomiting." C. "Because this drug may affect the lungs in large doses, it may also help your breathing." D. "Make position changes slowly, especially when going from lying down to a standing position."

D. "Make position changes slowly, especially when going from lying down to a standing position." Metolazone is a diuretic and can cause orthostatic hypotension. For this reason, the client should be instructed to rise slowly, especially when moving from a recumbent to a standing position.

Which of the following instructions should the nurse provide to a client who is about to undergo Holter monitoring? A. "You may remove the monitor only to shower or bathe." B. "You should connect the monitor whenever you feel symptoms." C. "You should refrain from exercising while wearing this monitor." D. "You will need to keep a diary of all your activities and symptoms."

D. "You will need to keep a diary of all your activities and symptoms." A Holter monitor is worn for at least 24 hours while a client continues with usual activity and keeps a diary of activities and symptoms. The client should not take a bath or shower while wearing this monitor.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? A. It stimulates plasma cells directly. B. A delayed titer of antibodies is generated. C. It provides immediate active immunity. D. A passive immunity is produced.

D. A passive immunity is produced. Tetanus antitoxin stimulates the body to create protective antibodies to the tetanus toxin. It helps provide these antibodies, which confer immediate passive immunity that lasts about seven to 14 days. Passive immunization is the administration of immunoglobulin prepared from individuals known to have high levels of antibodies to the infectious agent in question. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity.

For which of the following conditions is percutaneous coronary intervention (PCI) most clearly indicated? A. Chronic stable angina B. Left-sided heart failure C. Coronary artery disease (CAD) D. Acute myocardial infarction

D. Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

A client who had a myocardial infarction requests assistance to have a bowel movement. What should the nurse do? A. Place the client on a bedpan. B. Help the client into the bathroom. C. Roll the client onto a fracture pan. D. Assist the client to a bedside commode

D. Assist the client to a bedside commode Defecation in the sitting position on a bedside commode uses less energy than walking to the bathroom or getting on and off a bedpan. Defecation is difficult on a bedpan and may cause straining and an increase in oxygen demands. Walking to the bathroom uses more energy than using a bedside commode. Although the use of a fracture pan takes less energy than using a regular bedpan, it takes more energy than using a commode.

For which of the following antilipemic medications would the nurse question an order in a client with cirrhosis of the liver? A. Niacin B. Ezetimibe C. Gemfibrozil D. Atorvastatin

D. Atorvastatin Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Thus liver disease is a contraindication for atorvastatin.

The nurse is administering a dose of carvedilol to a client with heart failure (HF). Which of the following symptoms are adverse effects of this medication? A. Muscle aches B. Constipation C. Hypertension D. Bradycardia

D. Bradycardia Major adverse effects of carvedilol include edema, hypotension, fatigue, asthma exacerbations, and bradycardia.

The nurse is evaluating a client's knowledge regarding a low-sodium, low-fat cardiac diet. Which of the following food choices when selected by the client indicates that additional teaching is required? A. Baked flounder B. Angel food cake C. Baked potato with margarine D. Canned chicken noodle soup

D. Canned chicken noodle soup Canned soups are very high in sodium content. Clients need to be taught to read food labels for sodium and fat content.

A client was admitted to the emergency department 24 hours earlier with symptoms of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). Which of the following complications of MI should the nurse anticipate? A. Unstable angina B. Cardiac tamponade C. Sudden cardiac death D. Cardiac dysrhythmias

D. Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80% of clients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes; cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? A. Stroke volume B. Venous pressure C. Coronary artery patency D. Left ventricular functioning

D. Left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Although a central venous pressure reading can be obtained with the pulmonary catheter, it is not as specific as a pulmonary wedge pressure, which reflects pressure in the left side of the heart. The patency of the coronary arteries usually is evaluated by cardiac catheterization.

The nurse is caring for an older-adult client with pneumonia whose blood pressure is 160/70 mm Hg. Which of the following age-related changes contributes to this finding? A. Stenosis of the heart valves B. Decreased adrenergic sensitivity C. Increased parasympathetic activity D. Loss of elasticity in arterial vessels results

D. Loss of elasticity in arterial vessels An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel and hypertension results.

The nurse is caring for a client with stable chronic heart failure who has Class III symptoms. Which of the following information should the nurse provide to the client related to exercise? A. Exercise should be avoided until symptoms have improved. B. Walk for 10-15 minutes/day but avoid stairs. C. Climb two flights of stairs each day. D. Moderate exercise three to five times per week for 30 minutes.

D. Moderate exercise three to five times per week for 30 minutes. Regular activity and exercise periods should be prescribed for all clients with stable chronic HF. Even clients with NYHA Class III symptoms should exercise three to five times per week for 30-45 minutes at a time.

The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the drug of choice for this client? A. Diazepam B. Meperidine C. Flurazepam D. Morphine sulfate

D. Morphine sulfate For myocardial infarction, morphine sulfate is the drug of choice because it relieves pain quickly and reduces anxiety while decreasing cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the pain of a myocardial infarction. Although meperidine is effective, it is not the drug of choice. Flurazepam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the pain of a myocardial infarction.

A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? A. Tingling of the fingertips and toes B. Dry and sticky mucous membranes C. Abdominal cramping and irritability D. Muscle weakness and cardiac dysrhythmias

D. Muscle weakness and cardiac dysrhythmias Muscle weakness and cardiac dysrhythmias are related to potassium depletion in the skeletal and cardiac muscles; the sodium-potassium pump facilitates conduction of nerve impulses and muscle activity. Tingling of the fingertips and toes is related to hypocalcemia or hyperkalemia, not hypokalemia. Dry and sticky mucous membranes are related to hypernatremia, not hypokalemia. Abdominal cramping and irritability are related to hyperkalemia, not hypokalemia.

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, what is the most accurate measurement of the client's left ventricular pressure? A. Right atrial pressure B. Cardiac output by thermodilution C. Pulmonary artery diastolic pressure D. Pulmonary capillary wedge pressure

D. Pulmonary capillary wedge pressure Pulmonary capillary wedge pressure is an indirect measure of left ventricular end-diastolic pressure, an indication of ventricular contractility. Right atrial pressure measures only the function of the right side of the heart and indirectly its ability to receive blood. Cardiac output by thermodilution does not measure intracardiac pressures. Pulmonary artery diastolic pressure may not be as accurate an indicator of left ventricular pressure if chronic obstructive pulmonary disease or pulmonary hypertension exists.

A client with osteomyelitis is receiving antibiotic therapy through a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics was administered, and peak levels were obtained 30 minutes after the infusion was completed. The laboratory results reveal that the trough level is higher than the peak level. What should the nurse conclude that this finding probably indicates? A. The dose should be increased. B. The dose is in excess of the client's needs. C. There was an adequate administration of the antibiotic. D. There was a problem with the obtaining of blood specimens.

D. There was a problem with the obtaining of blood specimens. Peak levels will always be higher than trough levels; therefore, this result indicates that there has been some mix-up while drawing the samples. Increasing the dose would be an appropriate action if the trough level was too low. Concluding that the dose is in excess of the client's needs would be appropriate if the trough level was too high; however, the trough level still should never exceed the peak level. There is not enough information provided to determine whether there was adequate antibiotic administration.