exam 1

mitral valve regurgitation is heard where?

5th intercostal space- apical pulse

client with an abdominal aortic aneurysm who is suddenly pale and reports feeling lightheaded and having abdominal pain

check the blood pressue for hypotension

which client in the emergency department would the nurse assess first?

client with chest pressure and ST segment elevation on the ECG- needs treatment for STEMI, transport to the cath lab within 90 minutes and should be seen first

which findings would indicate a need to refer a client to a health care provider when the nurse is screening clients for hypertension?

diastolic blood pressure reading greater than 89 mm Hg.

after the nurse has completed teaching a client with hypertension about a heart healthy diet, which meal choice by the client indicates that the teaching has been effective?

grilled steak and green salad

Which activity might casue chest pain in a client with stable angina?

walking outside on a cold day sexual activity smoking a cigarette use of an oral decongestant

the nurse would instruct a client with an acute exacerbation of COPD to monitor for which indication of right sided heart failure upon discharge

weight gain

which response would the nurse give to a client with possible past history of myocardial infarction who asks about the purpose of the ECG that has been prescribed?

The ECG will show if there has been damage to the heart muscle

how would the nurse describe heart failure to a client?

an inability of the heart to pump blood in proportion to metabolic needs

which potential cause of dysrhythmia would the nurse consider when assessing a client who has sinus tachycardia?

anxiety caffeine exercise anemia

which action is best for nurse to take for a client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but i didnt feel any different so i decided id only take them when i feel sick"

ask the client questions to determine the current understanding of high blood pressure

which explanation would the nurse include when teaching a client with heart failure about the reason for a low sodium diet

decrease fluid retention

Which lab result will the nurse expect for a client who presents to the ED with a STEMI

elevated serum troponins I and T- indicative and specific for cardiac muscle damage

which finding would the nurse expect when assessing a client admitted for elevated endovascular repair of a large abdominal aortic aneurysm

visible pulsating abdominal mass

client with a hx of heart failure has a daily weight gain of 4 lbs since the previous day. what should you do next?

perform a head-to-toe assessment

Which prescription would the nurse question when a clients serum sodium is 123 mEq/L

provide 0.45% sodium chloride intravenously at 125 ml/h- its a hypotonic solution and is contraindicated

which description would the nurse expect the client to use to characterize the pain when admitted to the coronary care unit with a diagnosis of ST segment elevation myocardial infarction?

severe, intense chest pain

which conditions are priority nursing assessment in the ED

unstable vital signs severe abdominal pain chest pain with diaphoreses

when taking a health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?

using several pillows at night to sleep- HF causes pulmonary congestion, leading to orthopnea and the need to elevate the head and chest with pillows when lying down.

which finding by the nurse is most important to communicate to the health care provider when assessing a client who has aortic stenosis and is scheduled for aortic valve replacement?

multiple dental caries- increases the risk for endocarditis in clients with valvular disease, and caries should be treated before surgery.

which therapeutic effect is associated with digoxin prescribed to a patient with heart failure

slows and strengthens cardiac contractions

which finding in a client seen in the ED with chest pain is most important to communicate to the health care provider

ST segment elevation on ECG- requires rapid treatment with thromboltyic medications

Which information is most important to include when the nurse is teaching a client who has had an STEMI about the purpose of salt restriction?

Salt intake increases the work of the heart.

which medication would a nurse conclude is the cause of a decreased HR in a client receiving a cardiac glycoside, a diuretic, an angiotensin-converting enxyme inhibitor, and a vasodilator?

cardiac glycoside- Ex. digoxin decreased the conduction speed within the myocardium and slows the HR

Which changes would the nurse expect to find in a client with left ventricular heart failure and supraventricular tachycardia when the prescribed digoxin 0.25 mg daily is therapeutically effective?

diuresis, decreased edema, decreased pulse rate

which actions do you take for a client in V. Fib

initiate CPR assessing the EKG Use the defibrillator obtaining electrolytes administer epinephrine

when the ED nurse provides care for a client with acute coronary syndrome who reports severe crushing chest pressure, which prescribed medication is best for the nurse to administer?

Morphine sulfate 4 mg intravenously- relieves pain and decreases SNS stimulation associated with pain.

the nurse notes a clients blood pressure of 200/110 mm Hg and swelling of the operative leg after a femoropopliteal bypass graft. Which action would the nurse take first?

Notify the clients HCP. High BP and leg swelling indicate possible graft leaking or rupture

How would anxiety affect outcomes for a client with heart failure?

increases the cardiac workload- anxiety increases sympathetic nervous system activity, leading to increases in heart rate, vasoconstriction, and increased metabolic rate, which increases cardiac workload and worsen outcomes in clients with heart failure.

nurse provides post op care to a client. the client reports sudden onset of shortness of breath and chest pain. Which action would the nurse take?

provide supplemental oxugen

which action would the nurse take next when a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 during a clinic appoitment

question the client about symptoms such as headache or chest pain

when assigned the care of a client arriving in the ED with possible acute coronary syndrome, which prescribed action would the nurse take first?

Obtain a 12 lead ECG