Exam 2 NRS 204
A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. A health care provider prescribes a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the following is the therapeutic serum level (range) for digoxin? 1. 3 to 5 ng/mL 2. 0.5 to 2 ng/mL 3. 1.2 to 2.8 ng/mL 4. 3.5 to 5.5 ng/m
2. 0.5 to 2 ng/mL
how long is a loop recorder implanted
3 years
A Client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available.
3. Monitor for signs of bleeding.
A nurse at a provider's office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A. Cholesterol (total) 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. Troponin | 0.02 ng/mL
A. Cholesterol (total) 245 mg/dL C. LDL 140 mg/dL
What race has the most problems with cardiovascular disease?
African American Patients
What are the risks for loop recorder implantation?
Bleeding or bruising Infection (might require device removal) Damage to your heart or blood vessels Mild pain at your implantation site Your own risks will depend on your age, your other medical conditions, and other factors. Ask your healthcare provider about any risks of the procedure for you.
On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. The priority nursing intervention is:
Assessing neurological status
1. The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How should the nurse interpret this rhythm? a. Bradycardia b. Tachycardia c. Atrial fibrillation d. Normal sinus rhythm
C . A fib
2. A client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on the monitor. The nurse quickly assesses the client, knowing that this rhythm is indicative of which rhythm? Refer to figure. a. Atrial fibrillation b. Ventricular fibrillation c. Ventricular tachycardia d. Premature ventricular complexes
C V tach
A nurse is caring for a client following an angioplastythat was inserted through the femoral artery.While turning the client, the nurse discovers bloodunderneath the client's lower back. Which of thefollowing findings should the nurse suspect? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incisional site D. Heart failure
C. Bleeding from the incisional site
A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? A. Intake & output B. Baseline peripheral pulse rates C. Height & weight D. Allergy to iodine or shellfish
D. Allergy to iodine or shellfish
A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture
D. Throat culture
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
Heart rate 45 beats/min
An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?
Increase the rate for the sodium nitroprusside infusion.
The nurse is taking care of a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is what?
Low LDL values and high HDL values
What happens after a loop recorder implantation?
You will be able to go home the day of the procedure. You can ask for pain medicine if you need it. You will need someone to drive you home after the procedure. You can return to normal after the procedure. But you may want to rest. Tell your healthcare provider if you have bleeding or swelling at the insertion site. they also come with a handheld activator that tells the loop recorder to save the signals collected over a certain period of time. This is important because it can also help explain if a fast or slow heartbeat is not what is causing your problems. Someone will make sure you know how to use your activator before you go home.
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client?
alerting the healthcare provider of the third-degree heart block
1. APTT of 28, nurse notifies physican for adjustment of what medicine
heparin or warfarin
1. Sickle cell nurse priority : 2/L, catheter, start an iv, oxygen
oxygen
1. Pt 26, anticipate to admin what med
vitamin K
A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk of acquiring rheumatic endocarditis? A. Older adult who has chronic obstructive pulmonary disease B. Child who has streptococcal pharyngitis C. Middle‐age adult who has lupus erythematosus D. Young adult who recently received a body tattoo
B. Child who has streptococcal pharyngitis
a client has undergone a lymph node biopsy. the nurse anticipates that the report will reveal which result if the client has Hodgkin's lymphoma? 1. Reed-Sternberg cells. 2. Philadelphia chromosome. 3. Epstein-Barr virus. 4. Herpes simplex virus.
1. Reed-Sternberg cells.
The nurse is obtaining a health history on a client admitted with a diagnosis of "rule out aplastic anemia." Considering the diagnosis, which data is most important for the nurse to elicit during the interview? 1. Recent travel outside the country 2. Exposure to chemicals and drugs 3. History of blood transfusion 4. Medication allergies.
2. Exposure to chemicals and drugs
A nurse is completing discharge teaching with a client following placement of an ICD. Which of the following information should the nurse include? (Select all that apply.) A. Avoid large magnetic fields. B. Caution family members that they can receive harmful unexpected shocks from the ICD. C. Take body temperature at the same time each D. Wear tight clothing to hold the device in place. E. Perform arm stretching exercises to strengthen muscles surrounding the ICD.
A. Avoid large magnetic fields. C. Take body temperature at the same time each
The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. What is the primary factor for the charge nurse to consider when delegating care?
Skill level and scope of practice of each staff member
A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse?
Stop the infusion, and notify the registered nurse.
A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.
a. Give normal saline IV at 500 mL/hr.
A newly licensed nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." This statement indicates which of the following events is occurring? A. The cardioverter is being charged to the appropriate setting. B. The team should initiate CPR due to pulseless electrical activity. C. Team members cannot be in contact with equipment connected to the client. D. A time-out is being called to verify correct protocols.
C. Team members cannot be in contact with equipment connected to the client.
A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing :1. Premature ventricular contractions 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Sinus tachycardia
2. Ventricular tachycardia
A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: 1. Premature ventricular contractions 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Sinus tachycardia
2. Ventricular tachycardia
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse?1.Call a code. 2.Call the health care provider. 3.Check the client's status and lead placement. 4.Press the recorder button on the electrocardiogram console
3.Check the client's status and lead placement.
Heparin sodium is prescribed for the client. The nurse expects that the health care provider will prescribe which of the following to monitor for a therapeutic effect of the medication? 1. Hematocrit level 2. Hemoglobin level 3. Prothrombin time (PT) 4. Activated partial thromboplastin time (aPTT)
4. Activated partial thromboplastin time (aPTT)
A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of thisprocedure? (Select all that apply.) A Follow up ECG B Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes
A Follow up ECG B Energy settings used E. Skin condition under electrodes
A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea
A. Tachypnea B. Persistent cough E. Orthopnea
A nurse is teaching a client with heart failure and a new perception of furosemide and digoxin. Which of the following information should the nurse include? (SATA) A. Weight daily, first thing in the morning B. Decrease intake of Potassium C. Expect muscle weakness while taking digoxin D. Hold digoxin if HR is <70 E. Decrease Sodium intake
A. Weight daily, first thing in the morning E. Decrease Sodium intake
A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. The client is able to inspire 200 mL withthe incentive spirometer, then declines to try to cough because of fatigue and pain. Which ofthe following actions should the nurse take? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as anappropriate inspired volume. D. Tell the client coughing after incentivespirometry is required.
B. Administer IV bolus analgesic, and return in 15 min.
A nurse is completing discharge teaching with a client who had a surgical placement of a mechanicalheart valve. Which of the following statements by the client indicates understanding of the teaching? A. "I will be glad to get back to my exercise routine right away." B. "I will have my prothrombin time checked on a regular basis." C. "I will talk to my dentist about no longer needing antibiotics before dental exams." D. "I will continue to limit my intake of foods containing potassium."
B. "I will have my prothrombin time checked on a regular basis."
A nurse is caring for a client who has heart failure and reports increased shortness of breath. Which of the following actions should the nurse take first? A. Obtain the client's weight. B. Assist the client into high-Fowler's position. C. Auscultate lung sounds. D. Check oxygen saturation with pulse oximeter.
B. Assist the client into high-Fowler's position.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which findings would the nurse anticipate when auscultating the client's breath sounds? A. Stridor B. Crackles C. Scattered rhonchi D. Diminished breath sounds
B. Crackles
A nurse is completing the admission physical assessment of client who has mitral valveinsufficiency. Which of the following is an expected finding?A. S4 heart sound B. Petechiae C. Neck vein distention D. Splenomegaly
B. Petechiae
A client with thrombocytopenia has neurologic checks prescribed every hour. The nurse shares with a curious unlicensed assistant which reason for frequent neurologic assessment? A. to determine if the coagulopathy is related to a neurologic disorder B. to monitor for signs of intracranial bleeding C. to evaluate the effectiveness of pharmacological interventions D. to correlate increasing platelet counts with the neurologic status
B. to monitor for signs of intracranial bleeding
A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub
D. Friction rub
A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best? A. It is due to side effects of medications for bronchodilation. b.it is from overactive bone marrow in response to chronic disease. c.It combats the anemia caused by an increased metabolic rate. D. It compensates for tissue hypoxia caused by lung disease.
D. It compensates for tissue hypoxia caused by lung disease.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24hrs before the procedure and for 48hrs after the procedure? A. Regular insulin B. Glipizide (Glucotrol) C. Repaglinide (Prandin) D. Metformin (Glucophage)
D. Metformin (Glucophage)
A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of thefollowing findings should the nurse expect? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication the affected leg
D. Report of intermittent claudication the affected leg
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse?
Report of severe chest pain
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.
a. Notify the surgeon and anesthesiologist.
The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due
b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.
b. Apply sequential compression device whenever the patient is in bed.
A patient is diagnosed with intermittent claudication. The nurse expects the patient's treatment plan to include what medication? a. Iloprost b. Cilostazol c. Ibuprofen d. Omeprazole
b. Cilostazol
Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias?a. Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole .b. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia c .Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
b. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask.
b. Start cardiopulmonary resuscitation (CPR).
Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.
b. The pain has lasted longer than 30 minutes.
A 59-year-old male is admitted complaining of chest pain and dyspnea. ST elevation and T-wave inversion were seen on the ECG in V2, V3, and V4. IV thrombolytic therapy was started in the ED. Indications of successful reperfusion would include all of the following EXCEPT: a. pain cessation. b. decrease in CK or troponin. c. reversal of ST segment elevation with return to baseline. d. short runs of ventricular tachycardia.
b. decrease in CK or troponin.
The nurse is monitoring a client with hypertension who is taking Propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? a Report of infrequent insomnia b. development of expiratory wheezes c. a baseline blood pressure of 150 over 80MM HG followed by a blood pressure of 138 / 72 MM HG after two doses of the medication d. a baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72 beats per minute after two doses of the medication
b. development of expiratory wheezes
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be a. LDL cholesterol. b. troponins T and I. c. C-reactive protein .d. creatine kinase-MB (CK-MB).
b. troponins T and I.
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).
c. Bilateral crackles are auscultated in the mid-lower lobes.
A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the clients legs. b. Elevate the clients legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the clients legs.
c. Keep the lower extremities warm.
A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient's vital signs including O2 saturation .d. Prepare to give a β-blocker medication to slow the heart rate.
c. Obtain the patient's vital signs including O2 saturation
The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. a serosanguineous drainage from the ulcer.
c. prolonged capillary refill in all the toes.
A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs). IDK IF GOES W GOT FROM QUIZLET
c. third-degree atrioventricular (AV) block.
A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these prescribed interventions should the nurse implement first? a. Place the patient on continuous cardiac monitor. b. Draw blood to type and crossmatch for transfusions. c. Insert two 14-gauge IV catheters in antecubital space. d. Administer oxygen at 100% per non-rebreather mask.
d. Administer oxygen at 100% per non-rebreather mask.
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 bpm. Which would be a correct interpretation based on these characteristics? a. Check vital signs b. Check laboratory test results c. Notify the health care provider d. Continue to monitor for any rhythm change
d. Continue to monitor for any rhythm change
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.
d. Help the patient to use a pillow to splint while coughing.
A. A client is diagnosed with cardiogenic shock. The nurse should plan interventions to address which of the following potential complications of this disorder? A. Pulmonary embolism b. Deep vein thrombosis c. Renal failure d. Myocardial infarction
d. Myocardial infarction
The nurse anticipates that which medication will be prescribed to a patient with intermittent claudication? a. Ramipril b. Warfarin c. Simvastatin d. Pentoxifylline
d. Pentoxifylline
The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress) testing on a treadmill. The symptom that has the most immediate implications for the patient's care during the exercise testing is a. the BP rising from 134/68 to 150/80 mm Hg. b. the heart rate (HR) increasing from 80 to 96 beats/min .c. the patient complaining of feeling short of breath. d. the ECG indicating the presence of coronary ischemia.
d. the ECG indicating the presence of coronary ischemia.
why would someone need a loop recorder
fainting episodes or palpitations, and other tests have not yet given you any answers. provider wants to look for very fast or slow heartbeats. These abnormal heartbeats can cause palpitations, or even lead to strokes. You also might need a loop recorder if you are an older adult with unexplained falls. Healthcare providers sometimes use it in people believed to have epilepsy who have not responded to medicine. In both cases, the recorder can determine whether an abnormal rhythm is the problem. The most common ones include looking for causes of fainting, palpitations, very fast or slow heartbeats, and hidden rhythms that can cause strokes.
b. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the Primary Health care provider and prepares to implement which priority interventions? (SATA) i. Administering oxygen ii. inserting a Foley catheter iii. administering furosemide iv. administering morphine sulfate intravenously v. transporting the client to the coronary care unit vi. placing the client in a low Fowlers side lying position
i. Administering oxygen ii. inserting a Foley catheter iii. administering furosemide iv. administering morphine sulfate intravenously
b. The nurse should evaluate that Defibrillation of a client was most successful if which observation was made? i. Arousable, sinus rhythm, blood pressure 116 / 72 mmHg ii. non arousable, sinus rhythm, blood pressure 88 / 60 mmHg iii. arousable, marked Bradycardia, blood pressure 86 / 54 mmHg iv. Nonarousable, superventricular tachycardia, blood pressure 122 / 60 mmHg
i. Arousable, sinus rhythm, blood pressure 116 / 72 mmHg
a. A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? i. Chest Pain ii. Urge to cough iii. Warm, flushed feeling iv. Pressure at the insertion site
i. Chest Pain
a. A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? (SATA) i. Dyspnea ii. Client report of fatigue iii. Bradycardia iv. Pleural friction rub v. Peripheral edema
i. Dyspnea ii. Client report of fatigue v. Peripheral edema
b. The nurse is preparing a plan of care for a child with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the child? i. Initiate an IV line for the administration of fluids ii. Consult with the psychiatric department regarding genetic counseling iii. Call the blood bank and request preparation of a unit of packed red blood cells iv. Call the respiratory department to prepare for intubation and mechanical ventilation
i. Initiate an IV line for the administration of fluids
a. A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions are a priority? Select all that apply. i. Stop the infusion ii. Raise the head of the bed iii. Administer protamine sulfate iv. Administer diphenhydramine v. Call for rapid response team
i. Stop the infusion iv. Administer diphenhydramine v. Call for rapid response team
a. A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy? i. Tarry stools ii. Nausea and vomiting iii. Orange-colored urine iv. Decreased urine output
i. Tarry stools
a. A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value comes back elevated? i. Troponin ii. Myoglobin iii. C-reactive protein iv. Creatine kinase (CK)
i. Troponin
* A nurse is teaching a client who has heart failure and new prescription for furosemide and digoxin. Which of the following information should the nurse include? (SATA) i. Weigh daily, first thing each morning ii. Decrease intake of potassium iii. Expect muscle weakness while taking digoxin iv. Hold digoxin if heart rate is less than 70/min v. Decrease sodium intake
i. Weigh daily, first thing each morning v. Decrease sodium intake
d. The nurse has provided self-care activity instructions to a client after insertion of an implanted cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement? i. "I need to avoid doing anything that could involve rough contact with the IDC insertion site" ii. "I can perform activities such as swimming, driving, or operating heavy equipment as I need to" iii. "I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cut off on the ICD" iv. "I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors, and I shouldn't lean over running motors"
ii. "I can perform activities such as swimming, driving, or operating heavy equipment as I need to"
b. A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? i. Anterior chest pain ii. Pericardial friction rub iii. Weakness and irritability iv. Chest pain that worsens on inspiration
ii. Pericardial friction rub
b. A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as daily prescribed medications. The nurse tells the client to report which finding as an indication that the medications are not having the intended effect? i. Sudden increase in appetite ii. Weight gain of 2-3lbs in a few days iii. Increased urine output during the day iv. Cough accompanied by other signs of respiratory infection
ii. Weight gain of 2-3lbs in a few days
a. A nurse is caring for a client who is 4 hours postoperative following coronary artery bypass grafting surgery. The client is able to inspire 200mL with the incentive spirometer, then declines to try to cough because of fatigue and pain. Which of the following actions should the nurse take? i. allow the client to rest, and return in one hour ii. administer IV bolus analgesic, and return in 15 minutes iii. document the 200mL as an appropriate inspired volume iv. tell the client coughing after incentive spirometry is required
ii. administer IV bolus analgesic, and return in 15 minutes
b. A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? (SATA) i. trace of bloody drainage on dressing ii. capillary refill of affected limb of 6 seconds iii. mottled appearance of the limb iv. throbbing pain of affected limb that is decreased following IV bolus analgesic v. pulse of 2+ in the affected limb
ii. capillary refill of affected limb of 6 seconds iii. mottled appearance of the limb
b. The home health nurse is visiting a client who has had a mechanical valve replacement for severe mitral valve stenosis. Which statement by the client reflects an understanding of specific postoperative care after this surgery? i. "I need to count my pulse every day" ii. "I have to do deep-breathing exercises every 2 hours" iii. "I need to throw away y straight razor and buy an electric razor" iv. "I have to go to the bathroom frequently because of my medication
iii. "I need to throw away y straight razor and buy an electric razor"
a. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take? i. Check vital signs ii. Check lab test results iii. Monitor for any rhythm change iv. Notify the PHCP
iii. Monitor for any rhythm change
7. Placement of ICD, what should you include in discharge teaching a. The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? i. Anxiety level of pt and family ii. Activation status and settings of device iii. Presence of a Medic Alert card for pt to carry iv. Knowledge of restrictions on post discharge physical activity
iii. Presence of a Medic Alert card for pt to carry
a. The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? i. The client is not experiencing dyspnea ii. The client is not experiencing nausea or vomiting iii. The pain has not been relieved by rest and nitroglycerin tablets iv. The client says the pain began while she was trying to open a stuck dresser drawer
iii. The pain has not been relieved by rest and nitroglycerin tablets
a. A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse determines that the client is receiving the therapeutic effect based on which results? i. Prothrombin time of 12.5 seconds ii. aPTT of 28 iii. aPTT of 60 iv. aPTT longer than 120 seconds
iii. aPTT of 60
c. The home health nurse makes a home visit to a client who has an implanted cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? i. "If I feel an internal defibrillator shock, I should sit down" ii. "I won't be able to have an MRS" iii. "My wife knows how to call the EMS if I need it" iv. "I can stop taking my antidysrhythmic medicine now because I have a pacemaker"
iv. "I can stop taking my antidysrhythmic medicine now because I have a pacemaker
b. A client with a history of heart failure who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and is complaining of anorexia. The primary health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range? i. 0.3 ii. 0.5 iii. 0.8 iv. 1.0
iv. 1.0
3 mEq/L (3 mmol/L) and reports anorexia. The health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should recognize which level that is outside of the therapeutic range? i. 0.5 ii. 0.8 iii. 0.9 iv. 2.2
iv. 2.2
b. A client is scheduled for a cardiac catheterization using an iodine agent. Which assessment is most critical before the procedure? i. Intake and output ii. Height and weight iii. Baseline peripheral pulse rates iv. Previous allergies to contrast agents
iv. Previous allergies to contrast agents
c. A primary health care provider (PHCP) writes a prescription for digoxin, 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is most important to be sure to implement which measure? i. Count the radial and carotid pulses every morning ii. Check the bp every morning and evening iii. Stop taking the medication if the pulse is faster than 100 beats/min iv. Withhold the medication and call the PHCP if the pulse is slower than 60 beats/min
iv. Withhold the medication and call the PHCP if the pulse is slower than 60 beats/min
a. A nurse is admitting a client who has complete heart block as demonstrated by ECG. the client's heart rate is 34/min and blood pressure is 83/48 mm Hg. the client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? i. transport the client to the cardiovascular laboratory ii. prepare the client for insertion of a permanent pacemaker iii. obtain a signed informed consent form for a pacemaker iv. apply transcutaneous pacemaker pads
iv. apply transcutaneous pacemaker pads
What happens during a loop recorder implantation?
ou may be given medicine to help you relax. A local anesthetic will be put on your skin to numb it. Your healthcare provider will make a small incision in your skin. This is usually done in the left upper chest. Your healthcare provider will create a small pocket under your skin. He or she will place the loop recorder in this pocket. The machine is about the size of a flat AA battery. Your incision will be closed with sutures. A bandage will be put on the area.
1. Pt w bleeding disorder find small hemorrage under the skin, arms / legs.. document as
petechia