Exam 4- MSN 377 Ch 31-36

668. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

681. The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2. Nonarousable, sinus rhythm, BP 88/60 mm Hg 3. Arousable, marked bradycardia, BP 86/54 mm Hg 4. Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

1. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg Rationale: After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.

678. The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia

1. Atrial fibrillation Rationale: Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.

675. A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

1. It can develop into ventricular fibrillation at any time. Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.

684. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm

1. Sinus tachycardia Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.

685. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctlyinterprettheclient'sneurovascularstatus? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

1. The neurovascular status is normal because of increased blood flow through the leg. Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.

CH 32: The nurse obtains a blood pressure of 176/82 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?

113 mm Hg MAP = (SBP + 2 DBP)/3

686. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1. Muffled heart sounds 2. A rise in blood pressure 3. Jugular venous distention 4. Client expressions of dyspnea

2. A rise in blood pressure Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.

671. A client who had cardiac surgery 24 hours ago has had a urine output averaging 20mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL(16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4.. Urinary tract infection

2. Acute kidney injury Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN,10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine: male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.

687. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L) and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morn- ing. Which nursing action is the priority? 1. Check the urine specific gravity. 2. Call the health care provider (HCP). 3. Put the IV line on a pump so that the infusion rate is sure to stay stable. 5.Check to see if the client had a blood sample for a serum albumin level drawn.

2. Call the health care provider (HCP). Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine: male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). Options 1 and 4 are not associated with the data in the question. The IV should have already been on a pump. Urine output lower than 30 mL/hour is reported to the HCP.

669. A client with myocardial infarctions suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

2. Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

666. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin

2. Metformin Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.

682, The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness

2. Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.

670. A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

2. Ventricular dysrhythmias Rationale: Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

676. A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Sensation of palpitations 2. Causative factors, such as caffeine 3. Blood pressure and oxygen saturation 4. Precipitating factors, such as infection

3. Blood pressure and oxygen saturation Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to mon- itor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.

673. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 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. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.

677. The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms? 1.Flatneckveins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Hypertension and headache

3. Hypotension and dizziness Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

689. The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia

3. Ventricular fibrillation Rationale: Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

674. The 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 more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions

3. Ventricular tachycardia Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular.

688. A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I should notify my doctor if my feet or legs start to swell." 2. "My doctor told me to call his office if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." Rationale: Variant angina, or Prinzmetal's angina, is pro- longed and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the health care provider. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client should be able to continue morn- ing walks with his or her spouse.

680. A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1.50J 2.120J 3.200J 4. 360 J

4. 360 J Rationale: The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.

683. 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? 1. Anxiety level of the client and family 2. Presence of a MedicAlert card for the client to carry 3. Knowledge of restrictions on post-discharge physical activity 4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver

4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver Rationale: The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

679. The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1. Ensure that the client has been intubated. 2. Set the defibrillator to the "synchronize" mode. 3. Administer an amiodarone bolus intravenously. 4. Confirm that the rhythm is actually ventricular fibrillation.

4. Confirm that the rhythm is actually ventricular fibrillation. Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.

672. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PRinterval is 0.16 seconds, and QRScomplexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Notify the health care provider. 4. Continue to monitor for any rhythm change.

4. Continue to monitor for any rhythm change. Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

667. A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1. Administer digoxin. 2. Defibrillate the client 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing

4. Prepare for transcutaneous pacing Rationale: Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.

CH 33: A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? A. "What do you think caused your chest pain?" B. "Where are you planning to go for your vacation?" C. "Sometimes plans need to change after a heart attack." D. "Recovery from a heart attack takes at least a few weeks."

A. "What do you think caused your chest pain?" Explanation/Rationale:When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

CH 32: The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? A. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain B. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication C. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL D. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria

A. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain Explanation/Rationale:The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.

CH 36: A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that discomfort in the joints prevents favorite activities such as taking a daily walk and working on sewing projects. Based on these findings, which nursing diagnosis statement would be appropriate? A. Activity intolerance related to arthralgia B. Anxiety related to permanent joint fixation C. Altered body image related to polyarthritis D. Social isolation related to pain and swelling

A. Activity intolerance related to arthralgia Explanation/Rationale:The patient's joint pain will lead to difficulty with activity. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes. This patient did not provide any data to support a diagnosis of social isolation, anxiety, or altered body image.

CH 35: A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the student denies any health problems. What action by the nurse is most appropriate? A. Allow the student to participate on the soccer team. B. Refer the student to a cardiologist for further testing. C. Tell the student to stop playing immediately if any dyspnea occurs. D. Obtain more detailed information about the student's family health history.

A. Allow the student to participate on the soccer team. Explanation/Rationale:In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal.

CH 36: When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is most appropriate for the nurse to include? A. Arrange for placement of a long-term IV catheter. B. Monitor labs for levels of streptococcal antibodies. C. Teach the importance of completing all oral antibiotics. D.Encourage the patient to begin regular aerobic exercise

A. Arrange for placement of a long-term IV catheter. Explanation/Rationale:Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.

CH 33: When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? A. Attach the heart monitor. B. Obtain the blood pressure. C. Assess the peripheral pulses. D. Auscultate the breath sounds.

A. Attach the heart monitor. Explanation/Rationale:Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.

CH 36: Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first? A. Auscultate the heart sounds. B. Check the patient's temperature. C. Give the PRN acetaminophen (Tylenol). D. Notify the patient's health care provider.

A. Auscultate the heart sounds. Explanation/Rationale:The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. Acetaminophen (Tylenol) is not very effective for pericarditis pain, and an analgesic would not be given before assessment of a new symptom.

CH 32: Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? A. Collect a detailed diet history. B. Provide a list of low-sodium foods. C. Help the patient make an appointment with a dietitian. D. Teach the patient about foods that are high in potassium.

A. Collect a detailed diet history. Explanation/Rationale:The initial nursing action should be assessment of the patient's baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

CH 33: A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? A. Generalized muscle aches and pains B. Dizziness with rapid position changes C. Nausea when taking the drugs before meals D. Flushing and pruritus after taking the drugs

A. Generalized muscle aches and pains Explanation/Rationale:Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.

CH 33: When caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Give the scheduled aspirin and lipid-lowering medication. B. Perform the initial assessment of the catheter insertion site. C. Teach the patient about the usual postprocedure plan of care. D. Titrate the heparin infusion according to the agency protocol.

A. Give the scheduled aspirin and lipid-lowering medication. Explanation/Rationale:Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

CH 31: The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate as soon as possible to the health care provider? A. High troponin I level B. Increased triglyceride level C. Very low homocysteine level D. Elevated high-sensitivity C-reactive protein level

A. High troponin I level Explanation/Rationale:The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention.

CH 35: After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? A. Increase in the patient's heart rate B. Increase in strength of peripheral pulses C. Decrease in premature atrial contractions D. Decrease in premature ventricular contractions

A. Increase in the patient's heart rate Explanation/Rationale:Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

CH 34: Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? A. Monitor blood pressure frequently. B. Encourage patient to ambulate in room. C. Titrate nesiritide slowly before stopping. D. Teach patient about home use of the drug.

A. Monitor blood pressure frequently. Explanation/Rationale:Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting.

CH 34: Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? A. O2 saturation of 88% B. Weight gain of 1 kg (2.2 lb) C. Heart rate of 106 beats/min D. Urine output of 50 mL over 2 hours

A. O2 saturation of 88% Explanation/Rationale:A decrease in O2 saturation to less than 92% indicates hypoxemia, and the nurse should start supplemental O2 immediately. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require nursing actions, but the low O2 saturation rate requires the most immediate nursing action.

CH 32: The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? A. Serum creatinine of 2.8 mg/dL B. Serum potassium of 4.5 mEq/L C. Serum hemoglobin of 14.7 g/dL D. Blood glucose level of 96 mg/dL

A. Serum creatinine of 2.8 mg/dL Explanation/Rationale:The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

CH 31: The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line. How will the nurse record this information? A. Systolic murmur heard at mitral area B. Systolic murmur heard at Erb's point C. Diastolic murmur heard at aortic area D. Diastolic murmur heard at the point of maximal impulse

A. Systolic murmur heard at mitral area Explanation/Rationale:The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle.

CH 36: The nurse is caring for a patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? A. The patient complains of chest pressure when ambulating. B. A loud systolic murmur is heard along the right sternal border. C. A thrill is palpated at the second intercostal space, right sternal border. D. The point of maximum impulse (PMI) is at the left midclavicular line.

A. The patient complains of chest pressure when ambulating. Explanation/Rationale:Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

CH 34: During a visit to a 78-yr-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, a correct nursing diagnosis for the patient is A. activity intolerance related to fatigue. B. impaired skin integrity related to edema. C. disturbed body image related to weight gain. D. impaired gas exchange related to dyspnea on exertion.

A. activity intolerance related to fatigue. Explanation/Rationale:The patient's statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for additional patient problems.

CH 35: A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about A. anticoagulant therapy. B. permanent pacemakers. C. emergency cardioversion. D. IV adenosine (Adenocard).

A. anticoagulant therapy. Explanation/Rationale:Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

CH 34: A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been ordered for the patient. The nurse's priority action will be to A. give PRN IV morphine sulfate 4 mg. B. give PRN IV diazepam (Valium) 2.5 mg. C. increase nitroglycerin infusion by 5 mcg/min. D. increase dopamine infusion by 2 mcg/kg/min.

A. give PRN IV morphine sulfate 4 mg. Explanation/Rationale:Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

CH 32: The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to A. increase the dietary intake of high-potassium foods. B. make an appointment with the dietitian for teaching. C. check the blood pressure (BP) at home at least once a day. D. move slowly when moving from lying to sitting to standing.

A. increase the dietary intake of high-potassium foods. Explanation/Rationale:The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

CH 31: The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the A. postoperative patient with a BP of 116/42 mm Hg. B. newly admitted patient with a BP of 150/87 mm Hg. C. patient with left ventricular failure who has a BP of 110/70 mm Hg. D. patient with a myocardial infarction who has a BP of 140/86 mm Hg.

A. postoperative patient with a BP of 116/42 mm Hg. Explanation/Rationale:The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg.

CH 36: While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate nursing intervention for this patient would be to A. promote rest to decrease myocardial oxygen demand. B. teach the patient about the need for anticoagulant therapy. C. teach the patient to use sublingual nitroglycerin for chest pain. D.raise the head of the bed 60 degrees to decrease venous return

A. promote rest to decrease myocardial oxygen demand. Explanation/Rationale:Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

CH 33: The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include A. when cardiac rehabilitation will begin. B. the typical emotional responses to AMI. C. information regarding discharge medications. D. the pathophysiology of coronary artery disease.

A. when cardiac rehabilitation will begin. Explanation/Rationale:Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease. Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction.

CH 32: A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings? A. "Have you recently taken any antihistamines?" B. "Have you consistently taken your medications?" C. "Did you take any acetaminophen (Tylenol) today?" D. "Have there been recent stressful events in your life?"

B. "Have you consistently taken your medications?" Explanation/Rationale:Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

CH 36: The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history focuses on a pertinent risk factor for rheumatic fever? A. "Do you use any illegal IV drugs?" B. "Have you had a recent sore throat?" C. "Have you injured your chest in the last few weeks?" D. "Do you have a family history of congenital heart disease?"

B. "Have you had a recent sore throat?" Explanation/Rationale:Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and it would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

CH 32: The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? A. "The medication may not work well if I take aspirin." B. "I can expect some swelling around my lips and face." C. "The doctor may order a blood potassium level occasionally." D. "I will call the doctor if I notice that I have a frequent cough."

B. "I can expect some swelling around my lips and face." Explanation/Rationale:Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

CH 33: When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? A. "They will circulate my blood with a machine during surgery." B. "I will have incisions in my leg where they will remove the vein." C. "They will use an artery near my heart to go around the area that is blocked." D."I will need to take an aspirin every day after the surgery to keep the graft open."

B. "I will have incisions in my leg where they will remove the vein." Explanation/Rationale:When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

CH 33: After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? A. "Carvedilol will help my heart muscle work harder." B. "It is important not to suddenly stop taking the carvedilol." C. "I can expect to feel short of breath when taking carvedilol." D. "Carvedilol will increase the blood flow to my heart muscle."

B. "It is important not to suddenly stop taking the carvedilol." Explanation/Rationale:Patients who have been taking b-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking b-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries.

CH 33: A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when sexual intercourse can be resumed. Which response by the nurse is best? A. "Most patients are able to enjoy intercourse without any complications." B. "Sexual activity uses about as much energy as climbing two flights of stairs." C. "The doctor will provide sexual guidelines when your heart is strong enough." D. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

B. "Sexual activity uses about as much energy as climbing two flights of stairs." Explanation/Rationale:Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.

CH 32: Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension? A. 98/56 mm Hg B. 128/76 mm Hg C. 128/92 mm Hg D. 142/78 mm Hg

B. 128/76 mm Hg Explanation/Rationale:The 8th Joint National Committee's recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 140/90 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

CH 34: After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? A. A patient who reported dizziness after receiving the first dose of captopril B. A patient who is cool and clammy, with new-onset confusion and restlessness C. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. D. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

B. A patient who is cool and clammy, with new-onset confusion and restlessness Explanation/Rationale:The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

CH 33: Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous about my heart to be alone while I get washed up." Based on this information, which nursing diagnosis is appropriate? A. Activity intolerance related to weakness B. Anxiety related to change in health status C. Denial related to lack of acceptance of the MI D. Altered body image related to cardiac disease

B. Anxiety related to change in health status Explanation/Rationale:The patient data indicate anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or altered body image.

CH 33: When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the drug? A. Monitor heart rate. B. Ask about chest pain. C. Check blood pressure. D. Observe for dysrhythmias.

B. Ask about chest pain. Explanation/Rationale:The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

CH 32: A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? A. Tell the patient why a change in drug dosage is needed. B. Ask the patient if the medication is being taken as prescribed. C. Inform the patient that multiple drugs are often needed to treat hypertension. D. Question the patient regarding any lifestyle changes made to help control BP.

B. Ask the patient if the medication is being taken as prescribed. Explanation/Rationale:Because nonadherence with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient adherence with the prescribed therapy.

CH 31: The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? A. Teaching a patient about exercise electrocardiography B. Attaching ECG monitoring electrodes after a patient bathes C. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram D. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram

B. Attaching ECG monitoring electrodes after a patient bathes Explanation/Rationale:UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice.

CH 31: When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To acquire more information about the murmur, which action will the nurse take? A. Palpate the peripheral pulses. B. Determine the timing of the sound. C. Find the point of maximal impulse. D. Compare apical and radial pulse rates.

B. Determine the timing of the sound. Explanation/Rationale:Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is important in the cardiac assessment but will not provide information that is relevant to the murmur.

CH 33: To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take? A. Stress that weight loss is a major benefit of increased exercise. B. Determine what kind of physical activities the patient usually enjoys. C. Tell the patient that older adults should exercise for no more than 20 minutes at a time. D. Teach the patient to include a short warm-up period at the beginning of physical activity.

B. Determine what kind of physical activities the patient usually enjoys. Explanation/Rationale:Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.

CH 35: Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? A. Turn the synchronizer switch to the "off" position. B. Give a sedative before cardioversion is implemented. C. Set the defibrillator/cardioverter energy to 360 joules. D. Provide assisted ventilations with a bag-valve-mask device.

B. Give a sedative before cardioversion is implemented. Explanation/Rationale:When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

CH 32: Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient? A. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. B. Have the patient sit in a chair with the feet flat on the floor. C. Assist the patient to the supine position for BP measurements. D. Obtain two BP readings in the dominant arm and average the results.

B. Have the patient sit in a chair with the feet flat on the floor. Explanation/Rationale:The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

CH 33: After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient's response to the activity, which data would indicate that the exercise level should be decreased? A. O2 saturation drops from 99% to 95%. B. Heart rate increases from 66 to 98 beats/min. C. Respiratory rate goes from 14 to 20 breaths/min. D. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

B. Heart rate increases from 66 to 98 beats/min. Explanation/Rationale:A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise.

CH 33: Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? A. Inform the patient about a diet containing no saturated fat and minimal salt. B. Help the patient modify favorite high-fat recipes by using monounsaturated oils. C. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. D. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.

B. Help the patient modify favorite high-fat recipes by using monounsaturated oils. Explanation/Rationale:Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

CH 35: A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? A. I B. II C. V2 D. V6

B. II Explanation/Rationale:Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area.

CH 35: 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 Explanation/Rationale:Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more teaching about treatment of heart dysrhythmias. The RN should hold the diltiazem until discussing it with the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating.

CH 35: Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? A. Explain the association between dysrhythmias and syncope. B. Instruct the patient to call for assistance before getting out of bed. C. Teach the patient about the need to avoid caffeine and other stimulants. D.Tell the patient about the benefits of implantable cardioverter-defibrillators

B. Instruct the patient to call for assistance before getting out of bed. Explanation/Rationale:A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient is up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope but are not appropriate for syncope of unknown origin.

Ch 31 The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure? A. Iron B. Iodine C. Aspirin D. Penicillin

B. Iodine Answer: B - The physician will usually use an iodine-based contrast to perform this procedure. Therefore it is imperative to know whether or not the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.

CH 36: The nurse is assessing a patient with myocarditis before giving the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? A. Leukocytosis B. Irregular pulse C. Generalized myalgia D. Complaint of fatigue

B. Irregular pulse Explanation/Rationale:Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these.

CH 32: The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? A. Low dietary fiber intake B. No regular physical exercise C. Drinks a beer with dinner every night D. Weight is 5 pounds above ideal weight

B. No regular physical exercise Explanation/Rationale:The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake is within guidelines and will not increase the hypertension risk.

CH 35: Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? A. Decide whether a patient's heart rate of 116 requires urgent treatment. B. Observe heart rhythms for multiple patients who have telemetry monitoring. C. Monitor a patient's level of consciousness during synchronized cardioversion. D. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

B. Observe heart rhythms for multiple patients who have telemetry monitoring. Explanation/Rationale:UAP serving as telemetry technicians can monitor heart rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.

CH 36: Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? A. Administer ceftriaxone 1 g IV. B. Order blood cultures drawn from two sites. C. Give acetaminophen (Tylenol) PRN for fever. D. Arrange for a transesophageal echocardiogram.

B. Order blood cultures drawn from two sites. Explanation/Rationale:Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before starting antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority.

CH 33: Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? A. Complaints of incisional chest pain B. Pallor and weakness of the right hand C. Fine crackles heard at both lung bases D. Redness on both sides of the sternal incision

B. Pallor and weakness of the right hand Explanation/Rationale:The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions.

CH 36: After receiving information about four patients during change-of-shift report, which patient should the nurse assess first? A. Patient with acute pericarditis who has a pericardial friction rub B. Patient who has just returned to the unit after balloon valvuloplasty C. Patient who has hypertrophic cardiomyopathy and a heart rate of 116 D. Patient with a mitral valve replacement who has an anticoagulant scheduled

B. Patient who has just returned to the unit after balloon valvuloplasty Explanation/Rationale:The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention.

CH 34: After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L C. Patient who is taking captopril and has a frequent nonproductive cough D. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache

B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L Explanation/Rationale:The patient's low potassium level increases the risk for digoxin toxicity and potentially life-threatening dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their drugs, but their symptoms do not indicate potentially life-threatening complications.

CH 36: After receiving change-of-shift report on four patients, which patient should the nurse assess first? A. Patient with rheumatic fever who has sharp chest pain with a deep breath B. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg C. Patient with infective endocarditis who has a murmur and splinter hemorrhages D. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

B. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg Explanation/Rationale:Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea, chest pain or tachycardia. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.

CH 33: Which patient at the cardiovascular clinic requires the most immediate action by the nurse? A. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL B. Patient with stable angina whose chest pain has recently increased in frequency C. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL D. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

B. Patient with stable angina whose chest pain has recently increased in frequency Explanation/Rationale:The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable.

CH 35: A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? A. Give epinephrine (Adrenalin) IV. B. Perform immediate defibrillation. C. Prepare for endotracheal intubation. D. Ventilate with a bag-valve-mask device.

B. Perform immediate defibrillation. Explanation/Rationale:The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first.

CH 32: Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? A. Blood glucose level of 175 mg/dL B. Serum potassium level of 3.0 mEq/L C. Orthostatic systolic BP decrease of 12 mm Hg D. Most recent blood pressure (BP) reading of 168/94 mm Hg

B. Serum potassium level of 3.0 mEq/L Explanation/Rationale:Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is symptomatic.

CH 35: A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable pulses. What action should the nurse take next? A. Perform synchronized cardioversion. B. Start cardiopulmonary resuscitation (CPR). C. Give atropine per agency dysrhythmia protocol. D. Provide supplemental O2 via non-rebreather mask.

B. Start cardiopulmonary resuscitation (CPR). Explanation/Rationale:The patient's clinical manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

CH 36: Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? A. Generalized muscle aching B. Sudden onset right flank pain C. Janeway's lesions on the palms D. Temperature 100.7°F (38.1°C)

B. Sudden onset right flank pain Explanation/Rationale:Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE but do not require any new interventions.

CH 36: When developing a community health program to decrease the incidence of rheumatic fever, which action should the community health nurse include? A. Vaccinate high-risk groups in the community with streptococcal vaccine. B. Teach community members to seek treatment for streptococcal pharyngitis. C. Teach about the importance of monitoring temperature when sore throats occur. D. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.

B. Teach community members to seek treatment for streptococcal pharyngitis. Explanation/Rationale:The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever.

CH 32: An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of the hypertension? A. Instruct the patient about the need to decrease stress levels. B. Teach the patient how to self-monitor and record BPs at home. C. Schedule the patient for regular blood pressure (BP) checks in the clinic. D. Inform the patient and caregiver that major dietary changes will be needed.

B. Teach the patient how to self-monitor and record BPs at home. Explanation/Rationale:In the phenomenon of "white coat" hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.

CH 33: The nurse is admitting a patient who has chest pain. Which assessment data 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. Explanation/Rationale:Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

CH 32: The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? A. Urine output over 8 hours is 250 mL less than the fluid intake. B. The patient cannot move the left arm and leg when asked to do so. C. Tremors are noted in the fingers when the patient extends the arms. D.The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale

B. The patient cannot move the left arm and leg when asked to do so. Explanation/Rationale:The patient's inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

CH 36: The nurse is caring for a 64-yr-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? A. The patient has 4+ peripheral edema. B. The patient has diffuse bilateral crackles. C. The patient has a loud systolic murmur across the precordium. D.The patient has a palpable thrill felt over the left anterior chest

B. The patient has diffuse bilateral crackles. Explanation/Rationale:Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

CH 31: When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? A. The patient's pedal pulses are +1. B. The patient is allergic to shellfish. C. The patient had a heart attack 1 year ago. D. The patient has not eaten anything today.

B. The patient is allergic to shellfish. Explanation/Rationale:The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the angiogram. The other information is also communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications.

CH 36: The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? A. Fever, chills, and diaphoresis B. Urine output less than 30 mL/hr C. Petechiae on the inside of the mouth and conjunctiva D. Increase in heart rate of 15 beats/minute with walking

B. Urine output less than 30 mL/hr Explanation/Rationale:Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/min is normal with exercise.

CH 35: The nurse notes that a patient's heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? A. Ventricular couplets B. Ventricular bigeminy C. Ventricular R-on-T phenomenon D. Multifocal premature ventricular contractions

B. Ventricular bigeminy Explanation/Rationale:Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions are multifocal or that the R-on-T phenomenon is occurring.

CH 36: During the assessment of a young adult patient with infective endocarditis (IE), the nurse would expect to find A. substernal chest pressure. B. a new regurgitant murmur. C. a pruritic rash on the chest. D. involuntary muscle movement.

B. a new regurgitant murmur. Explanation/Rationale:New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.

CH 33: When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that A. sudden cardiac death events rarely reoccur. B. additional diagnostic testing will be required. C. long-term anticoagulation therapy will be needed. D. limiting physical activity will prevent future SCD events.

B. additional diagnostic testing will be required. Explanation/Rationale:Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

CH 36: To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should A. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest. B. auscultate with the diaphragm of the stethoscope on the lower left sternal border. C. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub. D. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.

B. auscultate with the diaphragm of the stethoscope on the lower left sternal border. Explanation/Rationale:Pericardial friction rubs are best heard with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.

CH 31: To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the A. diaphragm of the stethoscope with the patient lying flat. B. bell of the stethoscope with the patient in the left lateral position. C. diaphragm of the stethoscope with the patient in a supine position. D.bell of the stethoscope with the patient sitting and leaning forward

B. bell of the stethoscope with the patient in the left lateral position. Explanation/Rationale:Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2.

CH 33: The nurse suspects that the patient with stable angina is experiencing a side effect of the prescribed drug metoprolol (Lopressor) if the A. patient is restless and agitated. B. blood pressure is 90/54 mm Hg. C. patient complains about feeling anxious. D. heart monitor shows normal sinus rhythm.

B. blood pressure is 90/54 mm Hg. Explanation/Rationale:Patients taking b-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm.

CH 31: When auscultating over the patient's abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a A. thrill. B. bruit. C. murmur. D. normal finding.

B. bruit. Explanation/Rationale:A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology.

CH 35: A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. The most appropriate intervention by the nurse would be to A. notify the health care provider immediately. B. document the finding and monitor the patient. C. give atropine per agency dysrhythmia protocol. D.prepare the patient for temporary pacemaker insertion

B. document the finding and monitor the patient. Explanation/Rationale:First-degree atrioventricular block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.

CH 36: A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of A. blood cultures. B. echocardiography. C. cardiac catheterization. D. 24-hour Holter monitor.

B. echocardiography. Explanation/Rationale:Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor are not diagnostic procedures for pericarditis.

CH 33: When developing a teaching plan for a 61-yr-old patient with multiple risk factors for coronary artery disease (CAD), the nurse should focus primarily on the A. family history of coronary artery disease. B. elevated low-density lipoprotein (LDL) level. C. increased risk associated with the patient's gender. D. increased risk of cardiovascular disease as people age.

B. elevated low-density lipoprotein (LDL) level. Explanation/Rationale:Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.

CH 36: The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should A. subtract the diastolic blood pressure from the systolic blood pressure. B. note when Korotkoff sounds are auscultated during both inspiration and expiration. C. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle. D. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.

B. note when Korotkoff sounds are auscultated during both inspiration and expiration. Explanation/Rationale:Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

CH 31: A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse A. presses on the skin over the tibia for 10 seconds to check for edema. B. palpates both carotid arteries simultaneously to compare pulse quality. C. documents a murmur heard along the right sternal border as a pulmonic murmur. D. places the patient in the left lateral position to check for the point of maximal impulse.

B. palpates both carotid arteries simultaneously to compare pulse quality. Explanation/Rationale:The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.

CH 33: A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care? A. captopril B. sildenafil (Viagra) C. furosemide (Lasix) D. warfarin (Coumadin)

B. sildenafil (Viagra) Explanation/Rationale:The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications should also be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

CH 31: 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 laboratory test result most helpful in indicating myocardial damage will be A. myoglobin. B. troponins T and I. C. homocysteine (Hcy) D. creatine kinase-MB (CK-MB).

B. troponins T and I. Explanation/Rationale:Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. Low-density lipoprotein cholesterol is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels. Homocysteine (Hcy) is an amino acid that is produced during protein catabolism. Elevated Hcy levels can be either hereditary or acquired from dietary deficiencies of vitamin B6, cobalamin (vitamin B12), or folate. Elevated levels of Hcy have been linked to a higher risk of CVD, peripheral vascular disease, and stroke.

CH 34: When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include A. canned and frozen fruits. B. yogurt and milk products. C. fresh or frozen vegetables. D. eggs and other high-protein foods.

B. yogurt and milk products. Explanation/Rationale:Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction.

CH 36: The home health nurse is visiting a 30-yr-old patient recovering from rheumatic fever without carditis. The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when the patient makes which statement? A. "I will need prophylactic antibiotic therapy for 5 years." B. "I can take aspirin or ibuprofen (Motrin) to relieve my joint pain." C. "I will be immune to future episodes of rheumatic fever after this infection." D. "I should call the health care provider if I am fatigued or have difficulty breathing."

C. "I will be immune to future episodes of rheumatic fever after this infection." Explanation/Rationale:Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever without carditis require prophylaxis until age 20 years and for a minimum of 5 years. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.

CH 34: A patient with heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? A. "I will be sure to take the medication with food." B. "I will need to eat more potassium-rich foods in my diet." C. "I will call for help when I need to get up to use the bathroom." D. "I will expect to feel more short of breath for the next few days."

C. "I will call for help when I need to get up to use the bathroom." Explanation/Rationale:Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of b-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

CH 33: In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? A. "I will check my pulse rate before I take any nitroglycerin tablets." B. "I will put the nitroglycerin patch on as soon as I get any chest pain." C. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." D. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."

C. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." Explanation/Rationale:The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

CH 34: A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most accurate? A. "Your heart failure has not reached the end stage yet." B. "You could not manage the multiple complications of that surgery." C. "The suitability of a heart transplant for you depends on many factors." D. "Because you have diabetes, you would not be a heart transplant candidate."

C. "The suitability of a heart transplant for you depends on many factors." Explanation/Rationale:Indications for a heart transplant include end-stage heart failure (stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Patients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, there are no data to suggest that the patient could not manage the care.

CH 33: A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? A. "Do you have any allergies?" B. "Do you take aspirin on a daily basis?" C. "What time did your chest pain begin?" D. "Can you rate your chest pain using a 0 to 10 scale?"

C. "What time did your chest pain begin?" Explanation/Rationale:Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy.

CH 35: A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/min. A. 15 to 20 B. 20 to 40 C. 40 to 60 D. 60 to 100

C. 40 to 60 Explanation/Rationale:If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. The slower rates are typical of the bundle of His and Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/min.

CH 35: A 19-yr-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? A. Insert an IV catheter for emergency use. B. Start supplemental O2 at 2 to 3 L/min via nasal cannula. C. Ask the patient about current stress level and caffeine use. D. Have the patient taken to the nearest emergency department (ED).

C. Ask the patient about current stress level and caffeine use. Explanation/Rationale:In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. The patient is hemodynamically stable, so there is no indication that the patient needs supplemental O2, an IV, or to be seen in the ED.

: CH 36: Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are most effective? A. Assess for the presence of a paradoxical pulse. B. Monitor for changes in the patient's sedimentation rate. C. Assess for the presence of jugular venous distention (JVD). D. Check the electrocardiogram (ECG) for ST segment changes.

C. Assess for the presence of jugular venous distention (JVD). Explanation/Rationale:Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis.

CH 33: A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? A. Assess the feet for pedal edema. B. Palpate the radial pulses bilaterally. C. Auscultate for a pericardial friction rub. D. Check the heart monitor for dysrhythmias.

C. Auscultate for a pericardial friction rub. Explanation/Rationale:The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

CH 34: A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? A. Auscultate the abdomen. B. Check the capillary refill. C. Auscultate the breath sounds. D. Ask about the patient's allergies.

C. Auscultate the breath sounds. Explanation/Rationale:This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

CH 34: Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? A. Serum troponin B. Arterial blood gases C. B-type natriuretic peptide D. 12-lead electrocardiogram

C. B-type natriuretic peptide Explanation/Rationale:B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

CH 33: 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 having a heart attack. C. Bilateral crackles in the mid-lower lobes. D. Occasional premature atrial contractions (PACs).

C. Bilateral crackles in the mid-lower lobes. Explanation/Rationale:The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

CH 35: A patient's heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? A. Place the transcutaneous pacemaker pads on the patient. B. Give atropine sulfate 1 mg IV per agency dysrhythmia protocol. C. Call the health care provider before giving scheduled metoprolol (Lopressor). D. Document the patient's rhythm and assess the patient's response to the rhythm.

C. Call the health care provider before giving scheduled metoprolol (Lopressor). Explanation/Rationale:The patient has progressive first-degree atrioventricular (AV) block, and the b-blocker should be held until discussing the drug with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.

CH 32: A patient has just been diagnosed with hypertension and has been started on captopril . Which information is most important to include when teaching the patient about this drug? A. Include high-potassium foods such as bananas in the diet. B. Increase fluid intake if dryness of the mouth is a problem. C. Change position slowly to help prevent dizziness and falls. D. Check blood pressure (BP) in both arms before taking the drug.

C. Change position slowly to help prevent dizziness and falls. Explanation/Rationale:The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

CH 33: A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first? A. Chest x-ray B. Troponin level C. Electrocardiogram (ECG) D. Insertion of a peripheral IV

C. Electrocardiogram (ECG) Explanation/Rationale:The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral access will be needed but not before the ECG.

CH 35: A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? A. Obtain a 12-lead electrocardiogram (ECG). B. Notify the health care provider of the change in rhythm. C. Give supplemental O2 at 2 to 3 L/min via nasal cannula. D. Assess the patient's vital signs including O2 saturation.

C. Give supplemental O2 at 2 to 3 L/min via nasal cannula. Explanation/Rationale:Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly.

CH 33: A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication? A. Administer the medication at the patient's usual bedtime. B. Have the patient take the colesevelam 1 hour before breakfast. C. Give the patient's other medications 2 hours after colesevelam. D. Have the patient take the dose at the same time as the prescribed aspirin.

C. Give the patient's other medications 2 hours after colesevelam. Explanation/Rationale:The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals.

CH 33: Heparin is ordered for a patient with a non‒ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? A. Heparin enhances platelet aggregation at the plaque site. B. Heparin decreases the size of the coronary artery plaque. C. Heparin prevents the development of new clots in the coronary arteries. D. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

C. Heparin prevents the development of new clots in the coronary arteries. Explanation/Rationale:Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

Ch 32: Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension? A. Most people are able to control BP through dietary changes. B. Annual BP checks are needed to monitor treatment effectiveness. C. Hypertension is usually asymptomatic until target organ damage occurs. D. Increasing physical activity alone controls blood pressure (BP) for most people.

C. Hypertension is usually asymptomatic until target organ damage occurs. Explanation/Rationale:Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.

31: When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? A. Patient complaint of feeling tired B. Sinus tachycardia at a rate of 110 beats/min C. Inversion of T waves on the electrocardiogram D. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg

C. Inversion of T waves on the electrocardiogram Explanation/Rationale:ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate O2 delivery and that the exercise test should be terminated immediately. Increases in BP and heart rate are normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases during the stress testing.

CH 36: Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? A. Pulsus paradoxus 8 mm Hg B. Blood pressure (BP) of 168/94 mm Hg C. Jugular venous distention (JVD) to jaw level D. Level 6 (0 to 10 scale) chest pain with a deep breath

C. Jugular venous distention (JVD) to jaw level Explanation/Rationale:The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis.

CH 36: A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? A. Biologic valves will require immunosuppressive drugs after surgery. B. Mechanical mitral valves need to be replaced sooner than biologic valves. C. Lifelong anticoagulant therapy is needed after mechanical valve replacement. D.Ongoing cardiac care by a health care provider is not necessary after valvuloplasty

C. Lifelong anticoagulant therapy is needed after mechanical valve replacement. Explanation/Rationale:Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system and immunosuppressive therapy is not needed.

CH 34: A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Teach the patient the reasons for remaining on bed rest. B. Change the peripheral IV site according to agency policy. C. Monitor the patient's blood pressure and heart rate every hour. D. Titrate the rate to keep the systolic blood pressure >90 mm Hg.

C. Monitor the patient's blood pressure and heart rate every hour. Explanation/Rationale:An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive drugs, and inserting a new peripheral IV catheter require RN level education and scope of practice.

CH 33: Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? A. An increase in troponin levels from baseline B. A large bruise at the patient's IV insertion site C. No change in the patient's reported level of chest pain D. A decrease in ST-segment elevation on the electrocardiogram

C. No change in the patient's reported level of chest pain Explanation/Rationale:Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac biomarkers into the circulation as the blocked vessel is opened.

CH 36: A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give? A. Fentanyl 1 mg IV B. IV morphine sulfate 4 mg C. Oral ibuprofen (Motrin) 600 mg D. Oral acetaminophen (Tylenol) 650 mg

C. Oral ibuprofen (Motrin) 600 mg Explanation/Rationale:The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (e.g., ibuprofen) are most effective. Opioid analgesics and acetaminophen are not very effective for the pain associated with pericarditis.

CH 36: The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient? A. Patient admitted with a large acute myocardial infarction B. Patient being discharged after an exacerbation of heart failure C. Patient who had a mitral valve replacement with a mechanical valve D. Patient being treated for rheumatic fever after a streptococcal infection

C. Patient who had a mitral valve replacement with a mechanical valve Explanation/Rationale:Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.

CH 31: A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? A. Start an IV line. B. Start O2 per nasal cannula. . C. Place the patient on NPO status. D. Give lorazepam (Ativan) 1 mg IV

C. Place the patient on NPO status. Explanation/Rationale:The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.

CH 35: A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? A. Immediately notify the health care provider. B. Document the rhythm and continue to monitor the patient. C. Prepare to give IV amiodarone per agency dysrhythmia protocol. D. Perform synchronized cardioversion per agency dysrhythmia protocol.

C. Prepare to give IV amiodarone per agency dysrhythmia protocol. Explanation/Rationale:The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

CH 33: 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? A. Heart rate 102 beats/min B. Pedal pulses 1+ bilaterally C. Report of severe chest pain D. Blood pressure 103/54 mm Hg

C. Report of severe chest pain Explanation/Rationale:The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

CH 33: Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? A. Inverted P wave B. Sinus tachycardia C. ST-segment elevation D. First-degree atrioventricular block

C. ST-segment elevation Explanation/Rationale:The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly.

CH 34: A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? A. Presence of 1+ to 2+ edema in the feet and ankles B. Palpable liver edge 2 cm below the ribs on the right side C. Serum potassium level 3.0 mEq/L after 1 week of therapy D. Weight increase from 120 pounds to 122 pounds over 3 days

C. Serum potassium level 3.0 mEq/L after 1 week of therapy Explanation/Rationale:Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions) and potentiate the actions of digoxin. Hypokalemia also increases the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

CH 31: Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan? A. Insert an IV catheter. B. Administer oral sedative medications. C. Teach the patient about the procedure. D. Confirm that the patient has been fasting.

C. Teach the patient about the procedure. Explanation/Rationale:The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary.

CH 35: Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of patients with ICDs? A. The nurse administers amiodarone (Cordarone) to the patient. B. The nurse helps the patient fill out the application for obtaining a Medic Alert device. C. The nurse encourages the patient to do active range of motion exercises for all extremities. D. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.

C. The nurse encourages the patient to do active range of motion exercises for all extremities. Explanation/Rationale:The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

CH 32: After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most effective? A. The patient avoids eating nuts or nut butters. B. The patient restricts intake of chicken and fish. C. The patient drinks low-fat milk with each meal. D. The patient has two cups of coffee in the morning.

C. The patient drinks low-fat milk with each meal. Explanation/Rationale:For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

CH 31: Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI? A. The patient has an allergy to shellfish. B. The patient has a history of atherosclerosis. C. The patient has a permanent cardiac pacemaker. D. The patient took the prescribed heart medications today.

C. The patient has a permanent cardiac pacemaker. Explanation/Rationale:MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information does not affect whether or not the patient can have an MRI.

CH 32: During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? A. The patient's pulse has dropped from 68 to 57 beats/min. B. The patient complains that the fingers and toes feel quite cold. C. The patient has developed wheezes throughout the lung fields. D. The patient's blood pressure (BP) reading is now 158/91 mm Hg.

C. The patient has developed wheezes throughout the lung fields.

CH 35: Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? A. The procedure prevents or minimizes the risk for sudden cardiac death. B. The procedure uses cold therapy to stop the formation of the flutter waves. C. The procedure uses electrical energy to destroy areas of the conduction system. D. The procedure stimulates the growth of new conduction pathways between the atria.

C. The procedure uses electrical energy to destroy areas of the conduction system. Explanation/Rationale:Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect.

CH 35: The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? A. Count the number of large squares in the R-R interval and divide by 300. B. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. C. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. D. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

C. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. Explanation/Rationale:This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer.

CH 33: During the administration of the thrombolytic agent to a patient with an acute myocardial infarction, the nurse should stop the drug infusion if the patient experiences A. bleeding from the gums. B. increase in blood pressure. C. a decrease in level of consciousness. D. a nonsustained episode of ventricular tachycardia.

C. a decrease in level of consciousness. Explanation/Rationale:The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

CH 31: A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that A. it will be important not to move at all during the procedure. B. monitored anesthesia care will be provided during the procedure. C. a flushed feeling may be noticed when the contrast dye is injected. D. arterial pressure monitoring will be required for 24 hours after the test.

C. a flushed feeling may be noticed when the contrast dye is injected. Explanation/Rationale:A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

CH 34: IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate down if the patient develops A. ventricular ectopy. B. a dry, hacking cough. C. a systolic BP below 90 mm Hg. D. a heart rate below 50 beats/min.

C. a systolic BP below 90 mm Hg. Explanation/Rationale:Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

CH 31: During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to A. ask about risk factors for atherosclerosis. B. determine family history of heart disease. C. assess for symptoms of left ventricular hypertrophy. D. auscultate carotid arteries for the presence of a bruit.

C. assess for symptoms of left ventricular hypertrophy. Explanation/Rationale:The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.

CH 34: A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. The nurse's priority action will be to A. have the patient recall the dietary intake for the past 3 days. B. ask the patient about the use of the prescribed medications. C. assess the patient for clinical manifestations of acute heart failure. D. teach the patient about the importance of restricting dietary sodium.

C. assess the patient for clinical manifestations of acute heart failure. Explanation/Rationale:The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

CH 36: While caring for a 23-yr-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to A. take antibiotics before any dental appointments. B. limit physical activity to avoid stressing the heart. C. avoid over-the-counter (OTC) drugs that contain stimulants. D. take an aspirin a day to prevent clots from forming on the valve.

C. avoid over-the-counter (OTC) drugs that contain stimulants. Explanation/Rationale:Use of stimulant drugs should be avoided by patients with MVP because they may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.

CH 33: Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will A. reduce heart palpitations. B. prevent coronary artery plaque. C. decrease coronary artery spasms. D. increase contractile force of the heart.

C. decrease coronary artery spasms. Explanation/Rationale:Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and b-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.

CH 32: A 56-yr-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that A. a BP recheck should be scheduled in a few weeks. B. dietary sodium and fat content should be decreased. C. diagnosis, treatment, and ongoing monitoring will be needed. D. there is an immediate danger of a stroke, requiring hospitalization.

C. diagnosis, treatment, and ongoing monitoring will be needed. Explanation/Rationale:A sudden increase in BP in a patient older than age 50 years with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

CH 34: While assessing a 68-yr-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates A. decreased fluid volume. B. jugular vein atherosclerosis. C. increased right atrial pressure. D. incompetent jugular vein valves.

C. increased right atrial pressure. Explanation/Rationale:The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

CH 36: During discharge teaching with an older patient who had a mitral valve replacement with a mechanical valve, the nurse must instruct the patient on the A. use of daily aspirin for anticoagulation. B. correct method for taking the radial pulse. C. need for frequent laboratory blood testing. D. need to avoid any physical activity for 1 month.

C. need for frequent laboratory blood testing. Explanation/Rationale:Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.

CH 34: The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include A. limit dietary sources of potassium. B. take the hydrochlorothiazide before bedtime. C. notify the health care provider if nausea develops. D.take the digoxin if the pulse is below 60 beats/min.

C. notify the health care provider if nausea develops. Explanation/Rationale:Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60 beats/min, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

CH 34: A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as A. orthopnea. B. pulsus alternans. C. paroxysmal nocturnal dyspnea. D. acute bilateral pleural effusion.

C. paroxysmal nocturnal dyspnea. Explanation/Rationale:Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

CH 33: A patient with diabetes mellitus and chronic stable angina has a new order for captopril . The nurse should teach the patient that the primary purpose of captopril is to A. decrease the heart rate. B. control blood glucose levels. C. prevent changes in heart muscle. D. reduce the frequency of chest pain.

C. prevent changes in heart muscle. Explanation/Rationale:The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

CH 32: Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of A. daily alcohol use. B. peptic ulcer disease. C. reactive airway disease. D. myocardial infarction (MI).

C. reactive airway disease. Explanation/Rationale:Nonselective b-blockers block b1- and b2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. b-Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. b-Blocker therapy is recommended after MI.

CH 34: The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that A. she will take furosemide (Lasix) every day at bedtime. B. the nitroglycerin patch is to be used when chest pain develops. C. she will call the clinic if her weight goes up 3 pounds in 1 week. D. an additional pillow can help her sleep if she is short of breath at night.

C. she will call the clinic if her weight goes up 3 pounds in 1 week. Explanation/Rationale:Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as needed" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed.

CH 36: When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for A. diastolic murmur. B. peripheral edema. C. shortness of breath on exertion. D. right upper quadrant tenderness.

C. shortness of breath on exertion. Explanation/Rationale:The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia, which is a priority.

CH 36: When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of A. flank pain. B. splenomegaly. C. shortness of breath. D. mental status changes.

C. shortness of breath. Explanation/Rationale:Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves.

CH 35: 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).

C. third-degree atrioventricular (AV) block. Explanation/Rationale:The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent PR intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.

CH 36: I The nurse obtains a health history from an older patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most focused on identifying a risk factor for IE? A. "Do you have a history of a heart attack?" B. "Is there a family history of endocarditis?" C. "Have you had any recent immunizations?" D. "Have you had dental work done recently?"

D. "Have you had dental work done recently?" Explanation/Rationale:Dental procedures place the patient with a prosthetic mitral valve at risk for IE. Myocardial infarction, immunizations, and a family history of endocarditis are not risk factors for IE.

CH 33: After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? A. "I can expect nausea as a side effect of nitroglycerin." B. "I should only take nitroglycerin when I have chest pain." C. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart." D. "I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart."

D. "I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart." Explanation/Rationale:The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

CH 33: Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? A. "I will switch from whole milk to 1% milk." B. "I like salmon and I will plan to eat it more often." C. "I can have a glass of wine with dinner if I want one." D. "I will miss being able to eat peanut butter sandwiches."

D. "I will miss being able to eat peanut butter sandwiches." Explanation/Rationale:Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

CH 36: Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective? A. "I will avoid taking aspirin or other antiinflammatory drugs." B. "I can restart my exercise program that includes hiking and biking." C. "I will need to limit my intake of salt and fluids even in hot weather." D. "I will take antibiotics before my teeth are cleaned at the dental office."

D. "I will take antibiotics before my teeth are cleaned at the dental office." Explanation/Rationale:Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or nonsteroidal antiinflammatory drugs.

CH 35: The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states A. "It will be several weeks before I can return to my usual activities." B. "I will avoid cooking with a microwave oven or being near one in use." C. "I will notify the airlines when I make a reservation that I have a pacemaker." D. "I won't lift the arm on the pacemaker side until I see the health care provider."

D. "I won't lift the arm on the pacemaker side until I see the health care provider." Explanation/Rationale:The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

CH 33: Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? A. "The pain wakes me up at night." B. "The pain is level 3 to 5 (0 to 10 scale)." C. "The pain has gotten worse over the last week." D. "The pain goes away after a nitroglycerin tablet."

D. "The pain goes away after a nitroglycerin tablet." Explanation/Rationale:Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

Ch 31 Which instruction by the nurse is given to a patient who is about to undergo Holter monitoring is most appropriate? 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." Answer: D A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.

CH 36: A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder? A. A heart transplant should be scheduled as soon as possible. B. Elevating the legs above the heart will help relieve dyspnea. C. Careful compliance with diet and medications will prevent heart failure. D.Notify the health care provider about symptoms such as shortness of breath

D. .Notify the health care provider about symptoms such as shortness of breath Explanation/Rationale:The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation.

CH 33: After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? A. A 39-yr-old patient with pericarditis who is complaining of sharp, stabbing chest pain B. A 56-yr-old patient with variant angina who is scheduled to receive nifedipine (Procardia) C. A 65-yr-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge D. A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)

D. A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI) Explanation/Rationale:After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

CH 35: 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

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due Explanation/Rationale:The frequent firing of the ICD indicates that the patient's ventricles are very irritable and the priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given.

CH 35: A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? A. Recheck the heart rhythm and BP in 5 minutes. B. Have the patient perform the Valsalva maneuver. C. Give the scheduled dose of diltiazem (Cardizem). D. Apply the transcutaneous pacemaker (TCP) pads.

D. Apply the transcutaneous pacemaker (TCP) pads. Explanation/Rationale:The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.

CH 32: Hypertension Item Bank: Lewis Medical-Surgical Nursing, 10th Edition Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension? A. Encourage the use of hard candy to prevent dry mouth. B. Teach the patient that headaches often occur with this drug. C. Instruct the patient to call for help if heart palpitations occur. D. Ask the patient to request assistance before getting out of bed.

D. Ask the patient to request assistance before getting out of bed. Explanation/Rationale:Labetalol decreases sympathetic nervous system activity by blocking both a- and b-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

CH 31: To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory test result will the nurse plan to review? A. Troponin B. Homocysteine (Hcy) C. Low-density lipoprotein (LDL) D. B-type natriuretic peptide (BNP)

D. B-type natriuretic peptide (BNP) Explanation/Rationale:Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).

CH 34: Which topic will the nurse plan to include in discharge teaching for a patient with heart failure with reduced ejection fraction (HFrEF)? A. Need to begin an aerobic exercise program several times weekly B. Use of salt substitutes to replace table salt when cooking and at the table C. Importance of making an annual appointment with the health care provider D. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

D. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors Explanation/Rationale:The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.

CH 34: An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? A. 2+ bilateral pedal edema B. Heart rate of 56 beats/min C. Complaints of increased fatigue D. Blood pressure (BP) of 88/42 mm Hg

D. Blood pressure (BP) of 88/42 mm Hg Explanation/Rationale:The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of 56 is not unusual though it may need to be monitored. b-Adrenergic blockade initially will worsen symptoms of heart failure in many patients and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

CH 33: A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI? A. Myoglobin B. Homocysteine C. C-reactive protein D. Cardiac-specific troponin

D. Cardiac-specific troponin Explanation/Rationale:Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease but are not helpful in determining whether an acute MI is in progress.

CH 33: A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which nursing diagnosis is a priority for the patient? A. Acute pain related to myocardial infarction B. Anxiety related to perceived threat of death C. Stress overload related to acute change in health D. Decreased cardiac output related to cardiogenic shock

D. Decreased cardiac output related to cardiogenic shock Explanation/Rationale:All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

CH 31: While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next? A. Teach the patient about aneurysms. B. Notify the hospital rapid response team. C. Instruct the patient to remain on bed rest. .D. Document the finding in the patient chart.

D. Document the finding in the patient chart. Explanation/Rationale:Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.

CH 31: The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat in bed. Which follow-up action should the nurse take next? A. Obtain vital signs, including oxygen saturation. B. Have the patient perform the Valsalva maneuver. C. Document this JVD finding in the patient's record. D. Observe for JVD with the patient elevated 45 degrees.

D. Observe for JVD with the patient elevated 45 degrees. Explanation/Rationale:When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated.

CH 32: The nurse is caring for a 70-yr-old patient who uses hydrochlorothiazide and enalapril (Norvasc) but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? A. Patient takes a daily multivitamin tablet. B. Patient checks BP daily just after getting up. C. Patient drinks wine three to four times a week. D. Patient uses ibuprofen (Motrin) treat osteoarthritis.

D. Patient uses ibuprofen (Motrin) treat osteoarthritis. Explanation/Rationale:Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient's alcohol intake is not excessive.

CH 35: To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's A. P wave. B. Q wave. C. PR interval. D. QRS complex.

D. QRS complex. Explanation/Rationale:The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short.

CH 35: When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) A. isoelectric ST segment. B. PR interval of 0.18 second. C. QT interval of 0.38 second. D. QRS interval of 0.14 second.

D. QRS interval of 0.14 second. Explanation/Rationale:Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat).

CH 34: The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? A. Weight loss of 2 lb in 24 hours B. Hourly urine output greater than 60 mL C. Reduction in patient complaints of chest pain D. Reduced dyspnea with the head of bed at 30 degrees

D. Reduced dyspnea with the head of bed at 30 degrees Explanation/Rationale:Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response.

CH 33: A patient had a non‒ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Evaluation of the patient's response to walking in the hallway B. Completion of the referral form for a home health nurse follow-up C. Education of the patient about the pathophysiology of heart disease D. Reinforcement of teaching about the purpose of prescribed medications

D. Reinforcement of teaching about the purpose of prescribed medications Explanation/Rationale:LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient's response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning and referral are skills that require RN education and scope of practice.

CH 35: Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? A. Blood glucose of 243 mg/dL B. Serum chloride of 92 mEq/L C. Serum sodium of 134 mEq/L D. Serum potassium of 2.9 mEq/L

D. Serum potassium of 2.9 mEq/L Explanation/Rationale:Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values are also abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction.

CH 32: The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside . Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). B. Assess the patient's environment for adverse stimuli that might increase BP. C. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. D. Set up the automatic noninvasive BP machine to take readings every 15 minutes.

D. Set up the automatic noninvasive BP machine to take readings every 15 minutes. Explanation/Rationale:LPN/LVN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. The other actions require advanced nursing judgment and education, and should be done by RNs.

CH 31: The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse? A. A right bundle-branch block. B. The PR interval is 0.21 seconds. C. The QRS duration is 0.13 seconds. D. The heart rate (HR) is 41 beats/min.

D. The heart rate (HR) is 41 beats/min. Explanation/Rationale:The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches.

CH 36: The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important? A. The patient has a history of a recent upper respiratory infection. B. The patient has a family history of coronary artery disease (CAD). C. The patient reports using cocaine a "couple of times" as a teenager. D. The patient's 29-yr-old brother died from a sudden cardiac arrest.

D. The patient's 29-yr-old brother died from a sudden cardiac arrest. Explanation/Rationale:About half of all cases of hypertrophic CMP have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (e.g., an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not currently at risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy but not for hypertrophic CMP.

CH 32: Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? A. Organize nursing activities so that the patient has undisturbed sleep for 8 hours at night. B. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. C. Assist the patient up in the chair for meals to avoid complications associated with immobility. D. Use an automated noninvasive blood pressure machine to obtain frequent measurements.

D. Use an automated noninvasive blood pressure machine to obtain frequent measurements. Explanation/Rationale:Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

CH 36: Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? A. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. B. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. C. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. D. Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

D. Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates. Explanation/Rationale:Under the supervision of registered nurses (RNs), UAPs check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.

CH 34: Following an acute myocardial infarction, a previously healthy 63-yr-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about A. b-Adrenergic blockers. B. calcium channel blockers. C. digitalis and potassium therapy regimens. D. angiotensin-converting enzyme (ACE) inhibitors.

D. angiotensin-converting enzyme (ACE) inhibitors. Explanation/Rationale:ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The b-adrenergic blockers are not used as initial therapy for new onset heart failure.

CH 34: A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? A. captopril 25 mg B. furosemide (Lasix) 60 mg C. digoxin (Lanoxin) 0.125 mg D. carvedilol (Coreg) 3.125 mg

D. carvedilol (Coreg) 3.125 mg Explanation/Rationale:Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other drugs are appropriate for the patient with ADHF.

CH 31: A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require A. emergent cardioversion. B. a cardiac catheterization. C. hourly blood pressure (BP) checks. D. electrocardiographic (ECG) monitoring.

D. electrocardiographic (ECG) monitoring. Explanation/Rationale:Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.

31: The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to A. connect the recorder to a computer once daily. B. exercise more than usual while the monitor is in place. C. remove the electrodes when taking a shower or tub bath. D. keep a diary of daily activities while the monitor is worn.

D. keep a diary of daily activities while the monitor is worn. Explanation/Rationale:The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed.

CH 33: Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for A. decreased blood pressure and heart rate. B. fewer complaints of having cold hands and feet. C. improvement in the strength of the distal pulses. D. participation in daily activities without chest pain.

D. participation in daily activities without chest pain. Explanation/Rationale:Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective b-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

CH 36: The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. An appropriate intervention by the nurse for this problem is to A. teach the patient to take deep, slow breaths to control the pain. B. force fluids to 3000 mL/day to decrease fever and inflammation. C. provide a fresh ice bag every hour for the patient to place on the chest. D. place the patient in Fowler's position, leaning forward on the overbed table.

D. place the patient in Fowler's position, leaning forward on the overbed table. Explanation/Rationale:Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Ice does not decrease this type of inflammation and pain.

CH 34: While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a A. plan for around-the-clock care. B. consultation with a psychologist. C. transfer to a long-term care facility. D. referral to a home health care agency.

D. referral to a home health care agency. Explanation/Rationale:The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.

CH 35: The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as A. atrial flutter. B. sinus tachycardia. C. ventricular fibrillation. D. ventricular tachycardia.

D. ventricular tachycardia. Explanation/Rationale:The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

CH 35: When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.

Explanation/Rationale:50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30.

CH 35: When preparing to defibrillate a patient, in which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear."

Explanation/Rationale:A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff.