EXAM 4
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first?
Assess airway, breathing, and level of consciousness
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. What would be the most focused follow-up action for the nurse to take?
Assess for symptoms of left ventricular hypertrophy.
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?
Attaching ECG monitoring electrodes after a patient bathes
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond?
Clients who use cocaine are at risk for fatal dysrhythmias.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization?
a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results.
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess?
a. Decrease in cardiac output d. Increase in blood pressure e. Decrease in urine output
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram?
b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
A 45-year-old American Indian woman with diabetes mellitus
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?
A 50-year-old who is post coronary artery bypass graft surgery
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
A patient is scheduled for a cardiac catheterization with coronary angiography. What information should the nurse provide before the procedure?
A flushed feeling is common when the contrast dye is injected.
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
Allergies to iodine-based agents
A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first?
Ask the client what medications he or she takes.
A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first?
Assess the clients medications.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
Assess the color and temperature of the left leg.
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next?
Assess vital signs and level of consciousness.
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?
Avoid straining while having a bowel movement.
Which laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure?
B-type natriuretic peptide (BNP)
How should the nurse document a loud humming sound auscultated over the patient's abdominal aorta?
Bruit
When the nurse is screening patients for possible peripheral arterial disease, indicate where the posterior tibial artery will be palpated
C
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?
Clean the skin and clip hairs if needed.
A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
Compare the results with previous pulmonary artery pressure readings.
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To obtain more information about the murmur, which action should the nurse take?
Determine the timing of the sound.
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
Disorientation and confusion
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?
Document the finding in the patient chart.
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard?
Document the finding.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client?
Ensure that everyone is clear of contact with the client and the bed.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
Heart rate of 120 beats/min
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate rapidly to the health care provider?
High troponin I level
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
I get short of breath when I climb stairs
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
I will avoid sources of strong electromagnetic fields.
The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next?
Initiate cardiopulmonary resuscitation (CPR).
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?
Initiation of an external pacemaker
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?
Inversion of T waves on the electrocardiogram
A patient will be evaluated for rhythm disturbances with a Holter monitor. What should the nurse teach the patient to do?
Keep a diary of daily activities while the monitor is worn.
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
Level of consciousness
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
Location A
A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?
Medication reconciliation
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
Mid-sternal chest pain
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching?
Minimize or abstain from caffeine.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
My shoes fit tighter by the end of the day
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
Notify the health care provider before scheduling the MRI.
The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat. Which follow-up action should the nurse take?
Observe the neck veins with the patient elevated 45 degrees.
A transesophageal echocardiogram (TEE) is planned for a patient hospitalized with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first?
Place the patient on NPO status.
The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." Which patient should the nurse call the health care provider about?
Postoperative patient with a BP of 116/42 mm Hg.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
Pulse decreased from 100 beats/min to 80 beats/min
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?
Schedule periods of exercise and rest during the day
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?
Short period of asystole
A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip?
Sinus rhythm with premature ventricular contractions (PVCs)
After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventriculartachycardia, the nurse documents the findings and compares these with the previous assessment findings:
Slow the amiodarone infusion rate.
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
Slurred speech and confusion
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
Speech alterations
While listening at the mitral area, the nurse notes abnormal heart sounds at the patient's 5th intercostal space, midclavicular line. After listening to the audio clip, describe how the nurse will document the assessment finding.
Systolic murmur at mitral area
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?
Systolic murmur heard at mitral area.
Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?
Teach the patient about the procedure.
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
Tell me more about your concerns about the surgery
The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy older adult patient who is having an annual physical examination. What finding should be of most concern to the nurse?
The heart rate (HR) is 41 beats/min.
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?
The patient has a permanent cardiac pacemaker.
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is important for the nurse to communicate to the health care provider before the test?
The patient is allergic to shellfish.
A registered nurse (RN) is observing a student nurse who is assessing a patient. Which action observed by the RN requires immediate intervention?
The student nurse palpates both carotid arteries simultaneously to compare pulse quality.
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial damage?
Troponins
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?
Turn off oxygen therapy.
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
Use pillows to elevate your head and chest while you are sleeping.
How should the nurse listen to auscultate for S3 or S4 gallops in the mitral area?
Use the bell of the stethoscope with the patient in the left lateral position.
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?
Ventricular and atrial depolarizations are initiated from different sites.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition?
Warfarin (Coumadin)
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
What do you understand about what happened to you?
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?
You should balance weight loss with consuming necessary nutrients.
A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching?
a. Smoking cessation b. Stress reduction and management d. Adverse effects of medications
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess?
a. Thrombophlebitis c. Pulmonary embolism e. Cardiac tamponade
A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis?
a. Total cholesterol: 280 mg/dL c. Triglycerides: 200 mg/dL e. Low-density lipoprotein cholesterol: 160 mg/dL
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching?
a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. e. Do not lift your left arm above the level of your shoulder for 8 weeks.
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure?
b. Prepare for continuous blood pressure and pulse monitoring. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse?
b. Serum potassium of 2.9 mEq/L d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor
An older adult patient who has just arrived in the emergency department has a pulse deficit of 46 beats. The nurse should expect that the patient may require:
electrocardiographic monitoring.
