Med surg exam 3 Ch 33, 34, 36

Surgical Management

Abdominal aortic aneurysm resection Thoracic aortic aneurysm repair Endovascular repair

Buerger's Disease

Pg 729 Table 36-7. Read on those..

Aortic Dissection

--->May be caused by sudden tear in aortic intima --->Pain described as tearing, ripping, stabbing --->Life threatening --->Emergency care goals: Eliminate pain Reduce blood pressure Decrease velocity of left ventricular ejection --->Nonsurgical treatment --->Surgical treatment

Assessment of Abdominal Aortic Aneurysm (AAA)

--->Pain related to AAA is usually steady with a gnawing quality, unaffected by movement, may last for hours or days --->Pain in abdomen, flank, back --->Abdominal mass is pulsatile --->Rupture is most frequent complication and is life threatening

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? a. Minimize or abstain from caffeine. b. Lie on your side until the attack subsides. c. Use your oxygen when you experience PACs. d. Take amiodarone (Cordarone) daily to prevent PACs.

ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

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? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. Clean the skin and clip hairs if needed. b. Add gel to the electrodes prior to applying them. c. Place the electrodes on the posterior chest. d. Turn off oxygen prior to monitoring the client.

ANS: A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic

3. A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.) a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder for 8 weeks.

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

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? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

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. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

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? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

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? a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

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? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98 F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Temperature: 98.2 F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the clients heart rate.

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? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

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? a. I should wear a snug-fitting shirt over the ICD. b. I will avoid sources of strong electromagnetic fields. c. I should participate in a strenuous exercise program. d. Now I can discontinue my antidysrhythmic medication.

ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

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? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

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? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. *QRS complexes without a P wave indicate a different source of initiation of depolarization*. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

Peripheral Arterial Disease (PAD)

Alters natural flow of blood through arteries and veins of peripheral circulation Result of systemic atherosclerosis

Aneurysms of Central Arteries

Aneurysm - Permanent localized dilation of artery, enlarging artery to twice its normal diameter Types: Fusiform Saccular Dissecting (aortic dissection) Abdominal aortic Thoracic aortic

The pt is having a treadmill test. Which of the following is an important teaching point? 1. Comfortable clothing & shoes should be worn for the test. 2. A pt gown & slippers should be worn for the test. 3. Smoking is permitted up until the time of the test. 4. There are no restrictions prior to the test in the foods eaten as long as small meals are planned the day of the test.

Answer: 1 Rationale 1: Pt teaching is based on understanding how the test will be conducted. Comfortable & safe clothing is essential. The pt may be more comfortable in exercise clothing instead of a pt gown. Rationale 2: Slippers may not be safe so secure shoes should be worn for walking since speed is increased during the test. Rationale 3: Smoking is discouraged prior to testing. Rationale 4: The diet may be restrictive regarding the amount & types of foods allowed in order to prevent nausea & oxygen deprivation to the cardiac muscle.

When completing the health history of a pt w/ a suspected cardiac disorder, which of the following childhood illnesses should the nurse ask about? 1. rheumatic fever & strep throat infections 2. rubella & chicken pox 3. asthma & bronchitis 4. otitis media & respiratory syncytial virus (RSV)

Answer: 1 Rationale 1: Rheumatic fever & streptococcal throat infections are caused by beta- hemolytic streptococci, which have a propensity to form growths & calcium deposits on the leaflets of heart valves. This sets the individual up for valvular stenosis. Rationale 2,3,4: The other childhood illnesses are not directly related to cardiac disorders.

What physical assessment data is necessary to calculate a pt's cardiac index (CI)? 1. weight & height 2. weight only 3. weight & waist measurement 4. waist measurement & height

Answer: 1 Rationale 1: Cardiac index (CI) is the cardiac output adjusted for the pt's body size or body surface area. Body surface area is calculated using height & weight measurements. Rationale 2,3,4: Body surface area is calculated using height & weight measurements.

In the pt w/ hypovolemic shock, the nurse realizes that the heart sounds will change in which of the following ways? 1. diminished S2 & accentuated S1 2. accentuated S2 & diminished S1 3. diminished S1 & S2 4. no change in S1 or S2

Answer: 1 Rationale 1: Diminished S2 occurs due to a fall in blood pressure & accentuated S1 occurs because of the tachycardia. The three earliest signs of hypovolemic shock are tachycardia, delayed capillary refill, & restlessness.

Pericardiocentesis would be utilized in which of the following pt situations? 1. cardiac tamponade 2. slow heart rhythm 3. chest pain 4. suspected damage to a heart valve

Answer: 1 Rationale 1: In the case of cardiac tamponade, pericardiocentesis is considered an emergency procedure. It is done to remove fluid from the pericardial sac, which is preventing the heart from pumping blood effectively. Rationale 2: This procedure would not be recommended in pts w/ chest pain. Rationale 3: This procedure would not be recommended in pts w/ slow heart. Rationale 4: This procedure would not be recommended in pts suspected damage to a heart valve.

The nurse is reviewing an electrocardiogram (ECG) rhythm strip. The P waves & QRS complexes are regular. The PR interval is 0.16 second & QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which of the following would be a correct interpretation based on these characteristics? 1. normal sinus rhythm 2. sick sinus syndrome 3. sinus bradycardia 4. first-degree heart block

Answer: 1 Rationale 1: Normal sinus rhythm is defined as regular rhythm w/ a rate of 60-100 beats per minute. The PR & QRS measurements are normal, measuring 0.12 to 0.20 second & 0.06 to 0.10 second respectively.

When palpating a thrill on the precordium, the nurse recognizes this sign as being associated w/ which of the following cardiac conditions? 1. an enlarged heart 2. severe valve stenosis 3. stenosis of the carotid arteries 4. aortic aneurysm

Answer: 2 Rationale 2: A palpable thrill over the precordium is indicative of severe valve stenosis. Rationale 1: A thrill is not present merely when the heart is enlarged. Rationale 3: Stenosis of the carotid arteries would produce a thrill palpable on the neck over the carotid arteries, not the precordium. Rationale 4: Increased pulsations in the aortic area are indicative of an aortic aneurysm.

At which location will S1 be heard the loudest? 1. left midclavicular line at the fifth intercostal space 2. left sternal border at the fifth intercostal space 3. right sternal border at the third intercostal space 4. right midclavicular line at the fifth intercostal space

Answer: 1 Rationale 1: S1 is the sound produced by the atrioventricular (AV) valves closing. The apex of the heart is located lower on the left chest wall than the base of the heart. The loudest sounds can be heard over the apex of the heart. Rationale 2: The sound is audible at the left sternal boarder, but would not be as loud. Rationale 3: This sound would not normally be audible on the right midclavicular line at the third or fifth intercostal space, or at the right sternal border. Rationale 4: This sound would not normally be audible on the right midclavicular line at the third or fifth intercostal space, or at the right sternal border.

Which of the following would be an example of the term cardiac reserve? 1. getting on a treadmill & gradually increasing the pace of walking 2. breathing in through the nose & out the mouth while sitting quietly 3. sitting in a chair, to cool down, after having completed an exercise routine 4. at the end of systole, approximately 50 mL of blood remains in the ventricles

Answer: 1 Rationale 1: The heart's ability to respond to the body's changing need for cardiac output is called cardiac reserve. Increasing the pace of walking would place demand on the heart to increase blood flow. Rationale 2,3,4: The other options do not place demand on the heart.

When assessing the adult heart, the nurse expects to hear the following normal heart sounds: 1. S1 then S2 2. S2 then S3 3. S3 then S4 4. S2 then S1

Answer: 1 Rationale 1: The normal sequence of heart sounds is S1, then S2. Rationale 2: 2. S3 & S4 are considered abnormal heart sounds in adults. Rationale 3: 3. S3 & S4 are considered abnormal heart sounds in adults. Rationale 4: 4. The normal sequence of heart sounds is S1, then S2.

The nurse is caring for a pt admitted w/ a grade III heart murmur heard during midsystole. The nurse realizes that the following cardiac conditions could result in which assessment finding? Select all that apply. 1. aortic stenosis 2. cardiomyopathy 3. atrioventricular (AV) valve disease 4. mitral valve prolapse

Answer: 1,2 Rationale 1: Midsystolic murmurs are associated w/ semilunar valve disease & hypertrophic cardiomyopathies. A grade III murmur can be heard clearly & can be categorized as systolic (between S1 & S2), diastolic (between S2 & S1), pansystolic (all of systole) or continuous (heard throughout systole & all or part of diastole). Rationale 2: Midsystolic murmurs are associated w/ semilunar valve disease & hypertrophic cardiomyopathies. A grade III murmur can be heard clearly & can be categorized as systolic (between S1 & S2), diastolic (between S2 & S1), pansystolic (all of systole) or continuous (heard throughout systole & all or part of diastole). Rationale 3: Murmurs associated w/ atrioventricular (AV) valve disease or mitral valve prolapse would more often be heard during early or middiastole. Rationale 4: Murmurs associated w/ atrioventricular (AV) valve disease or mitral valve prolapse would more often be heard during early or middiastole.

The nurse reviews an ECG tracing & determines that it is not a high quality tracing. Which of the following factors can negatively influence an ECG tracing? Select all that apply. 1. pt movement during recording 2. history of COPD 3. incorrect positioning of leads 4. morbid obesity 5. leads in firm contact w/ the skin

Answer: 1,2,3,4 Rationale 1: Factors that can negatively impact the quality of an ECG tracing include motion artifact, which occurs when a pt moves during the recording. Rationale 2: Factors that can negatively impact the quality of an ECG tracing: a history of COPD. Rationale 3: Factors that can negatively impact the quality of an ECG tracing: incorrect positioning of leads. Rationale 4: Factors that can negatively impact the quality of an ECG tracing : morbid obesity. Rationale 5: Leads that are properly positioned & in firm contact w/ the skin ensure accuracy of the test.

The nurse is caring for a pt admitted w/ a grade III heart murmur heard during midsystole. The nurse realizes that the following cardiac conditions could result in which assessment finding? Select all that apply. 1. aortic stenosis 2. pulmonary stenosis 3. atrioventricular (AV) valve disease 4. mitral valve prolapse 5. cardiomyopathy

Answer: 1,2,5 Rationale 1: Midsystolic murmurs are associated w/ semilunar valve & hypertrophic cardiomyopathies. A grade III murmur can be heard clearly & can be categorized as systolic (between S1 & S2), diastolic (between S2 & S1), pansystolic (all of systole), or continuous (heard throughout systole & all or part of diastole). Rationale 2: Midsystolic murmurs are associated w/ semilunar valve & hypertrophic cardiomyopathies. A grade III murmur can be heard clearly & can be categorized as systolic (between S1 & S2), diastolic (between S2 & S1), pansystolic (all of systole), or continuous (heard throughout systole & all or part of diastole). Rationale 3: Murmurs associated w/ atrioventricular (AV) valve disease or mitral valve prolapse would more often be heard during early or mid-diastole. Rationale 4: Murmurs associated w/ atrioventricular (AV) valve disease or mitral valve prolapse would more often be heard during early or middiastole. Rationale 5: Midsystolic murmurs are associated w/ semilunar valve & hypertrophic cardiomyopathies. A grade III murmur can be heard clearly & can be categorized as systolic (between S1 & S2), diastolic (between S2 & S1), pansystolic (all of systole), or continuous (heard throughout systole & all or part of diastole).

The pt is admitted to the hospital for evaluation & diagnosis of cardiovascular pathology. The pt is scheduled for an ejection fraction study. Correct facts that will guide pt teaching include which of the following? Select all that apply. 1. An ejection fraction (EF) study will measure the % of total blood in the ventricle ejected from the heart w/ each beat. 2. 4. The normal ejection fraction is 95-100%. 3. An ejection fraction (EF) provides information about how effectively the heart is pumping. 4. Cardiac output is not an indicator of how well the heart is functioning 5. Stroke volume times heart rate equals cardiac output.

Answer: 1,3,5 Rationale 1: Correct facts that will guide teaching include an ejection fraction (EF) study will measure the percentage of total blood in the ventricle ejected from the heart w/ each beat. Rationale 2: Normal ejection fraction is 50-70%. Rationale 3: Correct facts that will guide teaching include an EF provides info about how effectively the heart is pumping. Rationale 4: Cardiac output is an indicator of how well the heart is pumping. Rationale 5: Correct facts that will guide teaching include SV x HR= CO

When auscultating the chest of a 75-year-old pt who recently experienced a myocardial infarction (MI), the nurse hears an S3 heart sound immediately following S2. Because of these findings, the nurse would assess for which other condition? 1. extension of the MI 2. heart failure 3. renal failure 4. liver failure

Answer: 2

A pt comes into the health clinic asking for advice on lowering the individual's risk of heart disease. The nurse's best response is to do which of the following? 1. Conduct a physical exam of the pt & discuss the findings. 2. Conduct a health history & physical exam to determine the pt's area of risks & then educate the pt based upon these findings. 3. Determine the pt's risks based upon a prior chart for the pt. 4. Discuss the pt's perceived area of health risks.

Answer: 2 Rationale 2: A thorough health history & physical exam should disclose a pt's risk factors. Rationale 12: Conducting a physical exam would discover some risk factors, but is not inclusive of the health history. Rationale 3: Using the pt's old chart may disclose some risk factors, but would not include any recent concerns. Rationale 4: Discussing the pt's perceived area of health risks will not be inclusive & may only capture those risks the pt is aware of. Modifiable risk factors can be evaluated & discussed w/ the pt.

In the pt w/ hypovolemic shock, the nurse realizes that the heart sounds will change in the which of the following ways? 1. diminished S1 & S2 2. diminished S2 & accentuated S1 3. accentuated S2 & diminished S1 4. no change in S1 or S2

Answer: 2 Rationale 3: Diminished S2 occurs due to a fall in BP & accentuated S1 occurs because of the tachycardia. The 3 earliest signs of hypovolemic shock are tachycardia, delayed capillary refill, & restlessness. Rationale 1,3,4: Diminished S2 occurs due to a fall in BP & accentuated S1 occurs because of the tachycardia.

At which location will S1 be heard the loudest? 1. left sternal border at the fifth intercostal space 2. left midclavicular line at the fifth intercostal space 3. right midclavicular line at the fifth intercostal space 4. right sternal border at the third intercostal space

Answer: 2 Rationale: S1 is the sound produced by the atrioventricular (AV) valves closing. The apex of the heart is located lower on the left chest wall than the base of the heart. The loudest sounds can be heard over the apex of the heart. The sound is audible at the left sternal border, but would not be as loud. This sound would not normally be audible on the right midclavicular line at the 5th intercostal space. This sound would not normally be audible at the sternal border.

The pt's ECG shows the following characteristics: PR interval .08, QRS .08, & isoelectric ST segment. The nurse realizes that these characteristics indicate which of the following? 1. faster than normal conduction from the SA node to the ventricles, faster than normal conduction through the ventricles & normal ST segment 2. faster than normal conduction from the SA node to the ventricles, normal conduction through the ventricles & normal ST segment 3. normal conduction from the SA node to the ventricles, normal conduction through the ventricles & normal ST segment 4. normal conduction from the SA node to the ventricles, normal conduction through the ventricles & abnormal ST segment

Answer: 2 Rationale: The PR interval is normally 0.12 second (up to 0.24 second is considered normal in pts over age 65). Rationale 1: The normal duration of a QRS complex is from 0.06 to 0.10 second. Rationale 3: The PR interval is normally 0.12 second (up to 0.24 second is considered normal in pts over age 65). Rationale 4: The ST segment, the period from the end of the ARS complex to the beginning of the T wave, should be isoelectric.

Place the following terms in the correct order (from outer to inner) to describe the coverings & layers of the heart. Choice 1. parietal layer of serous pericardium Choice 2. fibrous pericardium Choice 3. pericardial cavity Choice 4. myocardium Choice 5. endocardium Choice 6. epicardium

Answer: 2,1,3,5,6, 4 Global Rationale: The heart is covered by the fibrous pericardium & a parietal layer of serous pericardium. A serous lubricating fluid fills the pericardial cavity & cushions the heart. The outermost layer of the heart wall is the epicardium; the middle layer is the myocardium; & the innermost layer is the endocardium.

The S1 heart sound corresponds to which of the following physiological events? 1. closure of the semilunar valves 2. ejection of blood from the atria 3. closure of the AV valves 4. the onset of relaxation

Answer: 3 Rationale 3: S1 corresponds to the closure of the AV valves. Rationale 1: Closure of the semilunar valves corresponds to S2. Rationale 2: These valves are not associated w/ ejection of blood from just the atria or relaxation of the muscle. Rationale 4: These valves are not associated w/ ejection of blood from just the atria or relaxation of the muscle.

At what location will S2 be heard the loudest? 1. right midclavicular line at the third intercostal space 2. left midclavicular line at the fifth intercostal space 3. right sternal border at the second intercostal space 4. left sternal border at the fifth intercostal space

Answer: 3 Rationale 3: S2 is the sound produced by the closure of the aortic & pulmonic valves, & is best heard at the base of the heart, which is at the second intercostal space at the right sternal border. Rationale 1: The right midclavicular line at the third intercostal space is not optimal for auscultating heart sounds. The base of the heart is actually located higher on the chest wall than the apex. Rationale 2: S1 is best heard at the left midclavicular line at the fifth intercostal space. Rationale 4: S1 is best heard at the left midclavicular line at the fifth intercostal space.

When listening to heart sounds, the nurse expects to hear S1 & S2. The presence of an additional sound immediately following S2 is called _______, which can result from ______. 1. S4, increased resistance to ventricular filling 2. S4, inflammation of the pericardial sac 3. S3, ventricular volume overload 4. S3, a stenotic mitral valve

Answer: 3 Rationale 3: S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop & results from conditions having increased ventricular filling such as congestive heart failure (CHF), mitral valve regurgitation, or tricuspid valve regurgitation. Rationale 1: S4 immediately precedes S1 & can result from conditions such as anemia or a change in ventricular compliance. Rationale 2: S4 immediately precedes S1 & can result from conditions such as anemia or a change in ventricular compliance. Rationale 4: S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop & results from conditions having increased ventricular filling such as congestive heart failure (CHF), mitral valve regurgitation, or tricuspid valve regurgitation.

When listening to heart sounds, the nurse expects to hear S1 & S2. The presence of an additional sound immediately following S2 is called _____, which can result from _____. 1. S4, increased resistance to ventricular filling 2. S4, inflammation of the pericardial sac 3. S3, ventricular volume overload 4. S3, a stenotic mitral valve

Answer: 3 Rationale: S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop & results from conditions such as congestive heart failure (CHF), mitral, or tricuspid valve regurgitation. S4 immediately precedes S1 & can result from conditions such as anemia or a change in ventricular compliance. S4 immediately precedes S1 & can result from conditions such as anemia or a change in ventricular compliance. S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop & results from conditions such as congestive heart failure (CHF), mitral, or tricuspid valve regurgitation.

When the nurse assesses an apical heart rate & hears _____, it is called tachycardia. 1. less than 60 beats per minute 2. 60-90 beats per minute 3. 90 beats per minute 4. greater than 100 beats per minute

Answer: 4

A pt being evaluated for cardiac pathology asks the nurse why sodium, calcium, & potassium are so important in his diet. What is the nurse's best response? 1. "Because you are on potassium supplements, it is important to monitor electrolytes." 2. "Heart rate is affected by the oxygen levels in your body, which involves the attachment of oxygen molecules to these electrolytes." 3. "It is the pacemaker of your heart that is responsible for the heart beat." 1. "The action potentials of the heart muscle cells are dependent upon the diffusion of sodium, potassium & calcium across the cell membrane."

Answer: 4 Rationale 4: Action potentials of the cardiac muscle involve shifts in potassium, calcium, & sodium across the cell membrane. Rationale 1: There is not enough data to justify. Rationale 2: Oxygen molecules attach to the hemoglobin molecule, not electrolytes. Rationale 3: The pacemaker is responsible for the heartbeat but this response does not answer the pt's question.

When auscultating heart sounds, the pt is asked to lie on the left side, then sit up & lean forward. What is the rationale for this action? 1. It diminishes the effect of respiratory sounds during auscultation. 2. Use of the stethoscope diaphragm improves auscultation of high pitched murmurs. 3. Use of the bell side of the stethoscope allows low pitched sounds to be readily identified. 4. The heart is closer to the chest wall.

Answer: 4 Rationale 4: Asking the pt to lie on the left side, then sit & lean forward brings the heart closer to the chest wall & enhances auscultation. Rationale 1,2,3: The other options are not correct rationales for this action.

The pt is being evaluated for left atrium thrombus due to a dysrhythmia (altered heart rhythm). Which of the following cardiac tests will be ordered to assess for thrombus? 1. pericardiocentesis 2. cardiac catheterization 3. computed tomography (CT) 4. transesophageal echocardiography (TEE)

Answer: 4 Rationale 4: For this pt, the TEE test can assess for left atrial thrombi & is an expected test. Transesophageal echocardiography (TEE) allows visualization of adjacent cardiac & extracardiac structures, left atrium for thrombus, dissection of the aorta, endocarditis, left ventricle function, & repairs being made during cardiac surgery. Rationale 1: Pericardiocentesis is a procedure to remove fluid from the pericardial sac. Rationale 2: Cardiac catheterization is used to identify coronary artery disease (CAD) or valve disease, measure pulmonary artery or heart chamber pressures, obtain a biopsy, evaluate artificial valves or to angioplasty or stent an area in the coronary arteries. Rationale 3: A computed tomography (CT) scan can show calcium deposits in coronary arteries.

Place the following statement regarding cardiac catheterization in the correct order. 1. Inject contrast. 2. Catheter insertion in the leg. 3. Heart activity is filmed 4. Thread catheter to heart chamber. 5. Peripheral IV insertion.

Answer: 5,2,4,1,3

Determine the cardiac output (CO) of a pt whose stroke volume (SV) is 80 mL/beat & whose heart rate (HR) is 75 beats/minute. Round to the nearest whole number & place the answer below. _______

Answer: 6000 Rationale : Cardiac output is the amount of blood pumped by the ventricles into the pulmonary & systemic circulations in one minute. It is determined by multiplying the stroke volume by the heart rate (SV × HR = CO). Multiplying 80 mL/beat by 75 beats/minute equals 6000 mL.

Determine the ejection fraction (EF) of a pt whose stroke volume (SV) is 75 mL/beat & whose end-diastolic volume is 120 mL. Round to the nearest whole number & place the answer below. ____

Answer: 63 Rationale : The ejection fraction is the stroke volume divided by the end-diastolic volume & represents the fraction or percent of the diastolic volume that is ejected from the heart during systole. The normal ejection fraction ranges from 50% to 70%. Dividing 75 mL/beat by 120 mL equals 63%.

Arteriosclerosis

Arteriosclerosis—thickening or hardening of arterial wall often associated with aging Etiology and genetic predisposition

Assessment of Thoracic Aortic Aneurysm

Assess for: Back pain Manifestation of compression of aneurysm on adjacent structures Assess for shortness of breath Hoarseness Difficulty swallowing Mass may be visible above suprasternal notch Sudden excruciating back or chest pain symptomatic of thoracic rupture

Atherosclerosis

Atherosclerosis—type of arteriosclerosis involving formation of plaque within arterial wall Etiology and genetic predisposition

Drug Therapy

Beta-adrenergic blockers Renin inhibitors Central alpha agonists Alpha-adrenergic agonists Diuretics Calcium channel blockers ACE inhibitors Angiotensin II receptor antagonists Aldosterone receptor antagonists

Assessment

Calf or groin tenderness or pain Sudden onset of unilateral swelling of leg Checking Homans' sign not advised Localized edema Venous flow studies—venous duplex ultrasonography MRI d-dimer

Raynaud's Phenomenon

Caused by vasospasm of arterioles and arteries of upper and lower extremities Drug therapy: Nifedipine (Procardia), cyclandelate, phenoxybenzamine Lumbar sympathectomy Restrict cold exposure Reinforce patient education

Secondary Hypertension

Common causes: Renal disease Primary aldosteronism Pheochromocytoma Cushing's syndrome Medications

The nurse is caring for a pt who has just undergone cardiac catheterization. The catheter insertion site is free from bleeding or signs of hematoma. Vital signs & distal pulses remain w/in normal range. IV fluids were discontinued. The pt denies hunger or thirst & refuses food or fluids, asking to be left alone. Which of the following is the best response by the nurse? 1. "It is important that you drink fluids after the procedure to protect kidney function. I will bring you some fresh water." 2. "It is important that you ambulate, so I will return in 30 minutes to walk w/ you." 3. "You are recovering well from the procedure & rest is a good idea." 4. "You need to do the leg exercises that you practiced before the procedure to maintain good circulation to your legs. After your exercises, you can rest."

Correct Answer: 1 Rationale 1: The dye used in angiography is nephrotoxic & a pt should have adequate fluids after the procedure to eliminate the dye. Rationale 2: The pt should lie w/ the affected leg extended for 6 to 12 hours (or as ordered). Rationale 3: Option 3 is giving false reassurance to a pt who could be at risk if fluids are not ingested. Rationale 4: Leg exercises are not recommended as this could dislodge the clot at the insertion site.

An important nutritional-metabolic interview question to ask pts who are being evaluated for heart conditions is which of the following? 1. "Have you had a recent weight gain or loss?" 2. "Is there any change in your usual bowel elimination?" 3. "Has there been a change in your usual daily activities?" 4. "Have you experienced chest pain in the last week?"

Correct Answer: 1 Rationale 1: Weight gain can be linked to abnormal retention of fluids, which can affect heart function. Weight loss can be linked to level of nutrition or dehydration. The nutritional-metabolic functional health pattern guides questions that are related to weight gain or loss. Rationale 2:?'s regarding elimination are important but are categorized under other functional health patterns. Rationale 3: ?'s regarding daily activity are important but are categorized under other functional health patterns. Rationale 4: ?'s regarding chest pain are important but are categorized under other functional health patterns.

A pt is scheduled for a cardiac ejection fraction (EF) study. Correct facts that guide pt teaching include which of the following? Select all that apply. 1. Stroke volume times heart rate equals cardiac output. 2. The effectiveness of the pumping action of the heart is evaluated. 3. The study measures the percentage of blood in the ventricle ejected during a heartbeat. 4. The normal ejection fraction is 95-100%. 5. The study identifies the ischemic areas of the heart.

Correct Answer: 1,2,3 Rationale 4: The normal ejection fraction is 50-75%. Rationale 5: An ischemic area of the heart is not identified during an EF study.

A pt returns to the unit following a cardiac catheterization. Which are appropriate nursing interventions for this pt? Select all that apply. 1. Assess cardiac rhythm & rate. 2. Assess pt for complaints of shortness of breath. 3. Assess pulses proximal to the insertion site. 4. Maintain fluid restriction. 5. Maintain bed rest as ordered.

Correct Answer: 1,2,5 Rationale 1: Nursing interventions after the cardiac catheterization procedure include monitoring vital signs every 15 minutes for the first hour & then every 30 minutes until stable. Assess cardiac rhythm & rate for alterations. Rationale 2: Assess pt for complaints of chest heaviness, shortness of breath, & abdominal or groin pain. Rationale 3: Assess pulses distal to the insertion site. Assessing pulses proximal to the insertion site is not appropriate. Rationale 4: Encourage oral fluids unless contraindicated. Maintaining fluid restrictions is not appropriate. Rationale 5: Instruct pt to remain on bed rest as ordered.

Place the following steps in the correct order for interpreting an electrocardiogram (ECG) rhythm strip. 1. Assess P to QRS relationship. 2. Determine rate. 3. Assess P wave. 4. Identify abnormalities. 5. Determine regularity. 6. Determine interval durations.

Correct Answer: 2,5,3,1,6,4

The pt is being interviewed by the nurse. Which functional health pattern is related to asking the pt if she has had tests to check the function of her heart? 1. cognitive-perceptual 2. nutritional-metabolic 3. health perception-health management 4. activity-exercise

Correct Answer: 3 Rationale 3: The category of health perception-health management assists the nurse to gather info about past heart problems, tx for problems, previous diagnoses, previous tests & findings, & meds the pt has been prescribed. Rationale 1: The cognitive-perceptual pattern refers to the pt's ability to understand & process information. Rationale 2: The nutritional-metabolic pattern assesses intake patterns. Rationale 4: The activity-exercise pattern refers to the pt's level of physical activity.

The primary factor regulating blood flow through the coronary arteries is which of the following? 1. blood vessel dilation 2. the low pressure systemic circulation 3. blood pressure in the aorta 4. the draining of blood into the coronary sinus by the coronary veins

Correct Answer: 3 Rationale: Blood flow through the coronary arteries is primarily regulated by the aortic BP. Other factors include the blood vessel tone (constriction), HR, & metabolic activity of the heart.

The nurse is analyzing an ECG. Identify the correct order of the steps in this analyzing. Choice 1. Identify abnormalities. Choice 2. Assess P wave. Choice 3. Determine heart rate. Choice 4. Determine regularity of the rhythm. Choice 5. Determine interval durations. Choice 6. Assess P to QRS relationship.

Correct Answer: 3,4,2,6,5,1 Rationale 1: Begin by determining the heart rate. Rationale 2: Then determine regularity of the rhythm. Rationale 3: Assess the P wave. Rationale 4: Assessment of the P to QRS relationship. Rationale 5: Determine the interval durations. Rationale 6: Identify abnormalities

High-Risk Patients

Diabetes without signs of vascular disease Framingham heart study with risk factor of >20% for CAD events Multiple metabolic risk factors

Varicose Veins

Distended, protruding veins that appear darkened and tortuous Collaborative care: Elastic stockings Elevation of extremities Sclerotherapy Surgical removal of veins Radio frequency energy to heat veins

Acute Peripheral Arterial Occlusion

Embolus—most common cause of occlusions, although local thrombus may be cause May affect upper extremities but most common in lower extremities Drug therapy - Heparin Surgical therapy - Thombectomy or embolectomy Systemic thrombolytic therapy - t-PA 24-36hrs. Nursing care - observe for compartment syndrome

Interventions

Evaluate total serum cholesterol levels and lifestyle changes Nutrition therapy Drug therapy Smoking cessation Exercise Complementary and alternative therapies

Nonsurgical Management

Exercise and positioning Promote vasodilation Drug therapy (antiplatelet agents) Percutaneous transluminal angioplasty-Placement of a stent Atherectomy - Rotablator device to scrape plaque from inside the artery.

Aneurysms of the Peripheral Arteries

Femoral and popliteal aneurysms Symptoms: Limb ischemia Diminished or absent pulses Cool to cold skin Pain Treatment: Surgery Postoperative care: Monitor for pain

Drug Therapy

HMG-CoA reductase inhibitors (statins) Fibrinic acids Ezetimibe (Zetia)

Surgical Management

Thrombectomy Inferior vena caval interruption Ligation or external clips

Diagnostic Assessments

Imaging assessment (720 -721 Other: Ankle-brachial index (ABI) Exercise tolerance testing Plethysmography

Venous Thromboembolism (VTE)

Thrombus—a blood clot Thrombophlebitis Deep vein thrombosis (DVT) Pulmonary embolism Virchow's triad - Stasis of blood flow, endothelial injury, and/or hypercoagulability. Phlebitis - Vein inflammation

Phlebitis

Inflammation of superficial veins Management—warm, moist soaks; elastic stockings Complications—tissue necrosis, infection, pulmonary embolus

Physical Assessment

Intermittent claudication:("to limp")-pt walk only a certain distance before a cramping, burning muscle discomfort or pain forces them to stop. The pain staop after the rest. The pain is reproducible. Pain that occurs even while at rest; numbness and burning Inflow disease discomfort in lower back, buttocks, thighs Outflow disease burning or cramping in calves, ankles, feet, toes Hair loss and dry, scaly, pale or mottled skin, thickened toenails Severe arterial disease—extremity is cold and gray-blue or darkened; pallor may occur with extremity elevation; dependent rubor; and/or muscle atrophy

Laboratory Assessment

Lipid level, including cholesterol and triglycerides, elevated HDL and LDL High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup

Physical Assessment/Clinical Manifestations

Monitor BP Palpate pulses in all major sites of body Assess for prolonged capillary refill Assess for bruit

Assessment

Patient history Physical assessment Psychological assessment Diagnostic assessment

Know the different stages of Chronic Peripheral Arterial Disease

Pg. 719

Surgical Management

Preoperative Intraoperative Postoperative ----Deep breathing every 1-2 hr -----Monitor for graft occlusion (emergency) ------Treatment of graft occlusion ------Monitor for compartment syndrome ------Assess for infection Preoperative Intraoperative Postoperative Warmth, redness & edema of the affected extremity are often expected outcomes. Mark the site where the distal (dorsalis pedis or posterior tibial) is best palpated or heard by Doppler. Deep breathing every 1-2 hr & IS Monitor for graft occlusion (emergency) Treatment of graft occlusion-Thrombectomy Monitor for compartment syndrome Assess for infection

Six P's of Arterial InsufficiencyKNOW!!

Pulselessness Paresthesia Paralysis Poikilothermia (coolness) Pain Pallor

Vascular Trauma

Punctures Lacerations Transections Assess for circulatory, sensory, motor impairment

Nonsurgical Management

Rest, preventive measures Drug therapy: Unfractionated heparin Low-molecular weight heparin Warfarin Thrombolytics

Venous Insufficiency

Result of prolonged venous hypertension, stretching veins and damaging valves Stasis dermatitis, stasis ulcers Management of edema Management of venous stasis ulcers Drug therapy Surgical management Patient Teaching: Teach the patient to elevate legs for at least 20mins 4 to 5x / day. When in bed elevate legs above the level of the heart.

Essential Hypertension

Results in damage to vital organs Causes medial hyperplasia (thickening) of arterioles Common risk factors: Obesity Smoking Stress Family history

Lifestyle Modifications

Sodium restriction Weight reduction Reduced alcohol intake Exercise Decrease stress levels Avoid alcohol, smoking

Other Disorders

Subclavian steal Occurring from artery occlusion or stenosis Thoracic outlet syndrome Resulting in arterial wall damage Popliteal entrapment

Hypertension

Systolic blood pressure ≥140 and/or diastolic blood pressure ≥90 in people who do not have diabetes mellitus Patients with DM should have BP < 130/90 "Normal" adult systolic BP < 120; diastolic < 80

1. What does stimulation of the sympathetic nervous system produce? a. Delayed electrical impulse that causes hypotension and bradypnea b. Contractility and dilation of coronary vessels and increased heart rate. c. Virtually no effect on the ventricles of the heart or vital signs d. A slowed AV conduction time that results in a slow heart rate

b. Contractility and dilation of coronary vessels and increased heart rate.

Diagnostic Assessment

X-ray "eggshell" appearance CT Aortic arteriography Ultrasonography Nonsurgical management: Monitor aneurysm growth Maintain BP at normal level to decrease risk of rupture

2. The primary pacemaker of the heart, the sinoatrial (SA) node, is functional if a patient's pulse is at what regular rate? a. Fewer than 60 beats/min b. 60 to 100 beats/min c. 80 to 100 beats/min d. Greater than 100 beats/min

b. 60 to 100 beats/min

3. The nurse is taking vital signs ad reviewing the electrocardiogram (ECG) of a patient who is training for a marathon. The heart rate is 45 beats/min and the ECG shows sinus bradycardia. How does the nurse interpret this data? a. A rapid filling rate that lengthens diastolic filling time and leads to decreased cardiac output b. The body's attempt to compensate for a decreased stroke volume by decreasing the heart rate c. An adequate stroke volume that is associated with cardiac conditioning d. A common finding in the health adult that would be considered normal

c. An adequate stroke volume that is associated with cardiac conditioning