Med-Surge Cardiac

The purpose of repeating the cardiac enzymes reading is to verify the original admission result. Is this statement true or false?

false Explanation: Cardiac enzymes begin to rise a few hours after myocardial injury. If a patient presents to the emergency department early in the course of an MI, the initial results may be normal while subsequent results are elevated, indicating myocardial injury.

The nurse is caring for a client who has developed junctional tachycardia with a heart rate (HR) of 80 bpm. Which of the following actions should the nurse complete? a) Request a digoxin level be ordered. b) Prepare to administer IV lidocaine. c) Prepare for emergent electrical cardioversion. d) Withhold the patient's oral potassium supplement.

a) Request a digoxin level be ordered. Explanation: The nurse should request a digoxin level be obtained. Junctional tachycardia generally does not have any detrimental hemodynamic effect; it may indicate a serious underlying condition, such as digitalis toxicity, myocardial ischemia, hypokalemia, or chronic obstructive pulmonary disease (COPD). Potassium supplements do not cause junctional tachycardia. Lidocaine is indicated for the treatment of premature ventricular contractions (PVCs). Because junctional tachycardia is caused by increased automaticity, cardioversion is not an effective treatment; in fact, it causes an increase in ventricular rate.

Which of the following is the hallmark of systolic heart failure? a) Low ejection fraction (EF) b) Pulmonary congestion c) Basilar crackles d) Limitation of activities of daily living (ADLs)

c) Low ejection fraction (EF) Explanation: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the patient's symptoms

The nurse is teaching a patient diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should a patient consume per day? a) 2 or fewer b) 4 or 5 c) 2 or 3 d) 7 or 8

a) 2 or fewer Explanation: Two or fewer servings of meat, fish, and poultry are recommended in the DASH diet.

The nurse recognizes which of the following lab tests is a key diagnostic indicator of heart failure? a) Brain natriuretic peptide (BNP) b) Complete blood count (CBC) c) Blood urea nitrogen (BUN) d) Creatinine

a) Brain natriuretic peptide (BNP) Explanation: The BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of HF. A BUN, creatinine, and CBC are included in the initial workup.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough b) Weight loss c) Ability to sleep through the night d) Increased appetite

a) Persistent cough Explanation: Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite should be reported immediately. Weight gain should be reported immediately. Frequent urination, causing interruption of sleep, should be reported immediately.

Decreased pulse pressure reflects which of the following? a) Reduced stroke volume b) Reduced distensibility of the arteries c) Elevated stroke volume d) Tachycardia

a) Reduced stroke volume Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

What should the nurse include in the education for the client taking simvastatin (Zocor)? a) Report muscle pain or weakness. b) It is not necessary to adhere to a low cholesterol diet while on statins. c) Take with grapefruit juice to enhance effectiveness. d) Dark urine is an expected side effect.

a) Report muscle pain or weakness. Explanation: Rhabdomyolysis, the destruction of muscle cells, is a serious potential side effect of statins. Symptoms include muscle pain, tenderness, and weakness, and darkening of the urine from the protein myoglobin. Grapefruit juice increases the serum level of many drugs. A low-cholesterol diet is still necessary, even while on statins.

The nurse is caring for a patient newly diagnosed with coronary artery disease (CAD). While developing a teaching plan for the patient to address modifiable risk factors for CAD, the nurse will include which of the following? Select all that apply. a) Alcohol use b) Elevated blood pressure c) Drug use d) Obesity e) Decreased LDL level

b) Elevated blood pressure, d) Obesity Explanation: Hypertension, obesity, hyperlipidemia, tobacco use, diabetes mellitus, metabolic syndrome, and physical inactivity are modifiable risk factor for CAD. Alcohol and drug use are not included in the list of modifiable risk factors for CAD.

What expectation would the nurse have regarding Ms. Anderson's chest tube drainage? a) It will decrease to 0 mL within 24 hours. b) It will change in color to sanguinous to serosanguinous to serous. c) It will be 500 mL to 600 mL for the first 6 hours. d) It will be sanguinous with tissue shreds.

b) It will change in color to sanguinous to serosanguinous to serous. Explanation: Chest tube drainage should be no more than 200 mL for the first 6 hours; it would be expected to begin to decrease after this. It will be sanguinous at first, changing to serosanguinous, and to serous as the drainage amount decreases.

The nurse assessing a patient with an exacerbation of heart failure identifies which of the following symptoms as a cerebrovascular manifestation of heart failure (HF)? a) Nocturia b) Ascites c) Tachycardia d) Dizziness

d) Dizziness Explanation: Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.

What additional assessments related to possible heart failure do you think the nurse should make?

The nurse should assess the patient's heart rate, evidence of edema, weight changes, skin color, temperature, behavioral changes, chest pain, lung sounds, and also question the patient about paroxysmal nocturnal dyspnea (PND). Tachycardia is a compensatory measure to increase cardiac output in HF. Edema may occur in dependant areas, liver, abdominal cavity, or lungs. Check for degree of pitting edema in extremities. Initially, there may be weight gain from fluid retention; later the client may be too ill to eat and may lose weight. Skin may be pale or cyanotic and cool. Decreased cerebral perfusion may lead to confusion, restlessness, or memory and concentration problems. Decreased coronary perfusion may lead to angina-like pain. Lungs should be auscultated for signs of pulmonary congestion, and the patient should be questioned about the presence of a cough and PND to assess for pulmonary involvement from possible left side heart failure.

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)? a) Spironolactone (Aldactone) b) Bumetanide (Bumex) c) Chlorothiazide (Diuril) d) Ethacrynic acid (Edecrin)

a) Spironolactone (Aldactone) Explanation: Aldactone is a potassium-sparing diuretic. A thiazide diuretic is Diuril. Bumex and Edecrin are loop diuretics

Which of the following describes difficulty breathing when a patient is lying flat? a) Bradypnea b) Orthopnea c) Paroxysmal nocturnal dyspnea (PND) d) Tachypnea

b) Orthopnea Explanation: Orthopnea occurs when the patient is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.

Hypertension that can be attributed to an underlying cause is termed which of the following? a) Essential b) Secondary c) Isolated systolic d) Primary

b) Secondary Explanation: Secondary hypertension may be caused by a tumor of the adrenal gland (eg, pheochromocytoma). Primary hypertension has no known underlying cause. Essential hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

A patient presents to the emergency room complaining of chest pain. The patient's orders include the following elements. Which order should the nurse complete first? a) Troponin level b) Oxygen 2 liters nasal cannula c) Aspirin 325 mg orally d) 12-lead ECG

d) 12-lead ECG Explanation: The nurse should complete the 12-lead ECG first. The priority is to determine if the patient is suffering an acute MI and implement appropriate interventions as quickly as possible. The other orders should be completed after the ECG.

The nurse is administering medications on a medical surgical unit. A patient is ordered to receive 40 mg of oral Corgard (nadolol) for the treatment of hypertension. Prior to administering the medication, the nurse should complete which of the following? a) Checking the patient's serum K+ level b) Weighing the patient c) Checking the patient's heart rate d) Checking the patient's urine output

c) Checking the patient's heart rate Explanation: Corgard is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in patients with tachycardia and an elevated blood pressure (BP). The nurse should check the patient's heart rate (HR) prior to administering Corgard to ensure that the patient's pulse rate is not below 60 (beats per minute (bpm). The other interventions are not indicated prior to administering a beta-blocker medication.

Due to which of the following factors is depression stated as a risk factor in the development or worsening of CAD? a) Depressed sympathetic nervous system b) Side effects of antidepressant drugs c) Elevated catecholamine levels d) Elevated homocysteine level

c) Elevated catecholamine levels Explanation: Elevated catecholemines, present in stressful states, can contribute to endothelial damage and inflammation and to platelet activation. Platelets play a role in the formation of athlerosclerotic plaques, which adhere more readily to a damaged endothelium. The sympathetic nervous system is stimulated, not depressed, in stressful states, leading to the release of catecholemines. Elevated homocysteine levels may be a risk factor in CAD development. However, elevation of this amino acid results from the breakdown of protein and not from depression. Antidepressant drug use does not lead to development of CAD.

The area of the heart that is located at the third intercostal (IC) space to the left of the sternum is which of the following? a) Pulmonic area b) Epigastric area c) Erb's point d) Aortic area

c) Erb's point Explanation: Erb's point is located at the third IC space to the left of the sternum. The aortic area is located at the second IC space to the right of the sternum. The pulmonic area is at the second IC space to the left of the sternum. The epigastric area is located below the xiphoid process.

A patient admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which of the following medications will the nurse administer to relieve the patient's anxiety and decrease cardiac workload? a) Norvasc (amlodipine) b) IV nitroglycerin c) IV morphine d) Tenormin (atenolol)

c) IV morphine Explanation: IV morphine is the analgesic of choice for treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart. IV nitroglycerin is given to alleviate chest pain. Administration of Tenormin and Norvasc are not indicated in this situation.

Administration of the fibrolytic agent alteplase includes certain tasks such as ECG and heart and lung assessments. Which of the following are the other expected tasks in nursing assessments and interventions during the administration of the fibrolytic agent alteplase? Select all that apply. a) Monitor for evidence of internal or external bleeding b) Assess neuro signs every 15 to 30 minutes c) Expect increase in chest pain as "clot buster" takes effect d) Expect spike in ST segment e) Expect reperfusion dysrhythmias

a) Monitor for evidence of internal or external bleeding, b) Assess neuro signs every 15 to 30 minutes, e) Expect reperfusion dysrhythmias Explanation: Altepase is a clot lysing agent that must be given within 6 hours of symptom onset (preferably within 1 hour). As hypotension and stroke are possible side effects, monitor neurologic and cardiovascular signs every 15 to 30 minutes. Other possible side effects are GI/GU bleeding and ecchymosis. All IV puncture sites require 30 minutes of manual pressure followed by a pressure dressing. Reperfusion dysrhythmias such as accelerated idioventricular rhythm or sinus bradycardia may occur, and are usually of short duration. Additional side effects include n/v and fever. The site of the lysed thrombus remains unstable, with the possibility of reocclusion of the affected artery; for this reason, patients will often also be on IV heparin to prevent clot reformation. Patients should be on bedrest for 8 to 12 hours following an uncomplicated MI. Chest pain should abate, and ST elevation should return to near baseline level as the clot is dissolved and the affected area is reperfused.

Which of the following risk factors for CAD does Ms. Bailey present with? a) Obesity b) Diabetes mellitus c) Bradycardia d) Stressful lifestyle e) Hypertension

a) Obesity, b) Diabetes mellitus, e) Hypertension Explanation: There is a strong correlation between obesity as a risk factor and the development of CAD. Ms. Bailey has a body mass index (BMI) of 41, which is considered obese. Any BMI over 25 is considered overweight. There is a strong correlation between diabetes and the development of CAD. Hyperglycemia contributes to dyslipidemia and platelet aggregation, which can lead to thrombus formation. There is a strong correlation between HTN and the development of CAD. HTN contributes to the stiffness of vessel walls, vessel wall injury, and inflammation. Bradycardia is not considered a risk factor for the development of CAD. Theresa has not suggested that her lifestyle is stressful.

The nurse is caring for a patient with clubbing of the fingers and toes. The nurse should complete which of the following actions given these findings? a) Obtain an oxygen saturation level. b) Assess the patient for pitting edema. c) Obtain a 12-lead ECG tracing. d) Assess the patient's capillary refill.

a) Obtain an oxygen saturation level. Explanation: Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease. The nurse should assess the patient's O2 saturation level and intervene as directed. The other assessments are not indicated.

The nurse is caring for a patient following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which of the following medications to neutralize the unfractionated heparin the patient received? a) Protamine sulfate b) Clopidogrel (Plavix) c) Alteplase (t-PA) d) Aspirin

a) Protamine sulfate Explanation: Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel (Plavix) is an antiplatelet medication that is given to reduce the risk of thrombus formation post coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

An anterior wall MI indicates occlusion of which of the following coronary arteries? a) Aorta b) Circumflex artery c) Left anterior descending artery d) Right coronary artery

c) Left anterior descending artery Explanation: Anterior wall infarctions involve occlusion of the left anterior artery and show ST elevations in V2--V4. Circumflex artery occlusions cause lateral wall infarctions with ST elevations in V5--V6, I, and aVL and inferior wall infarctions with ST elevations in II, III, aVF. Occlusion of the right coronary artery would result in an inferior wall infarction showing ST elevations in leads II, III, and aVF. The aorta is not a coronary artery.

The nurse auscultates the PMI (point of maximal impulse) at which of the following anatomic locations? a) Midsternum b) 1 inch to the left of the xiphoid process c) Left midclavicular line, fifth intercostal space d) 2 inches to the left of the lower end of the sternum

c) Left midclavicular line, fifth intercostal space Explanation: The left ventricle is responsible for the apical impulse or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. The right ventricle lies anteriorly, just beneath the sternum. Use of inches to identify the location of the PMI is inappropriate based on variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the PMI.

9:02 A.M. You measured Mrs. Downs's blood pressure at 112/64. However, what if you measured Mrs. Downs's blood pressure at 162/94? She tells you she's never had high blood pressure and had normal readings in the hospital. What should you do in such a situation? a) Reassure Mrs. Downs and help her relax. b) Report the reading to her physician. c) Wait for 30 to 60 seconds and repeat the reading. d) Check the size of the cuff. e) Check that the cuff is not wrapped too loosely around her arm. f) Administer Mrs. Downs' medication to lower her pressure. g) Check the physician's order for the next scheduled assessment. h) Tell Mrs. Downs that her pressure is high because she's anxious.

a) Reassure Mrs. Downs and help her relax., b) Report the reading to her physician., c) Wait for 30 to 60 seconds and repeat the reading., d) Check the size of the cuff., e) Check that the cuff is not wrapped too loosely around her arm. Explanation: You must repeat the reading, waiting at least 30-60 seconds to allow normal circulation to return in her arm. Make sure to deflate the cuff completely between attempts. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings. Reassure Mrs. Downs and help her relax to make sure that she is not anxious, which could cause a false high reading. Check the size of the cuff. A cuff that's too small can cause a false high reading. Check that the cuff is not wrapped too loosely around her arm. Allow the cuff to deflate at a rate of 2-3 mm Hg per second to eliminate venous congestion in the arm. If the reading remains high, record your findings and interventions and report the reading to her physician.

The nurse is screening a patient prior to a magnetic resonance angiogram (MRA) of the heart. Which of the following actions should the nurse complete prior to the patient undergoing the procedure? Select all that apply. a) Remove the patient's Transderm Nitro patch. b) Offer the patient a headset to listen to music during the procedure. c) Sedate the patient prior to the procedure. d) Remove the patient's jewelry. e) Position the patient on his/her stomach for the procedure.

a) Remove the patient's Transderm Nitro patch., b) Offer the patient a headset to listen to music during the procedure., d) Remove the patient's jewelry. Explanation: Transdermal patches that contain a heat-conducting aluminized layer (e.g., NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must be removed before MRA to prevent burning of the skin. A patient who is claustrophobic may need to receive a mild sedative before undergoing an MRA. During an MRA, the patient is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field. Patients are instructed to remove any jewelry, watches, or other metal items (e.g., ECG leads). An intermittent clanking or thumping that can be annoying is generated by the magnetic coils, so the patient may be offered a headset to listen to music.

hat clues suggest that Ms. Bailey has been noncompliant with her treatment plan? Select all that apply. a) Running out of medications without provisions for refills b) Complaints about the high cost of medications c) Comment about "watching her sugar" in her diet d) Report of monitoring her glucose daily at home

a) Running out of medications without provisions for refills, b) Complaints about the high cost of medications Explanation: The inability to pay for a medication often leads to non-compliance. The nurse should assess Theresa's finances and insurance, and her ability to pay for medications. The patient admitted to running out of medication and has not made the necessary appointment for a refill. The nurse should discuss the reasons for not following-up. The nurse needs to clarify the meaning of 'watching her sugar' before assuming non-compliance, and then assess for understanding of the diabetic diet. The patient states she has her BG checked at the clinic. The nurse should verify the treatment plan and determine if home blood glucose monitoring was part of her treatment plan.

The nurse is caring for a patient prescribed Bumex (bumetanide) for the treatment of stage 2 hypertension. Which of the following indicates the patient is experiencing an adverse effect of the medication? a) Serum potassium value of 3.0 mEq/L b) Blood glucose value of 160 mg/dL c) Urine output of 90 cc/mL 1 hour after medication administration d) Electrocardiogram (EGG) tracing demonstrating peaked T waves

a) Serum potassium value of 3.0 mEq/L Explanation: Bumex is a loop diuretic that can cause fluid and electrolyte imbalances. Patients taking these medications may experience a low serum potassium level. ECG changes associated with an elevated serum potassium levels include peaked T waves. Diuresis is a desired effect postadministration of Bumex. The serum glucose level is elevated and requires intervention; however, this elevation is not associated with the administration of Bumex.

The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that risk factors and cardiovascular problems related to hypertension include which of the following? Select all that apply. a) Smoking b) Decreased low-density lipoprotein (LDL) levels. c) Elevated high-density lipoprotein (HDL) cholesterol d) Obesity (BMI ≥ 30 kg/m2) e) Age ≥55 in men

a) Smoking, d) Obesity (BMI ≥ 30 kg/m2), e) Age ≥55 in men Explanation: Major risk factors (in addition to hypotension) include smoking, dyslipidemia (high LDL, low HDL cholesterol), diabetes mellitus, impaired renal function, obesity, physical inactivity, age (older than 55 years for men, 65 years for women), and family history of cardiovascular disease.

Which of the following assessments does the nurse need to perform on Mr. Easton? a) Monitor urine output every 4 hours b) Monitor neuro signs once a shift c) Monitor BP every 2 to 3 minutes during initial administration of sodium nitroprusside d) Get patient up to the commode to void

c) Monitor BP every 2 to 3 minutes during initial administration of sodium nitroprusside Explanation: Lowering BP more than 25% in the first hour could lead to stroke, MI, or renal failure. Urine output should be monitored hourly until stable to assess for renal function. The patient should remain on bedrest until stable. Neurologic signs should be monitored at least hourly until stable

Ms. Anderson wonders how so many different factors can contribute to her chest pain. Can you match the causes of her chest pain with their effects?

Heavy meals, Diverts blood, decreasing blood flow in the coronary artery system Stress, Stimulates the sympathetic nervous system and increases cardiac workload Exercise, Increases heart rate and myocardial O2 demand Explanation: Heavy meals divert blood to the GI tract, decreasing flow to the coronary arteries. Stress stimulates the SNS, increasing cardiac workload and O2 demand of the heart. Exercise increases O2 demand. Other precipitating factors for chronic stable angina include: temperature extremes, tobacco use, legal and illicit pharmaceuticals, and circadian rhythms (more occur in the AM after awakening).

Ms. Anderson looks at her new prescriptions and exclaims "So many meds! Why do I need all of these?" The nurse explains the use of these medications. Can you match the medication with its effect?

Lopressor, Delays the onset of exercise induced ischemia ASA, Prevents blood clots Lipitor, Lowers cholesterol levels NTG, Relieves acute angina pain Explanation: Beta-adrenergic blockers (Lopressor) reduce cardiac O2 demand by decreasing heart rate, BP, vascular resistance, and myocardial contractility; these actions help delay the onset of exercise-induced angina. Nitrates (Imdur and sublingual NTG) dilate veins (and in large doses, the arteriole bed), which decreases cardiac workload and myocardial O2 demand. A common side effect of nitrates is headache; Tylenol may be taken with Imdur to prevent this. Statins (Lipitor) lower cholesterol and reduce the risk for CAD, the primary cause of angina.

Which of the following statements about cardiac stress tests with thallium-201 (201ΤΙ ), confirming a diagnosis of angina, is true? a) The patient will continue the stress test for 1 minute after the onset of pain. b) The patient will be on radioactive precautions for 24 hours. c) Perfusion is restored to ischemic areas within 3 hours. d) 201ΤΙ is taken up by ischemic cardiac tissue.

c) Perfusion is restored to ischemic areas within 3 hours. Explanation: 201ΤΙ is not taken up by ischemic cardiac tissue, and shows as "cold spots" on imaging. 201ΤΙ will move into the ischemic tissue (shows as "hot spots") indicating reperfusion of the area if the patient experienced angina ischemia during the stress test. Unresolved "cold spots" indicate probable MI. 201ΤΙ involves no more radiation than a normal x-ray study. Cardiac stress testing is interrupted and stopped if the patient experiences pain, extreme fatigue, has drops in BP or pulse, or has S-T segment changes or dysrhythmias on her continuous ECG.

The nurse is caring for a patient with systolic blood pressure of 135 mm Hg. This finding would be classified as which of the following? a) Normal b) Stage 1 hypertension c) Prehypertension d) Stage 2 hypertension

c) Prehypertension Explanation: A systolic blood pressure of 135 mm Hg is classified as prehypertension. A systolic BP of less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg is stage I hypertension. A systolic BP of greater than or equal to 160 is classified as stage II hypertension.

The nurse correctly identifies which of the following data as an example of BP and HR measurements in a patient with postural hypotension? a) Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm b) Supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm c) Supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm d) Supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm

a) Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm Explanation: Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting to a standing position. The following is an example of BP and HR measurements in a patient with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure.

Which of the following statements are true when the nurse is measuring blood pressure (BP)? Select all that apply. a) The patient's arm should be positioned at the level of the heart. b) Using a BP cuff that is too small will give a higher BP measurement. c) Using a BP cuff that is too large will give a higher BP measurement. d) The patient's BP should be taken 1 hour after the consumption of alcohol. e) Ask the patient to sit quietly while the BP is being measured.

a) The patient's arm should be positioned at the level of the heart., b) Using a BP cuff that is too small will give a higher BP measurement., e) Ask the patient to sit quietly while the BP is being measured. Explanation: These statements are all true when measuring a BP. When using a BP cuff that is too large the reading will be lower than the actual BP. The patient should avoid smoking cigarettes or drinking caffeine for 30 minutes before BP is measured.

The nurse understands that an overall goal of hypertension management includes which of the following? a) There is no indication of target organ damage. b) There are no complaints of sexual dysfunction. c) There is no complaint of postural hypotension. d) The patient maintains a normal blood pressure reading.

a) There is no indication of target organ damage. Explanation: Prolonged blood pressure elevation gradually damages blood vessels throughout the body, particularly in target organs such as the heart, kidneys, brain, and eyes. The overall goal of management is that the patient does not experience target organ damage. The desired effects of antihypertensives are to maintain a normal BP. Postural hypotension and sexual dysfunction are side effects of certain antihypertension medications.

What is the purpose of the patient's cardiac catheterization procedure? a) To determine the extent of atherosclerosis and coronary artery patency b) To assess cardiac dysrhythmias c) To assess blood return to the right side of the heart and right ventricular function d) To determine if he has left ventricular hypertrophy (LVF)

a) To determine the extent of atherosclerosis and coronary artery patency Explanation: Radiopaque catheters are inserted into specific areas of the heart (cardiac cath) and a contrast media injected (arteriography) to assess coronary artery patency and the degree of atherosclerosis. LVF is diagnosed by cardiac imaging studies. Central venous pressure (CVP) monitoring is performed to assess blood return to the right side of the heart and right ventricular function. Dysrhythmias are assessed using ECG or electrophysiologic testing (EPS).

What is the reason Mrs. Melnik is being started on warfarin (Coumadin)? a) To prevent atrial fibrillation from forming thrombus in the atria b) To increase ejection fraction c) To prevent deep vein thrombosis (DVT) related to her increasing fatigue d) To increase cardiac output

a) To prevent atrial fibrillation from forming thrombus in the atria Explanation: Warfarin is an anticoagulant used to prevent thrombus formation. Mrs. Melnick is at risk for atrial thrombus formation related to atrial fibrillation. She will require close lab monitoring; her INR should be 2 to 3 to be therapeutic.

A 77-year-old woman presents to the local community center for a blood pressure screening. The women's blood pressure is recorded as 180/90 mm Hg. The woman has a history of hypertension, but she currently is not taking her medications. Which of the following questions is most appropriate for the nurse to ask the patient first? a) "What medications are you prescribed?" b) "Why is it that you are not taking your medications?" c) "Are you having trouble paying for your medication?" d) "Are you able to get to your pharmacy to pick up your medications?"

b) "Why is it that you are not taking your medications?" Explanation: It is important for the nurse to first ascertain if the reason why the patient is not taking her medications. Adherence to the therapeutic program may be more difficult for older adults. The medication regimen can be difficult to remember, and the expense can be a challenge. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive. The other questions are appropriate, but the priority is to determine why the medication regimen is not being followed.

Target organ damage from untreated/undertreated hypertension includes which of the following? Select all that apply. a) Retinal damage b) Diabetes c) Heart failure d) Stroke e) Hyperlipidemia

a) Retinal damage, c) Heart failure, d) Stroke Explanation: Target organ systems include cardiac, cerebrovascular, peripheral vascular, renal, and the eye. Hyperlipidemia and diabetes are risk factors for development of hypertension

The nurse is caring for a client who is prescribed diuretic medication for the treatment of hypertension. The nurse recognizes that which of the following medications conserves potassium? a) Spironolactone (Aldactone) b) Chlorthalidone (Hygroton) c) Chlorothiazide (Diuril) d) Furosemide (Lasix)

a) Spironolactone (Aldactone) Explanation: Aldactone is known as a potassium-sparing diuretic. Lasix causes loss of potassium from the body. Diuril causes mild hypokalemia. Hygroton causes mild hypokalemia.

Based on the information given, what do you think the admitting nurse suspects Mrs. Melnik to be experiencing? a) Myocardial infarction b) Acute decompensated heart failure c) Pneumonia d) Hypertensive crisis

b) Acute decompensated heart failure Explanation: The primary manifestation of ADHF is pulmonary edema, most commonly due to left ventricular failure. The client typically presents as anxious and pale (possibly cyanotic), with cold, clammy skin. Severe dyspnea is often present with a respiratory rate greater than 30 and tachycardia. BP may be elevated or decreased, depending on the severity of the HF. There may be orthopnea, adventitious lung sounds, and cough productive of frothy and/or blood-tinged sputum. Mrs. Melnik's WBC is within normal limits. Given her previous diagnosis of HF and the worsening of her LVH, her pulmonary symptoms are most likely due to ADHF, not a respiratory illness such as pneumonia. Hypertensive crisis includes a diastolic BP greater than 140 mm Hg. The patient is not exhibiting signs and symptoms associated with myocardial infarction.

Which of the following nursing interventions should a nurse perform when a patient with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta blockers? a) Withhold the drug and inform the primary health care provider. b) Observe for symptoms of pulmonary edema. c) Check for signs of toxicity. d) Continue the drug and document in the patient's chart.

a) Withhold the drug and inform the primary health care provider. Explanation: Before administering beta blockers, the nurse should monitor the patient's apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.

The nurse is caring for patient experiencing an acute MI (STEMI). The nurse anticipates the physician will prescribe alteplase (Activase). Prior to administering this medication, which of the following questions is most important for the nurse to ask the patient? a) "Do your parents have a history of heart disease?" b) "What time did your chest pain start today?" c) "How many sublingual nitroglycerin tabs did you take?" d) "What is your pain level on a scale of 1 to 10?"

b) "What time did your chest pain start today?" Explanation: The patient may be a candidate for thrombolytic (fibrolytic) therapy. These medications are administered if the patient's chest pain lasts longer than 20 minutes, unrelieved by nitroglycerin, ST-segment elevation in the at least two leads that face the same area of the heart, less than 6 hours from onset of pain. The most appropriate question for the nurse to ask is in relationship to when the chest pain began. The other questions would not aid in determining if the patient is a candidate for thrombolytic therapy.

A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention? a) Administer angiotensin-converting enzyme inhibitors b) Assess oxygen saturation level c) Administer angiotensin II receptor blockers d) Administer diuretics

b) Assess oxygen saturation level Explanation: Assessment is priority to determine severity of the exacerbation. It is important to assess the oxygen saturation level of a heart failure patient, as below normal oxygen saturation level can be life-threatening. Treatment options vary according to the severity of the patient's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve patient symptoms and reduce the workload on the heart by reducing afterload and preload.

The nurse is caring for a patient newly diagnosed with hypertension. Which of the following statements if made by the patient indicates the need for further teaching? a) "I will consult a dietician to help get my weight under control." b) "I think I'm going to sign up for a yoga class twice a week to help reduce my stress." c) "If I take my blood pressure and it is normal, I don't have to take my BP pills." d) "When getting up from bed, I will sit for a short period prior to standing up."

c) "If I take my blood pressure and it is normal, I don't have to take my BP pills." Explanation: The patient needs to understand the disease process and how lifestyle changes and medications can control hypertension. The patient must take his/her medication as directed. A normal BP indicates the medication is producing its desired effect. The other responses do not indicate the need for further teaching.

9:02 A.M. Your reassurance has made Mrs. Downs feel a little better. It's important to include interventions to prevent infection in your care. What steps will you take to break the chain of infection when assessing Mrs. Downs' blood pressure? a) Maintain surgical asepsis. b) Cleanse the equipment with an alcohol swab. c) Put on gown. d) Put on goggles and mask. e) Perform hand hygiene. f) Put on clean gloves. g) Put on sterile gloves.

b) Cleanse the equipment with an alcohol swab., e) Perform hand hygiene. Explanation: You must perform hand hygiene. You must also clean your equipment with an alcohol swab, specifically the diaphragm or bell of the stethoscope, depending on which side you are going to use. Also, clean the earpieces with a second swab if the stethoscope is not yours. This deters the spread of microorganisms. You usually do not need to put on gloves, a gown, goggles, or mask, or maintain surgical asepsis for assessing Mrs. Downs' blood pressure.

The nurse is preparing to apply ECG electrodes to a male patient who requires continuous cardiac monitoring. Which of the following should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? a) Clean the patient's chest with alcohol prior to application of the electrodes. b) Clip the patient's chest hair prior to applying the electrodes. c) Apply baby powder to the patient's chest prior to placing the electrodes. d) Once the electrodes are applied, change them every 72 hours.

b) Clip the patient's chest hair prior to applying the electrodes. Explanation: The nurse should complete the following actions when applying cardiac electrodes: Clip (do not shave) hair from around the electrode site, if needed; if the patient is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer). Change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); examine the skin for irritation and apply the electrodes to different locations.

Which of the following does Mrs. Melnick's diagnostic test results indicate? a) Renal failure b) Diastolic heart failure c) Decreased ejection fraction d) Systolic heart failure

b) Diastolic heart failure Explanation: Diastolic failure is marked by pulmonary congestion (evidenced by Mrs. Melnik's dyspnea, orthopnea, and edema), pulmonary hypertension, ventricular hypertrophy, and normal EF. Systolic failure is marked by a decreased LV EF. Mrs. Melnik's signs and symptoms and diagnostic tests do not indicate renal disease. Additionally, LVH is often seen in HF and her BNP indicates increased filling pressures. With LVH, changes in the heart's electrical system occur, resulting in dysrhythmias.

It is important for the nurse to encourage the patient diagnosed with hypertension to rise slowly from a sitting or lying position for which of the following reasons? a) Gradual changes in position help reduce the heart's work to resupply oxygen to the brain. b) Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain. c) Gradual changes in position provide time for the heart to reduce its rate of contraction to resupply oxygen to the brain. d) Gradual changes in position help reduce the blood pressure to resupply oxygen to the brain.

b) Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain. Explanation: It is important for the nurse to encourage the patient to rise slowly from a sitting or lying position because gradual changes in position provide time for the heart to increase its rate of contraction to resupply oxygen to the brain and not blood pressure or heart rate.

Can you identify the purpose of each of the medications given to Mr. Gruppman upon his arrival at the ED?

ASA, Inhibits platelet aggregation Morphine sulfate, Reduces pain and workload of the heart, and enhances oxygenation Nitroglycerin, Reduces angina pain, and improves coronary blood flow Atenolol, Reduces myocardial O2 demand Explanation: ASA reduces the possibility of blood clot formation, thus reducing the possibility of recurrent MI and death after MI. Morphine, a vasodilator, reduces preload and afterload of the heart, BP, and HR and relaxes bronchioles, thus enhancing oxygenation; additionally, morphine reduces pain and anxiety. Nitroglycerin relaxes vascular smooth muscle, thereby reducing preload, afterload, and systemic vascular resistance. Beta-blockers (atenolol) reduce HR and BP, thereby reducing the work of the heart; given within a few hours of MI, they can reduce the size of infarction and complications.

hypertension

Approximately 30% of Americans have hypertension. Hypertension places people at an increased risk for cardiovascular and renal disease and for stroke. Primary hypertension is the most prevalent form; however, people may also suffer from secondary hypertension, isolated systolic hypertension, or pseudohypertension. Some people may develop resistant hypertension. Current Joint Commission guidelines define four categories for classification. See chart. Clients often do not experience symptoms until target organ damage has occurred. Symptoms secondary to this damage may include fatigue, dyspnea, dizziness, reduced activity tolerance, and angina. In addition to hypertensive crisis, other acute hypertensive problems include hypertensive emergency and hypertensive urgency. Hypertensive emergency develops over hours to days with BPs over 180/120 and evidence of target organ damage, especially to the central nervous system. Hypertensive urgency develops over days to weeks with severely elevated BP and no evidence of target organ damage. HTN is treated by a combination of lifestyle changes and pharmacologic measures. The many classes of drugs for treatment of HTN include diuretics, calcium channel blockers, ACE inhibitors, angiotension II receptor blockers, direct vasodilators and adrenergic inhibitors, antagonists, and blockers.

Arrange the number against the correct text option in the sequence and click Show Answer. Number the following nursing interventions in order of priority.

Assist patient back to bed Apply O2 at 2L NC Administer nitroglycerine (NTG) Notify physician Explanation: NTG is a vasodilator which can dilate coronary arteries and increase blood flow to cardiac muscle. NTG should be given as ordered if the decrease in activity and oxygen do not relieve pain. Physical exertion can cause increased need for O2 and instigate angina in patient with partial blockages of coronary arteries. Bedrest decreases metabolic needs for O2. This is the first thing the nurse should do. The application of oxygen will increase available to oxygen deprived heart muscle and may relieve the pain associated with angina. The nurse should apply oxygen after the pain is assisted back to bed. The physician should be notified of change in patient condition as soon as possible after the other interventions are carried out.

List the initial assessments you would make when Ms. Anderson is transferred to your step-down unit for each of the following categories: Cardiac status assessments, Tube assessments, Respiratory assessments, and Fluids and electrolyte balance.

Cardiac status assessments: monitor cardiac rate and rhythm, ECG pattern, BP, peripheral pulses, review and continue to monitor cardiac labs. Tube assessments: check that F/C, chest tubes, and NG tube are all connected and patent; monitor and record output amount and character from each tube. Respiratory assessments: rate, rhythm, pattern; auscultate all fields for any adventitious sounds, assess patient knowledge of incentive spirometry, monitor 02 sats. Fluids and electrolyte balance: correct IV hanging at correct rate, site patent ans symptom-free; monitor labs; measure output from all tubes.

As you continue to care for Ms. Anderson, what assessments would you add? List these assessments for each of the following categories: Cardiac, Tubes, Fluid and electrolytes, and Pain.

Cardiac: Observe for s/sx of impending cardiac failure, cardiac tamponade, or MI. Tubes: Anticipate removal of F/C and monitor subsequent voiding and urine output pattern (should >30mL/hr). Chest tube drainage should be <200 ml and decrease daily. Anticipate removal of NG tube and assess for signs of distension or n/v. Fluid and electrolytes: Any trending abnormality in electrolytes must be noted and reported to the MD. Potassium, magnesium, sodium, and calcium abnormalities are of particular concern in the post-op cardiac patient. Glucose may be elevated, even in the non-diabetic patient due to surgical stress. Pain: Anticipate weaning patient off PCA onto oral narcotic pain relievers.

CAD

Coronary artery disease is one of the leading causes of death in the United States. CAD develops when atherosclerotic plaques build up in the endothelium of the coronary arteries, narrowing and/or blocking the coronary arteries. This decreases blood flow to the tissues, including cardiac muscle tissue. Additionally, plaques and formed thrombi can break off, leading to MI. It is believed that injury to the endothelium and the inflammatory response set the stage for plaque formation. A number of factors from hyperlipidemia and elevated homocysteines to modifiable disease states such as HTN and diabetes can contribute to endothelial injury. Measures to prevent the development of CAD in high-risk patients and to prevent the progression of diagnosed CAD include lifestyle modifications and lipid-lowering drugs. Clients with CAD are at risk for angina, MI, and sudden cardiac death.

Mr. Easton will begin to monitor his BP at home after his hospital discharge. List at least three teaching points for home blood pressure monitoring.

Do not smoke or drink caffeine for 30 minutes before taking BP; rest quietly for at least 5 minutes before taking BP. While measuring BP, sit with both feet on the floor and forearm supported at heart level. Wrap cuff snugly 1 inch above the antecubital space. Wait at least 1 minute before taking another reading to allow circulation to return to normal in arm. Factors that can briefly increase BP include cigarette smoking, drinking caffeine, and increased activity. Incorrect technique while taking a BP can result in a falsely higher or lower BP reading.

9:03 A.M. You've assisted Mrs. Downs to an appropriate position for the measurement of blood pressure using the brachial artery of her right arm. Now you must correctly place the cuff of the sphygmomanometer to obtain an accurate reading. The steps to correctly place the cuff of the sphygmomanometer are given here. They're out of order Palpate the location of the brachial pulse on the patient's arm. Expose the brachial artery by removing garments above the area where the cuff will be placed. Center the bladder of the cuff over the brachial artery. Wrap the cuff around the arm smoothly and snugly.

Expose the brachial artery by removing garments above the area where the cuff will be placed. Palpate the location of the brachial pulse on the patient's arm. Center the bladder of the cuff over the brachial artery. Wrap the cuff around the arm smoothly and snugly. Explanation: 1. Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight, above the area where the cuff will be placed. Clothing over the artery interferes with the ability to hear sounds and may cause inaccurate blood pressure readings. A tight sleeve would cause congestion of blood and possibly inaccurate readings. 2. Palpate the location of the brachial pulse on the patient's arm. Identification of the brachial pulse allows for accurate placement of the cuff and stethoscope. 3. Center the bladder of the cuff over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about one to two inches above the inner aspect of the elbow. The tubing should extend from the edge of the cuff nearer the patient's elbow. Pressure in the cuff applied directly to the artery provides the most accurate readings. If the cuff gets in the way of the stethoscope, readings are likely to be inaccurate. A cuff placed upside-down with the tubing toward the patient's head may give a false reading. 4. Wrap the cuff around the arm smoothly and snugly, and fasten it securely. Do not allow any clothing to interfere with the proper placement of the cuff. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff too loosely wrapped results in an inaccurate reading.

Ms. Anderson is worried that she might have a heart attack while exercising at her health club. As the nurse, how will you address her fears?

Heart attacks occur when there is irreversible ischemia resulting in tissue death. Chronic stable angina results in reversible ischemia with reperfusion of the affected areas. Ms. Anderson's new beta-blocker should help reduce the incidence of exercise-induced angina; if it does not, she should tell her MD, who may be able to increase the dosage. Ms. Anderson should stop exercising and take her sublingual NTG if she experiences angina while exercising. She may need to consider modifying her exercise program to a level that will not induce angina. Isometric exercises of the arms (weight lifting) are particularly prone to inducing angina. Ms. Anderson is not experiencing irreversible ischemia, the hallmark of MI. Medications and modification of her exercise program will help reduce her angina attacks. Continuing to exercise will reduce her risk factors for CAD, the primary cause of angina.

Heart failure

Heart failure affects about 5 million people in the United States and results in about 300,000 deaths annually. It is more common in people over age 65 and in African-Americans, who tend to develop HF at an earlier age. It affects men and women in near equal proportions. Risk factors for HF include hypertension, diabetes, coronary artery disease and valvular disorders, high cholesterol, obesity, and cigarette smoking. While pathology determination is based on systolic or diastolic failure, HF is often referred to as left-sided or right-sided failure. The most common form is left-sided failure which causes back-up of blood flow into the left atrium and lungs, leading to increased pulmonary pressure and pulmonary edema. Right-sided failure results from left-sided failure and pulmonary hypertension, causing blood flow backup in the right atrium and general circulation; this leads to peripheral edema, hepatomegaly, splenomegaly, vascular congestion in the GI tract, and jugular venous congestion. In addition to diuretics, ACE inhibitors, beta-blockers, and digitalis, pharmacologic management may include nitroglycerin to reduce preload, medications to reduce afterload (such as nitroprusside), aldosterone receptor antagonists and vasodilators. BiDil, a isosorbide dinitrate/hydralazine combination drug has recently been approved for use in African-Americans already being treated with standard treatment. Acutely severe cases of HF may require hemodynamic monitoring and beta-adrenergic agonists (such as dopamine), and eventually heart transplantation.

The nurse is caring for a patient in the ED who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse understands that this finding is most suggestive of which of the following? a) Ventricular hypertrophy b) Heart failure c) Pulmonary edema d) Myocardial infarction

b) Heart failure Explanation: A BNP level greater than 100 pg/mL is suggestive of HF. Because this serum laboratory test can be quickly obtained, BNP levels are useful for prompt diagnosis of HF in settings such as the ED. Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. Therefore, the clinician correlates BNP levels with abnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of HF.

The nurse writes a nursing diagnosis for Mr. Gruppman of Ineffective Cardiac Tissue Perfusion related to decreased coronary blood flow with a goal to decrease chest pain. Can you list at least two interventions with rationales for this goal?

Interventions (I) and their rationales (R) are listed below: I: Assess pain, including location, intensity, radiation, duration, factors affecting pain as well as associated symptoms such as nausea, etc. R: Establish a baseline with which to compare post-therapy symptoms; help rule out any other chest/abdomen conditions that include chest discomfort. I: Monitor ECG. R: A change in ECG strips could indicate extension of damage or identify life-threatening dysrhythmias. I: Monitor BP, heart sounds and rate, LOC, I&O, skin color. R: Decreased BP, LOC, and urine output may indicate decreased cardiac output; increased heart rate may indicate compensatory measure to maintain perfusion. I: Administer O2; R: increase O2 supply to damaged myocardium. I: Administer meds as ordered. R: ASA, nitroglycerine, beta-blockers, morphine, and ACE inhibitors are the first-line defense in preserving myocardial tissue and preventing further damage. I: Bedrest with gradual increase in activity as ordered. R: Rest reduces myocardial O2 requirements. I: Alleviate anxiety and fear. R: Both precipitate stress response, which increases O2 consumption and decreases pain threshold.

MI

Most MIs occur in the left ventricle as a result of a thrombus in a coronary artery. Perfusion to the area distal to the thrombus is halted, resulting in necrosis of the affected myocardium. The patient may develop a fever due to the resultant inflammatory process and may develop elevated glucose levels due to catecholamine release. The development of collateral circulation during this time helps increase perfusion and limits the size of the injury. Other causes for MI may include increased demand for O2 which the myocardium cannot meet, decreased O2 supply (e.g., anemia, hypotension), or vasospasm of a coronary artery. In addition to the classic symptoms of MI (severe pain unrelieved by rest or nitroglycerin, nausea and vomiting, cool, clammy skin), atypical symptoms may appear in certain groups. Women may experience fatigue, atypical discomfort, or shortness of breath; elderly people may present with confusion, a new dysrhythmia, or edema; diabetic people may exhibit no symptoms at all ("silent MI"). ECG changes following MI take place over time; ST segment elevation, the hallmark ECG change, evolves within hours and returns to baseline after successful reperfusion therapy and within 1 to 6 weeks; T wave inversion occurs within 1 to 3 days and may persist for weeks to months; abnormal Q waves appear within 1 to 3 days and may remain indefinitely. An abnormal Q wave without ST segment or T wave abnormalities indicates an old MI. In addition to pharmacologic treatment, the patient with acute MI may undergo an emergency percutaneous coronary intervention (PCI). During PCI, which must be performed within 90 minutes of arrival, coronary catheterization locates the thrombus and removes it and the underlying atherosclerotic plaque. Patients with MIs are often discharged before the healing process is complete, another reason cardiac rehab is so important. Scar tissue begins to form at 10 to 14 days and is most susceptible to increased stress during this time period. By 6 weeks post-MI, most necrotic tissue has been replaced by scar tissue. These scarred areas, which are less compliant than surrounding healthy myocardial tissue, may lead to ventricular dysfunctions and heart failure. Complications of MI include dysrhythmias, heart failure, cardiogenic shock, ventricular aneurysm, pericarditis, and Dressler syndrome. Patients may be discharged from the hospital on several medications and should expect to be in a cardiac rehabilitation program for 2 to 12 weeks.

9:04 A.M. You've noted the point on the gauge where the pulse disappears. This is the estimate of the systolic reading. You must deflate the cuff and wait for 15 seconds to allow the blood to refill and circulate through the arm before you continue with the blood pressure measurement. The steps to record the blood pressure measurement are given here. They're out of order.

Place stethoscope firmly over the brachial artery where you palpated it. Tighten the screw valve on the air pump bulb. Inflate the cuff to 30 mm above the estimated systolic pressure. Open the valve and allow the air to escape slowly. Note the point at which the first faint, but clear sound is heard. Note the pressure at which the sound first becomes muffled and the point it disappears. Allow the remaining air to escape quickly. Clean the stethoscope head with an alcohol prep and perform hand hygiene. Explanation: 1. Place the stethoscope firmly over the location where you palpated the brachial artery, making sure the stethoscope does not touch the cuff. Having the bell or diaphragm directly over the artery allows for readings that are more accurate. Heavy pressure on the brachial artery distorts the shape of the artery and the sound. Placing the bell or diaphragm away from clothing and the cuff prevents noise, which may distract you from the sounds made by blood flowing through the artery. 2. Tighten the screw valve on the air pump bulb so that the air you pump in doesn't escape. 3. Inflate the cuff to 30 mm above the point at which you palpated and estimated the systolic pressure. Increasing the pressure above the point where the pulse disappeared ensures a period of silence before hearing the first sound that corresponds with the systolic pressure. It prevents misinterpreting phase II sounds as phase I. 4. Open the valve on the bulb and allow the air to escape slowly, allowing the gauge to drop 2 to 3 mm per heartbeat. Allows for readings that are more accurate. 5. Note the point on the gauge at which there is an appearance of the first faint, but clear sound that slowly increases in intensity. Note this number as the systolic pressure reading. Systolic pressure is the point at which the blood in the artery is first able to force its way through the vessel at a similar pressure exerted by the air bladder in the cuff. The first sound is phase I of Korotkoff sounds. 6. Note the pressure at which the sound first becomes muffled and the point at which the sound completely disappears. This may occur separately or at the same point. The point at which the sound changes correspond to phase IV Korotkoff sounds and is considered the first diastolic pressure reading. This is used as the diastolic pressure recording in children. The last sound heard is the beginning of phase V and is the second diastolic reading. In adults, the point at which the sound disappears is recorded as the diastolic pressure. 7. Allow the remaining air to escape quickly to allow the blood to circulate normally through the limb. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings. 8. Clean the stethoscope head with an alcohol prep and perform hand hygiene to deter the spread of microorganisms.

Explain the rationale for changing Mr. Easton's medication to a combination drug.

The drugs are from two different classes and correct different pathophysiologic factors for HTN. A second drug of a different class should be added if the first drug does not control BP. Blood pressure is the force blood exerts against vessel walls; it must be high enough to maintain adequate tissue perfusion, yet not so high it causes organ damage. Factors affecting BP include cardiac output (CO), systemic vascular resistance (SVR), sympathetic nervous system activity, and enzymes excreted from the vascular endothelium, endocrine and renal systems. HCTZ (a thiazide diuretic) helps reduce CO by increased excretion of NA+ and water. Metoprolol (a beta-blocker) reduces CO, vasoconstriction, and renin secretion by blocking beta-adrenergic receptors.

During the auscultation of a patient's heart sounds, the nurse notes an S4. The nurse recognizes that an S4 is associated with which of the following? a) Heart failure b) Hypertensive heart disease c) Diseased heart valves d) Turbulent blood flow

b) Hypertensive heart disease Explanation: Auscultation of the heart requires familiarization with normal and abnormal heart sounds. An extra sound just before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3 heart sound is often an indication of heart failure in an adult. In addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves

angina

The most important cause of angina is coronary artery disease causing a 75% or more blockage of at least one coronary artery. Precipitating factors lead to either an increased demand for cardiac O2 or a decreased supply of cardiac O2; both conditions lead to myocardial ischemia. Perfusion to the ischemic areas in chronic stable angina is restored by rest and/or sublingual NTG. In addition to chronic stable angina, patients may experience silent angina (ischemia without symptoms; this often occurs in diabetic patients with neuropathy), nocturnal angina (occurs only at night, not necessarily during sleep), decubitus angina (occurs only when lying down, relieved by standing), or Prinzmetal's angina (often occurs at rest in response to coronary artery spasm; it may be relieved by moderate exercise or disappear spontaneously). The patient may be initially diagnosed with unstable angina, or the patient with chronic stable angina may progress to unstable angina. This is a worsening pattern that occurs without warning and at rest. Clinical manifestations of angina range from mild chest discomfort to crushing pain, and feelings of anxiety to feelings of impending death. Women with angina are likely to experience atypical symptoms, including fatigue, weakness, and shortness of breath. Elderly people may simply experience dyspnea. Angina is medically treated by both short- and long-acting nitrates (which are vasodilators, primarily in the venous system, that decrease preload, which in turn decreases myocardial O2 consumption; this decreases ischemia and relieves pain); by beta-adrenergic blockers which reduce cardiac rate and contractility (reducing myocardial O2 consumption); and by calcium channel blockers which lower heart rate and increase strength of contraction, thus decreasing cardiac workload and myocardial demand for O2. Calcium channel blockers also increase myocardial O2 supply by dilating coronary arterioles. Patients with angina also receive anticoagulant and antiplatelet medication to prevent thrombosis and attendant decreased blood flow. Patients with angina related to coronary artery blockage may be candidates for surgical intervention including percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Additional measures include lifestyle changes to reduce the risk of CAD.

Mr. Gruppman expresses that he is worried he is going to have another heart attack and end up "crippled." How should the nurse respond to his reaction?

The nurse should perform the following nursing interventions: Listen to Mr. Gruppman in a non-judgmental, interested manner. Encourage him to express what, specifically, he is afraid of. Determine what Mr. Gruppman knows about how an MI occurs and what his course of rehab will be. Correct any misconceptions and provide additional information as needed. Assess Mr. Gruppman's social/family support group and try to include them if appropriate; fear and anxiety perpetuate the stress response and hinder healing. Establish a therapeutic relationship with Mr. Gruppman that allows him to express his fears. Assessing his knowledge and beliefs, and correcting misconceptions will help lower anxiety levels; knowledge will give him a sense of control. Mr. Gruppman will likely be encouraged to join a MI support group when he is in cardiac rehab, pulling in his own social/family support system will also help him in his recovery.

Mr. Kingsolver is given a prescription for nitroglycerin 0.4 mg SL tablets. What patient education does the nurse provide to Mr. Kingsolver on how to take sublingual nitroglycerin and the common side effects that occur?

The nurse tells Mr. Kingsolver that he should place a tablet under his tongue at the first sign of chest pain, and allow it to dissolve. He should not swallow or chew the tablet, and may take another tablet 5 minutes later, if needed. He should not take more than three tablets, 5 minutes apart. If the pain is not better after the third tablet, he should go to the hospital immediately. The nurse also tells Mr. Kingsolver that he may experience headache, palpitations, and dizziness (especially after changing positions) after using nitroglycerin. She explains that nitroglycerin relieves angina pain by relaxing the smooth muscle of the vasculature. Dilation of the vessels reduces systemic vascular resistance (SVR) and afterload and it decreases the amount of blood returning to the heart, thereby decreasing preload. The nurse emphasizes that nitroglycerin should be kept in the original glass container to protect it from light and moisture, the cotton ball should be discarded, and the bottle dated when opened. The medication should be discarded 6 months after opening

The nurse gives Ms. Anderson instructions on the use of her sublingual NTG. What aspects of patient education should the nurse elaborate?

The nurse tells Ms. Anderson that she should place a tablet under her tongue at the first sign of chest pain and allow it to dissolve; she should not swallow or chew the tablet; she may take another tablet 5 minutes later if needed, and a third one 5 minutes after that, if needed; she should not take more than three tablets, 5 minutes apart. If the pain is not better after the third tablet, she should go to the hospital immediately. The nurse also tells Ms. Anderson that she may experience headache, palpitations, and dizziness (especially after changing positions) after using nitroglycerin. She explains that nitroglycerin relieves angina pain by relaxing the smooth muscle of the vasculature. Dilation of the vessels reduces systemic vascular resistance (SVR) and afterload and it decreases the amount of blood returning to the heart, thereby decreasing preload. The nurse emphasizes that nitroglycerin should be kept in the original glass container to protect it from light and moisture, the cotton ball should be discarded, and the bottle dated when opened. The medication should be discarded six months after opening to ensure full potency.

It's 9:00 a.m. You're visiting Mrs. Downs at her home as part of her scheduled home healthcare. She is somewhat anxious and nervous about learning how to administer the antibiotics herself. In response to your greeting she says: "I don't want to mess up. What if I make things worse?" She seems anxious, doesn't she? What will you say to her? What should you explain to Mrs. Downs regarding her blood pressure measurement?

You should allow Mrs. Downs to communicate her thoughts and feelings about her situation, the change in her health status, and any questions she may have. Explain the rationale for the measurement and the steps that are involved. You should explain that, now that she's at home, you will be monitoring her condition and responding to any symptoms or problems she may be having. Part of your assessment includes obtaining a set of vital sign measurements, including a blood pressure reading. Explain that a cuff will be placed around her arm and it will become tight and may be uncomfortable, but only for a minute or two.

A 66-year-old client presents to the emergency room (ER) complaining of a severe headache and mild nausea for the last 6 hours. Upon assessment, the patient's BP is 210/120 mm Hg. The patient has a history of HTN for which he takes 1.0 mg clonidine (Catapres) twice daily for. Which of the following questions is most important for the nurse to ask the patient next? a) "Have you taken your prescribed Catapres today?" b) "Do you have a dry mouth or nasal congestion?" c) "Are you having chest pain or shortness of breath?" d) "Did you take any medication for your headache?"

a) "Have you taken your prescribed Catapres today?" Explanation: The nurse must ask if the patient has taken his prescribed Catapres. Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Specifically, a side effect of Catapres is rebound or withdrawal hypertension. Although the other questions may be asked, it is most important to inquire if the patient has taken his prescribed HTN medication given the patient's severely elevated BP.

A nurse has provided discharge instructions to a patient who had an implantable cardioverter defibrillator (ICD) implanted. Which of the following statements, made by the patient, indicates the need for further teaching? a) "I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." b) "I can play golf with my son in about 2 or 3 weeks." c) "I should tell close friends and family members that I have an ICD." d) "I will document the date and time if my ICD fires."

a) "I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." Explanation: The patient does not need to take a CPR class. However, it is recommended that the family members and friends of a patient who has an ICD learn CPR. The other statements indicate that the nurse's teaching was effective.

Mr. Gruppman wonders why his blood sugar is so high - "I don't need diabetes on top of everything else!" What should the nurse tell him? a) "Your nervous system is causing increased levels of sugars and fats to help your damaged heart muscle function." b) "You need the increased sugars to heal your heart." c) "Diabetes is a potential complication of MI." d) "It is probably a lab error, don't worry about it."

a) "Your nervous system is causing increased levels of sugars and fats to help your damaged heart muscle function." Explanation: Catecholemines, released after infarction takes place, precipitate glycogenolysis and lipolysis. The extra glucose and free fatty acids are used for anaerobic metabolism by the oxygen-depleted myocardium. They are not used in the healing process, which involves scar formation, and diabetes is not a complication of MI. Temperature increases may occur due to the inflammatory process following tissue necrosis

Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a) 140, 90 b) 120, 70 c) 130, 80 d) 110, 60

a) 140, 90 Explanation: According to the categories of blood pressure levels established by the Joint National Committee (JNC) VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159, or a diastolic pressure of 90 to 99. Pressure of 130 systolic and 80 diastolic falls within the normal range for an adult. Pressure of 110 systolic and 60 diastolic falls within the normal range for an adult. Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult.

When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the healthy adult, which of the following is true? a) Pressures may vary 10 mm Hg or more between arms. b) Pressures should not differ more than 5 mm Hg between arms. c) Pressures may vary, with the higher pressure found in the left arm. d) Pressures must be equal in both arms.

b) Pressures should not differ more than 5 mm Hg between arms. Explanation: Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. The pressures in each arm do not have to be equal in order to be considered normal. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomic variant.

The nurse is caring for a client newly diagnosed with secondary hypertension. Which of the following conditions contributes to the development of secondary hypertension? a) Acid-based imbalance b) Renal disease c) Calcium deficit d) Hepatic function

b) Renal disease Explanation: Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoietin alfa [Epogen]), and coarctation of the aorta. High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attacks, strokes, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension.

Which of the following findings indicates that hypertension is progressing to target organ damage? a) Chest x-ray showing pneumonia b) Retinal blood vessel damage c) Urine output of 60 cc/mL over 2 hours d) Blood urea nitrogen (BUN) level of 12 mg/dL

b) Retinal blood vessel damage Explanation: Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated. All body systems must be assessed to detect any evidence of vascular damage. An eye examination with an ophthalmoscope is important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed. A BUN level and 60 cc/mL over 2 hours are normal findings. The presence of pneumonia does not indicate target organ damage.

Mr. Kingsolver returns to the short-stay unit following his procedure. His catheterization was accomplished via right femoral artery access. Which of the following would the nurse expect to do? Select all that apply. a) Administer IV fluids and encourage oral fluids b) Maintain bed rest for 30 minutes c) Monitor color, motion, sensitivity (CMS) and pulses in his right leg d) Monitor the puncture site for bleeding/hematoma e) Raise the head of his bed if he experiences a vasovagal reaction

a) Administer IV fluids and encourage oral fluids, c) Monitor color, motion, sensitivity (CMS) and pulses in his right leg, d) Monitor the puncture site for bleeding/hematoma Explanation: Mr. Kingsolver will be on bed rest for 2 to 6 hours depending on what type of closure device was used after the procedure. The nurse will closely monitor the puncture site for bleeding or hematoma formation. Peripheral pulses and CMS should be monitored every 15 minutes for the first hour, then hourly, if stable. The patient should be monitored for cardiac dysrhythmias; if a vasovagal response occurs, the patient's legs should be raised above the level of his head and IV fluids and IV atropine administered. Mr. Kingsolver should be instructed to immediately report any chest pain and should be assisted his first time out of bed. Discharge instructions should include signs/symptoms to report, how to avoid infection (including shower, not a tub bath, until healed), and measures to avoid straining.

The nurse has completed a teaching session on the self-administration of sublingual nitroglycerin. Which of the following patient statements indicates that the patient teaching has been effective? a) "After taking two tablets with no relief, I should call emergency medical services." b) "I can put the nitroglycerin tablets in my daily pill dispenser with my other medications". c) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". d) "Side effects of nitroglycerin include, flushing, throbbing headache, and hypertension".

c) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". Explanation: Nitroglycerin can be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e. before angina-producing activity, such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops. The client is instructed to take three tablets 5 minutes apart and if the chest pain is not relieved emergency medical services should be contacted. Nitroglycerin is very unstable; it should be carried securely in its original container (e.g., capped dark glass bottle); tablets should never be removed and stored in metal or plastic pillboxes. Side effects of nitroglycerin includes: flushing, throbbing headache, hypotension, and tachycardia.

The nurse is caring for a female client who has had 25 mg of oral hydrochlorothiazide added to her medication regimen for the treatment of hypertension (HTN). Which of the following instructions should the nurse give the patient? a) "You may develop dry mouth or nasal congestion while on this medication." b) "Take this medication before going to bed." c) "Increase the amount of fruits and vegetables you eat." d) "You may drink alcohol while taking this medication."

c) "Increase the amount of fruits and vegetables you eat." Explanation: Thiazide diuretics cause loss of sodium, potassium, and magnesium. The patient should be encouraged to eat fruits and vegetables which are high in potassium. Diuretics cause increased urination; the patient should not take the medication prior to going to bed. Thiazide diuretics to not cause dry mouth or nasal congestion. Postural hypotension (side effect) may be potentiated by alcohol.

How will you respond to the patient's concerns about his ED? a) "It's not from your antihypertensive, it's a normal aging change." b) "You have to take your BP medication, so I guess you'll have to learn to live with this." c) "Let's talk to your doctor about switching to a drug that does not have this side effect." d) "All antihypertensives have this side effect."

c) "Let's talk to your doctor about switching to a drug that does not have this side effect." Explanation: Some classes of antihypertensives (including thiazides and beta-blockers) can cause sexual dysfunction, including ED, loss of libido, and decreased ejaculation. There are other classes Mr. Easton could try that do not have this potential side effect.

A 55-year-old man newly diagnosed with hypertension returns to his physician's office for a routine follow-up appointment after several months of treatment with Lopressor (metoprolol). During the nurse's initial assessment the patient's blood pressure (BP) is recorded as 180/90 mm Hg. The patient states he does not take his medication as prescribed. The best response by the nurse is which of the following? a) "It is very important for you to take your medication as prescribed, or you could experience a stroke." b) "Be certain to discuss your noncompliance with your medication regimen with the physician." c) "The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?" d) "Your hypertension must be treated with medications; you need to take your Lopressor every day."

c) "The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?" Explanation: The nurse needs to understand why the patient is not taking his medication. Lopressor is a beta-blocker. All patients should be informed that beta-blockers might cause sexual dysfunction and that other medications are available if problems with sexual function occur. The other statements, although true, are nontherapeutic and would not elicit why the patient was not taking his medications as prescribed.

The nurse is assigned to care for the following patients admitted to a telemetry unit. Which patient should the nurse assess first? a) A patient returned from an electrophysiology (EP) procedure 2 hours ago complaining of constipation b) A patient diagnosed with new onset of atrial fibrillation requiring scheduled IV Cardizem c) A patient whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift requiring amiodarone IV d) A patient who received elective cardioversion 1 hour ago with a heart rate (HR) is 115 bpm

c) A patient whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift requiring amiodarone IV Explanation: The patient's ICD that has fired on the previous shift should be seen first. This patient is in need of antidysrhythmic medication and this is the priority intervention. The remaining patients should be seen after this patient and are in no acute distress.

9:02 A.M. Now that you've identified steps to prevent infection, you need to assess Mrs. Downs for conditions that would contraindicate the use of any of her limbs for blood pressure measurement. What will you assess for before selecting an extremity for measuring blood pressure? a) Assess for the presence of factors that may influence blood pressure reading. b) Breast or axilla surgery on the same side as the extremity. c) Baseline blood pressure reading. d) Presence of an intravenous infusion, a cast, or an arteriovenous shunt. e) Size of the patient's limb. f) Injury or disease of the limb. g) The patient's ability to follow instructions. h) Presence of tattoos and scars.

a) Assess for the presence of factors that may influence blood pressure reading., b) Breast or axilla surgery on the same side as the extremity., c) Baseline blood pressure reading., d) Presence of an intravenous infusion, a cast, or an arteriovenous shunt., e) Size of the patient's limb., f) Injury or disease of the limb. Explanation: You must assess for the presence of an intravenous infusion, a cast or arteriovenous shunt in the limb, breast or axilla, surgery on the side of the extremity, or injury or disease of the limb. These conditions would contraindicate the use of that limb for blood pressure measurement. Knowledge of factors that may influence the blood pressure reading allows for accurate interpretation of the reading. You should also assess the size of the limb so that the appropriate sized cuff can be used. Also, note the patient's baseline reading, if available, for comparison.

The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which of the following measures should the nurse complete to prevent deep venous thrombosis (DVT) and possible pulmonary embolism (PE) development? Select all that apply. a) Avoid elevating the knees on the bed. b) Initiate passive exercises. c) Apply antiembolism stockings. d) Place pillows in the popliteal space. e) Encourage the crossing of the legs.

a) Avoid elevating the knees on the bed., b) Initiate passive exercises., c) Apply antiembolism stockings. Explanation: Preventative measures utilized to prevent venous stasis include: Application of sequential pneumatic compression wraps or antiembolic stockings; discouraging leg crossing; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.

The nurse instructs Ms. Bailey to call the physician or hospital immediately with which one of the following signs and symptoms? a) Chest pain or shortness of breath b) Blood glucose of 180 1 hour after eating c) Open sores on toes d) Tension headaches

a) Chest pain or shortness of breath Explanation: Chest pain and shortness of breath are serious symptoms that should be reported immediately. Open sores on toes would be something Theresa should point out to her PCP on the follow-up visit next week. Blood glucose levels normally rise after a meal. Theresa can be instructed to treat tension headaches with rest and/or mild analgesics, such as Tylenol.

The nurse is caring for a patient who was admitted to the telemetry unit with a diagnosis of rule/out acute MI. The patient's chest pain began 3 hours ago. Which of the following laboratory tests would be most helpful in confirming the diagnosis of a current MI? a) Creatinine kinase-myoglobin (CK-MB) level b) Troponin C level c) Myoglobin level d) CK-MM

a) Creatinine kinase-myoglobin (CK-MB) level Explanation: Elevated CK-MB assessment by mass assay is an indicator of acute MI; the levels begin to increase within a few hours and peak within 24 hours of an MI. If the area is reperfused (due to thrombotic therapy or PCI), it peaks earlier. CK-MM (skeletal muscle) is not an indicator of cardiac muscle damage. There are three isomers of troponin: C, I, and T. Troponin I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results are an excellent parameter for ruling out an acute MI.

Which of the following nursing measures are priorities for Mrs. Melnik? a) Daily weights b) Vital signs every shift c) Semi-Fowler's position d) Oxygen at 6 L by nasal catheter

a) Daily weights, c) Semi-Fowler's position, d) Oxygen at 6 L by nasal catheter Explanation: IV morphine decreases O2 demands and O2 administration helps increase the percentage of inspired air. Daily weights help monitor fluid gain/loss in the client experiencing or at risk for fluid volume overload. The client should be in high Fowler's position to help decrease venous return and to increase thoracic capacity. Vital signs should be assessed every hour to every 4 hours depending on client condition and medications being administered. As she is being given IV furosemide, she needs to be more frequently monitored for dehydration and circulatory collapse (BP and pulse).

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain? a) Description of the pain b) Pulse rate in upper extremities c) Blood pressure in the left arm d) Sound of the apical pulses

a) Description of the pain Explanation: If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the patient and measures vital signs. The nurse may measure BP in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.

Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply. a) Direct vasodilators may cause headache and tachycardia. b) With thiazide diuretics, monitor serum potassium levels. c) With ACE inhibitors, assess for bradycardia. d) Beta-blockers may cause sedation. e) With adrenergic inhibitors, cough is a common side effect.

a) Direct vasodilators may cause headache and tachycardia., b) With thiazide diuretics, monitor serum potassium levels. Explanation: Thiazide diuretics may deplete potassium; many clients will need potassium supplementation. Angiotensin-converting enzyme (ACE) inhibitors can induce a mild to severe dry cough. Beta-blockers may induce decreased heart rate; pulse rate should be assessed before administration. Direct vasodilators may cause headache and increased heart rate. Adrenergic inhibitors can cause sedation and fatigue.

The nurse is caring for a patient in the ICU diagnosed with coronary artery disease (CAD). Which of the following assessment data indicates the patient is experiencing a decrease in cardiac output? a) Disorientation, 20 mL of urine over the last 2 hours b) Elevated jugular venous distention (JVD) and postural changes in BP c) BP 108/60 mm Hg, ascites, and crackles d) Reduced pulse pressure and heart murmur

a) Disorientation, 20 mL of urine over the last 2 hours Explanation: Assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced urine output, lethargy, or disorientation.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which of the following patient findings requires immediate intervention by the nurse? a) Chest pain: 2 of 10 (1-to-10 pain scale) b) Presence of reperfusion dysrhythmias c) Altered level of consciousness d) Minimal oozing of blood from the IV site

c) Altered level of consciousness Explanation: A patient receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low, and indicates the patient's chest pain is subsiding, an expected outcome of this therapy.

Which of the following is the most important principle the nurse considers in planning post-MI patient education? a) Establish the patient's priorities and plan teaching around them. b) Warn the patient that he will have another MI if he does not make some lifestyle changes. c) Determine patient's current knowledge level. d) Use handouts because the patient will not retain information you give him.

a) Establish the patient's priorities and plan teaching around them. Explanation: Establishing and working with the patient's priorities will give him a sense of control and ensure an investment in making lifestyle changes. Issuing "threats" is not often successful in effecting lifestyle change. Determining the patient's current knowledge level is an important part of planning patient education, but determining the patient's priorities has a higher value in ensuring successful lifestyle changes. Handouts are an important tool in patient education, but determining the patient's priorities has a higher value in ensuring successful lifestyle changes.

Which of the following medications is categorized as a loop diuretic? a) Furosemide (Lasix) b) Spironolactone (Aldactone) c) Chlorthalidone (Hygroton) d) Chlorothiazide (Diuril)

a) Furosemide (Lasix) Explanation: Lasix is commonly used in the treatment of cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide is categorized as a thiazide diuretic. Chlorthalidone is categorized as a thiazide diuretic. Spironolactone is categorized as a potassium-sparing diuretic

The nurse notes that Ms. Anderson's K+ level is 6.0. What is the most likely cause for this? a) Hemolysis from the cardiopulmonary bypass machine b) K+ added to IV bag c) Inadequate fluid intake d) NG tube suctioning

a) Hemolysis from the cardiopulmonary bypass machine Explanation: The CPB can cause hemolysis. Lysis of the RBCs will release K+ from the intracellular space resulting in serum hyperkalemia. Excessive NG tube drainage would cause hypokalemia. While it is likely the IV potassium additive would be discontinued, this is not the most likely cause of the patient's hyperkalemia. Inadequate fluid intake would lead to hypokalemia.

Which of the following complications of hypertensive crisis is Mr. Easton exhibiting? a) Hypertensive encephalopathy b) Aortic dissection c) Renal insufficiency d) Rapid cardiac decompensation

a) Hypertensive encephalopathy Explanation: Hypertensive encephalopathy manifests as a sudden rise in BP and may be associated with headache, nausea/vomiting, confusion, seizures, stupor, and coma. Rapid cardiac decompensation may manifest as chest pain and dyspnea. Symptoms of renal insufficiency vary depending on severity. Aortic dissection may manifest as extreme chest and back pain, diaphoresis, and loss of pulses in extremities.

The nurse understands that patient education related to antihypertensive medication should include all of the following instructions except which of the following? a) If a dosage of medication is missed, double up on the next one to catch up. b) Do not stop antihypertensive medication abruptly. c) Avoid hot baths, exercise, and alcohol within 3 hours of taking vasodilators. d) Avoid over the counter (OTC) cold, weight reduction, and sinus medications.

a) If a dosage of medication is missed, double up on the next one to catch up. Explanation: Doubling doses could cause serious hypotension (HTN) and is not recommended. Medications should be taken as prescribed. Hot baths, strenuous exercise, and excessive alcohol are all vasodilators and should be avoided. Many OTC preparations can precipitate HTN. Stopping antihypertensives abruptly can precipitate a severe hypertensive reaction and is not recommended.

Expected abnormalities in serum studies confirming angina include which of the following options? a) Increased CRP b) Increased myoglobin c) Decreased LDL d) Increased troponin

a) Increased CRP Explanation: Elevated CRP indicates inflammation; inflammation of the endothelium of the coronary arteries is a probable factor in the development of CAD; CAD is the primary cause of angina. Increased troponin and increased myoglobin indicate MI. LDL would likely be elevated in CAD.

The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient's prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? a) International normalized ratio (INR) b) Partial thromboplastic time (PTT) c) Complete blood count (CBC) d) Sodium

a) International normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of Coumadin.

Why is the nurse concerned about Mr. Easton's complaint of blurry vision? a) It signals possible target organ damage. b) It indicates he has increased his alcohol intake. c) It is a sign of hydrocholorthiazide toxicity. d) It is not of concern; he simply needs new eye glasses.

a) It signals possible target organ damage. Explanation: Target organ damage is the most common complication of untreated/under treated HTN. Affected organ systems are the heart (CAD, LVH, and heart failure), the cerebrovascular system (cerebroatherosclerosis, stroke, and hypertensive encephalopathy), the peripheral vascular system, kidneys, and the eye (retinal damage). Blurry vision is not a side effect of HTCZ.

A nurse is assessing a patient with congestive heart failure for jugular vein distension (JVD). Which of the following observations is important to report to the physician? a) JVD is noted 3 cm above the sternal angle. b) JVD is noted at the level of the sternal angle. c) No JVD is present. d) JVD is noted 1 cm above the sternal angle.

a) JVD is noted 3 cm above the sternal angle. Explanation: JVD is assessed with the patient sitting at a 45° angle. Jugular vein distention greater than 3 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

9:03 A.M. Your assessment reveals a PICC in the left upper arm, making it necessary to take the measurement in Mrs. Downs's right arm. She's somewhat anxious about her current situation and learning a new skill. This could elevate her blood pressure. Mrs. Downs is a new patient, so a baseline reading is not available. Now you should assist Mrs. Downs to an appropriate position for the measurement of blood pressure. Can you identity the appropriate position to which you must assist Mrs. Downs for the blood pressure measurement? a) Lying down with her right arm raised , fist clenched. b) Sitting with her right forearm at the level of her heart, fist clenched. c) Sitting with her right forearm at the level of her heart, palm upward. d) Sitting up with her right arm held loosely by her side. e) Lying down with her right arm by her side, palm down.

c) Sitting with her right forearm at the level of her heart, palm upward. Explanation: You should assist Mrs. Downs to a sitting position with her right arm exposed and placed in a comfortable position. Her forearm should be supported at the level of her heart and her palm facing upward. This position places the brachial artery on the inner aspect of the elbow so that the bell or diaphragm of the stethoscope can rest on it easily.

Prior to his discharge, Mr. Gruppman has a low-level treadmill test without evidence of ischemia. Based on this result, what information should he be given about his target heart rate during physical activity? a) His heart rate may exceed the target heart rate due to his atenolol. b) He should aim for 100% of his age-related heart rate while exercising. c) The most important factor to consider is his symptoms in response to activity. d) Isometric exercises would be better for him than isotonic exercises.

c) The most important factor to consider is his symptoms in response to activity. Explanation: Mr. Gruppman should be taught his exercise parameters and target heart rate; however, he should also be taught to "listen to his body" and stop if angina or dyspnea occurs. Beta-blockers slow heart rate, so Mr. Gruppman may not be able to reach a target heart rate. Isometric exercises rapidly increase BP and HR and should be avoided. Healthy persons should aim for 60% to 80% of their age-related target heart rate. Post-MI patients may be instructed to aim for a lower rate.

When a patient who has been diagnosed with angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina? a) Intractable b) Refractory c) Unstable d) Variant

c) Unstable Explanation: Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment

The nurse is reevaluating a patient 2 hours following a percutaneous transluminal coronary angioplasty (PTCA) procedure. Which of the following assessment findings may indicate the patient is experiencing a complication of the procedure? a) Heart rate of 100 bpm b) Potassium level of 4.0 mE/qL c) Urine output of 40 mL d) Dried blood at the puncture site

c) Urine output of 40 mL Explanation: Complications that may occur following a PTCA include myocardial ischemia, bleeding and hematoma formation, retroperitoneal hematoma, arterial occlusion, pseudoaneurysm formation, arteriovenous fistula formation, and acute renal failure. The urine output of 40 mL over a 2-hour period may indicate acute renal failure. The patient is expected to have a minimum urine output of 30 mL per hour. Dried blood at the insertion site is a finding warranting no acute intervention. A serum potassium level of 4.0 mEq/L is within normal range. The heart rate of 100 bmp is within the normal range and indicates no acute distress.

Mr. Gruppman asks why his "heart labs" keep increasing and wonders if he is having another heart attack. What is the ideal response that the nurse should provide? a) "No, but it is an indication that the cardiac damage is more extensive than initially thought." b) "Yes, it's possible, so we will be watching your ECG closely." c) "The cardiac marker labs will continue to elevate for 24 hours and then remain high indefinitely." d) "Cardiac marker labs continue to rise for 24 to 48 hours after your heart attack. They should start to fall tomorrow."

d) "Cardiac marker labs continue to rise for 24 to 48 hours after your heart attack. They should start to fall tomorrow." Explanation: CK levels peak in about 24 hours, returning to normal over 2 to 3 days. Troponin peaks in 24 to 48 hours, returning to normal over 5 to 14 days. Myoglobin usually returns to normal within 24 hours.

Mr. Kingsolver asks the nurse to explain the results of his cholesterol tests to him and tell him what he can do to improve them. What should the nurse's appropriate response be? a) LDL is the "good" cholesterol and HDL is the "bad" cholesterol. b) Exercise has no effect on lipid levels. c) A diet high in carbohydrates will help lower triglyceride levels. d) A high HDL is desirable because it helps clear the body of LDL.

d) A high HDL is desirable because it helps clear the body of LDL. Explanation: HDL ("good" cholesterol) transports LDL to the liver, where it is broken down and excreted. HDL should be greater than 40 mg/dL, ideally greater than 60 mg/dL. LDL ("bad" cholesterol) adheres to arterial endothelium, beginning the process of plaque formation and CAD; in a client at high risk for CAD, the LDL level should be less than 100 mg/dL. Triglycerides are produced from excess caloric intake (from any source) and contribute to heart disease; they should be less than 200 mg/dL. Increased physical activity has been shown to increase HDL and lower triglycerides. Total cholesterol should be below 200 mg/dL.

To assess for peripheral edema, the nurse will examine which of the following areas of the body? a) Under the sacrum b) Lips, earlobes c) Upper arms d) Feet, ankles

d) Feet, ankles Explanation: When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.

The nurse identifies which of the following symptoms as a characteristic of right-sided heart failure? a) Pulmonary crackles b) Cough c) Jugular vein distention (JVD) d) Dyspnea

d) Jugular vein distention (JVD) Explanation: JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure

The nurse teaches the patient which of the following guidelines regarding lifestyle modifications for hypertension? a) Stop alcohol intake b) Reduce smoking to no more than four cigarettes per day c) Limit aerobic physical activity to 15 minutes, three times per week d) Maintain adequate dietary intake of fruits and vegetables

d) Maintain adequate dietary intake of fruits and vegetables Explanation: Guidelines include adopting the dietary approaches to stop hypertension (DASH) eating plan: consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat, dietary sodium reduction: reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride), and physical activity: engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week), Moderate alcohol consumption: limit consumption to no more than two drinks (eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter-weight people. Tobacco: should be avoided because anyone with high blood pressure is already at increased risk for heart disease, and smoking amplifies this risk.

A patient has been diagnosed with congestive heart failure. Which of the following is a cause of crackles heard in the bases of the lungs? a) Pulmonary hypertension b) Heart palpitations c) Mitral valve stenosis d) Pulmonary congestion

d) Pulmonary congestion Explanation: Crackles heard in the bases of the lungs are a sign of pulmonary congestion. Heart palpitations are caused by tachydysrhythmias. Crackles heard in the bases of the lungs are not signs of pulmonary hypertension and mitral valve stenosis

A 35-year-old female patient has been diagnosed with hypertension. The patient is a stock broker, smokes daily, and is also a diabetic. During a follow-up appointment, the patient states that she finds it cumbersome and time consuming to visit the doctor regularly just to check her blood pressure (BP). As the nurse, which of the following aspects of patient teaching would you recommend? a) Discussing methods for stress reduction b) Administering glycemic control c) Advising a smoking cessation d) Purchasing a self-monitoring BP cuff

d) Purchasing a self-monitoring BP cuff Explanation: Because this patient finds it time consuming to visit the doctor just for a blood pressure reading, as the nurse, you can suggest the use of an automatic cuff at a local pharmacy, or purchasing a self-monitoring cuff. Discussing methods for stress reduction, advising a smoking cessation, and administering glycemic control would constitute patient education in managing hypertension.

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock? a) High blood pressure b) Increased urinary output c) Hyperactive bowel sounds d) Restlessness and confusion

d) Restlessness and confusion Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

What is the primary reason of adding Captopril to Mrs. Melnik's medication regimen? a) To reverse left ventricular hypertrophy b) To work as another diuretic c) To help control her blood pressure d) To prevent further left ventricular hypertrophy

d) To prevent further left ventricular hypertrophy Explanation: Captopril is an ACE inhibitor (not a diuretic). This class of drug has been demonstrated to prevent further LVH and is considered a standard of care for chronic HF. Beta-blockers have been demonstrated to reverse LVH and are also considered a standard of care for chronic HF. You recall that Mrs. Melnik was started on atenolol, a beta-blocker, at the start of the case. While captopril does reduce BP, its primary use for Mrs. Melnik is LVH protection.

Fatigue is a late manifestation of HF and is caused by increased cardiac output and decreased oxygenation of the tissues. False True

false Explanation: Fatigue is an early manifestation caused by decreased CO and consequent impaired perfusion/oxygenation of organs and tissues. DOE and orthopnea are due to increased pulmonary pressure and fluid build-up. Clients should report new dependant edema or weight gain of 3 pounds in 2 days to the health care provider as this is indicative of worsening HF. Clients with HF may also have decreased renal perfusion and urinary output. When they lie down at night, interstitial fluid moves back into the circulation increasing renal perfusion and output.

Frequent urination at night (nocturia) indicates a urinary tract infection.

false Explanation: Fatigue is an early manifestation caused by decreased CO and consequent impaired perfusion/oxygenation of organs and tissues. DOE and orthopnea are due to increased pulmonary pressure and fluid build-up. Clients should report new dependant edema or weight gain of 3 pounds in 2 days to the health care provider as this is indicative of worsening HF. Clients with HF may also have decreased renal perfusion and urinary output. When they lie down at night, interstitial fluid moves back into the circulation increasing renal perfusion and output.

DOE and orthopnea are caused by increased pulmonary pressure due to interstitial and alveolar edema. False True

true Explanation: Fatigue is an early manifestation caused by decreased CO and consequent impaired perfusion/oxygenation of organs and tissues. DOE and orthopnea are due to increased pulmonary pressure and fluid build-up. Clients should report new dependant edema or weight gain of 3 pounds in 2 days to the health care provider as this is indicative of worsening HF. Clients with HF may also have decreased renal perfusion and urinary output. When they lie down at night, interstitial fluid moves back into the circulation increasing renal perfusion and output.

The development of dependant (ankle) edema is a sign of exacerbated HF. True False

true Explanation: Fatigue is an early manifestation caused by decreased CO and consequent impaired perfusion/oxygenation of organs and tissues. DOE and orthopnea are due to increased pulmonary pressure and fluid build-up. Clients should report new dependant edema or weight gain of 3 pounds in 2 days to the health care provider as this is indicative of worsening HF. Clients with HF may also have decreased renal perfusion and urinary output. When they lie down at night, interstitial fluid moves back into the circulation increasing renal perfusion and output.

9:01 A.M. Good! You've recorded Mrs. Downs's systolic pressure at 112 and diastolic pressure at 64. Now you must document your findings. What will you document in relation to her blood pressure?

Date Time Patient appears somewhat anxious regarding the need to learn to self administer IV antibiotics; states, "I don't want to mess up. What if I make things worse?" Provided emotional support and reassurance. Explained rationale and procedure for measuring blood pressure Blood pressure reading obtained in right arm 112/64

What does Ms. Bailey's "elevation above normal" value in HgbA1c indicate?

Glycosylated hemoglobin (A1C) reflects average blood glucose over a period of 2 to 3 months, approximating the average lifespan of a red blood cell (RBC). When glucose levels are elevated, the glucose molecules attach to RBCs for the life of the RBCs (120 days). Therefore, increased HgbA1c reflects poor control of glucose. This appears to be true in Ms. Bailey's case.

Ms. Bailey asks why she is not receiving her metformin for her diabetes. How should the nurse respond to her query?

Metformin causes an increased risk of acute renal failure (ARF) and lactic acidosis with use of iodine based contrasts. Metformin should be discontinued or held for 48 hours prior to an angiogram (and for 48 hours afterward until renal function is confirmed normal).

Explain the rationale for changing Mrs. Melnik's furosemide from oral dosing to IV.

Mrs. Melnik is experiencing pulmonary edema and requires rapid and effective diuresis. Furosemide is a potent diuretic and is often used as a first-line agent in ADHF to reduce intravascular volume and preload. Onset of IV furosemide occurs within 5 minutes and peaks at 20 to 60 minutes. IV furosemide should be administered over 1 to 2 minutes to prevent ototoxicity. The client should be observed for signs/symptoms of hypovolemia, electrolyte imbalance (hypokalemia and hypochloremia), and thrombophlebitis.

9:03 A.M. You've applied the cuff of the sphygmomanometer correctly. Since Mrs. Downs is a new patient, a baseline reading is not available. Now you have to continue with the steps to estimate Mrs. Downs's systolic blood pressure. Estimating systolic blood pressure prevents underestimating it, ensuring accurate identification of the first sound. The steps are given here, but they're out of order.

Palpate the brachial pulse by pressing it gently with your fingertips. Tighten the screw valve on the air pump bulb. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. Explanation: 1. Palpate the brachial pulse by pressing it gently with your fingertips. Palpation allows for measurement of the approximate systolic reading. 2. Tighten the screw valve on the air pump bulb. The bladder within the cuff will not inflate with the valve open. 3. Inflate the cuff while continuing to palpate the artery. Inflation is necessary to apply pressure to the artery. 4. Note the point on the gauge where the pulse disappears. The point where the pulse disappears provides an estimate of the systolic pressure. To identify the first Korotkoff sound accurately, the cuff must be inflated to a pressure above the point at which the pulse can no longer be felt.

What pre-procedure education should the admitting nurse give to Mr. Kingsolver about the cardiac catheterization and angiography?

The admitting nurse needs to educate Mr. Kingsolver about the following: He will lie on a table for about 2 hours, under light IV sedation. He may feel an occasional pounding sensation in his chest (as the catheter touches his heart) or flushing throughout his body (as the contrast material is injected). He may feel he needs to void (as the contrast material is injected). These feelings should last less than a minute. He will be sedated, but will be awake enough to follow directions; he may be asked to cough or take a deep breath and hold it. Coughing will clear the contrast from his arteries or help correct a dysrhythmia. Deep breathing will lower the diaphragm, allowing a better view of the heart.

What is the desired BP for Ms. Bailey, given her medical history?

The goal of hypertension management is to prevent complications and death by achieving a BP of less than 130/80 for patients with diabetes mellitus or chronic kidney disease. This is lower than the goal of 140/90 for the general population.

List at least four teaching points the nurse should cover when Mrs. Melnik is discharged.

The patient should be provided information regarding balancing exercise and energy conservation. Recent research has shown that exercise (cardiac rehab training) does improve symptoms in HF, however, balancing exercise with energy conservation is also a concern in HF. Measures to prevent/monitor for future fluid volume overload should be taught. The patient must be told about the importance of a reduced salt diet, fluid restrictions as ordered by MD and daily weights. A restricted salt diet will help decrease edema and prevent fluid overload. The patient should be protected against respiratory infection with flu and pneumonia vaccines. Medication education should include how to take drugs, signs of toxicity, how to take BP and pulse, and when to hold the medication and call the MD. Finally, Mrs. Melnik should be taught early signs/symptoms of ADHF and know when to call her MD.

The nurse is caring for a male patient who is being evaluated for lipid-lowering medication. The patient's laboratory results reveal the following: Total cholesterol: 230 mg/dL, LDL: 120 mg/dL, and a triglyceride level of 310 mg/dL. Which of the following classes of medications would be most appropriate for the patient based on his laboratory findings? a) Bile acid sequestrants b) HMG-CoA reductase inhibitors c) Nicotinic acids d) Fibric acids

A nurse is caring for a patient post cardiac surgery. Upon assessment, the patient appears restless and is complaining of nausea and weakness. The patient's ECG reveals peaked T waves. The nurse reviews the patient's serum electrolytes anticipating which of the following abnormalities? a) Hypercalcemia b) Hyperkalemia c) Hyponatremia d) Hypomagnesemia

Following a percutaneous coronary intervention (PCI), a patient is returned to the nursing unit with large peripheral vascular access sheaths in place. The nurse understands that which of the following methods to induce hemostasis after sheath is contraindicated? a) Direct manual pressure b) Application of a vascular closure device c) Application of a mechanical compression device d) Application of a sandbag to the area

A patient has had a 12-lead -ECG completed as part of an annual physical examination. The nurse notes an abnormal Q wave on an otherwise unremarkable ECG. The nurse recognizes this finding indicates which of the following? a) A past MI b) Variant angina c) A cardiac dysrhythmia d) An evolving MI

The nurse has completed a teaching session on the self-administration of sublingual nitroglycerin. Which of the following patient statements indicates that the patient teaching has been effective? a) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". b) "After taking two tablets with no relief, I should call emergency medical services." c) "Side effects of nitroglycerin include, flushing, throbbing headache, and hypertension". d) "I can put the nitroglycerin tablets in my daily pill dispenser with my other medications".

a) "I can take nitroglycerin prior to having sexual intercourse so I won't develop chest pain". Explanation: Nitroglycerin can be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e. before angina-producing activity, such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops. The client is instructed to take three tablets 5 minutes apart and if the chest pain is not relieved emergency medical services should be contacted. Nitroglycerin is very unstable; it should be carried securely in its original container (e.g., capped dark glass bottle); tablets should never be removed and stored in metal or plastic pillboxes. Side effects of nitroglycerin includes: flushing, throbbing headache, hypotension, and tachycardia.

A 1-minute ECG tracing of a patient with a regular heart rate reveals 25 small square boxes within an RR interval. The nurse correctly identifies the patient heart rate as which of the following? a) 60 bpm. b) 80 bpm c) 70 bpm d) 100 bpm

a) 60 bpm. Explanation: A patient's HR can be obtained from the ECG tracing by several methods. A 1-minute strip contains 300 large boxes and 1500 small boxes. Therefore, an easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide by 1,500. In this instance, 1,500/25 = 60.

Which of the following terms is used to describe the ability of the heart to initiate an electrical impulse? a) Automaticity b) Contractility c) Excitability d) Conductivity

a) Automaticity Explanation: Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse. Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse. Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another. Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.

The nurse is caring for a patient following the insertion of a permanent pacemaker. Which of the following discharge instructions are appropriate for the nurse to review with the patient? Select all that apply. a) Avoid handheld screening devices in airports. b) Wear a medical alert noting the presence of a pacemaker c) Refrain from walking through antitheft devices. d) Check pulse daily, reporting sudden slowing or increase. e) Avoid the usage of microwave ovens and electronic tools

a) Avoid handheld screening devices in airports., b) Wear a medical alert noting the presence of a pacemaker, d) Check pulse daily, reporting sudden slowing or increase. Explanation: Handheld screening devices used in airports may interfere with the pacemaker. Patients should be advised to ask security personnel to perform a hand search instead of using the handheld screening device. With a permanent pacemaker, the patient should be instructed initially to restrict activity on the side of implantation. Patients also should be educated to perform a pulse check daily and to wear or carry medical identification to alert personnel to the presence of the pacemaker. Patients should walk through antitheft devices quickly and avoid standing in or near these devices. Patients can safely use microwave ovens and electronic tools.

The nurse is participating in the care of a client requiring emergent defibrillation. The nurse will complete the following steps in which order? a) Call "clear" three times ensuring patient and environmental safety. b) Turn on the defibrillator and place it in "not sync" mode. c) Charge the defibrillator to the prescribed voltage. d) Deliver the prescribed electrical charge. e) Apply the multifunction conductor pads to the patient's chest.

a) Call "clear" three times ensuring patient and environmental safety., b) Turn on the defibrillator and place it in "not sync" mode., c) Charge the defibrillator to the prescribed voltage., d) Deliver the prescribed electrical charge., e) Apply the multifunction conductor pads to the patient's chest. Explanation: This is the sequence of events the nurse should implement when delivering emergent defibrillation. If not followed correctly, the patient and health care team may be placed in danger.

A patient with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The patient's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of which of the following? a) Embolic stroke b) Heart failure c) Myocardial infarction d) Renal failure

a) Embolic stroke Explanation: Intervention is implemented to prevent the development of an embolic event/stroke. Patients with a history of previous stroke, transient ischemic attack (TIA), embolic event, mitral stenosis, or prosthetic heart valve and who develop atrial fibrillation are at significant risk of developing an embolic stroke. Antithrombotic therapy is indicated for all patients with atrial fibrillation, especially those at risk of an embolic event, such as a stroke, and is the only therapy that decreases cardiovascular mortality. These patients are often placed on warfarin, in contrast to patients who have no risk factors, who are often prescribed 81 to 325 mg of aspirin daily.

The nurse understands that asystole can be caused by several of the following. Select all that apply. a) Hypovolemia b) Acidosis c) Hypothermia d) Hypoxia e) Alkalosis

a) Hypovolemia, b) Acidosis, c) Hypothermia, d) Hypoxia Explanation: Ventricular asystole is treated the same as pulseless electrical activity (PEA), focusing on high-quality cardiopulmonary resuscitation (CPR) with minimal interruptions and identifying underlying and contributing factors. The key to successful treatment is a rapid assessment to identify a possible cause, which is known as the "Hs and Ts": hypoxia, hypovolemia, hydrogen ion (acid/base imbalance), hypo- or hyperglycemia, hypo- or hyperkalemia, hyperthermia, trauma, toxins, tamponade (cardiac), tension pneumothorax, or thrombus (coronary or pulmonary).

Age-related changes associated with the cardiac system include which of the following? Select all that apply. a) Increased size of the left atrium b) Myocardial thinning c) Endocardial fibrosis d) Increase in the number of SA node cells

a) Increased size of the left atrium, c) Endocardial fibrosis Explanation: Age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening.

A patient is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The patient's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV Nitropress (nitroprusside). Upon assessment, which of the following patient findings requires immediate intervention by the nurse? a) Left arm numbness and weakness b) Chest pain score of 3/10 (on a scale of 1 to 10) c) Urine output of 40 cc/mL over the last hour d) Nausea and severe headache

a) Left arm numbness and weakness Explanation: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of left arm numbness and weakness may indicate the patient is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP and requires immediate interventions. A urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes.

When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as which of the following? a) Pulmonary artery wedge pressure b) Central venous pressure c) Pulmonary artery pressure d) Cardiac output

a) Pulmonary artery wedge pressure Explanation: When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems? a) Pulmonary embolism b) Pulmonary edema c) Myocardial infarction d) Pneumonia

a) Pulmonary embolism Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction where emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A 26-year-old male patient, who has been diagnosed with paroxysmal supraventricular tachycardia (PSVT), is being treated in the emergency department. The patient is experiencing occasional runs of PSVT lasting up to several minutes at a time. During these episodes, the patient becomes lightheaded but does not lose consciousness. Which of the following maneuvers may be used to interrupt the patient's atrioventricular nodal reentry tachycardia (AVNRT)? Select all that apply. a) Stimulating the patient's gag reflex b) Instructing the patient to vigorously exercise c) Performing carotid massage. d) Placing the patient's face in cold water e) Instructing the patient to breathe deeply

a) Stimulating the patient's gag reflex, c) Performing carotid massage., d) Placing the patient's face in cold water Explanation: The following vagal maneuvers can be used to interrupt AVNRT: stimulating the patient's gag reflex, having the patient hold his breath, cough, bear down, placing his face in cold water, or performing carotid massage. These measures elicit a vagal response which will slow AV conduction time and help restore a regular rhythm. Because of the risk of a cerebral embolic event, carotid massage is contraindicated in patients with carotid bruits. If the vagal maneuvers are ineffective, the patient may receive a bolus of adenosine to correct the rhythm; this is nearly 100% effective in terminating AVNRT. Overexertion and deep inspirations are measures that could precipitate SVT.

The nurse is reviewing the laboratory results for a patient diagnosed with coronary artery disease (CAD). The patient's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as which of the following? a) Within normal limits b) High c) Low d) Critically high

b) High Explanation: The normal LDL range is 100 mg/dL to 130 mg/dL. A level of 115 mg/dL is considered to be high. The goal of treatment is to decrease the LDL level below 100 mg/dL (less than 70 mg/dL for very high-risk patients).

The nurse is caring for a 56-year-old male patient who had an implantable cardioverter defibrillator (ICD) implanted 2 days prior. The patient tells the nurse "My wife and I can never have sex again now that I have this ICD." The nurse's best response is which of the following? a) "I will be sure to share your concerns with the physician." b) "You seem apprehensive about resuming sexual activity." c) "Sex is permitted following the implantation of an ICD." d) "You really should speak to your wife about your concerns."

b) "You seem apprehensive about resuming sexual activity." Explanation: The patient treated with an electronic device experiences not only lifestyle and physical changes but also emotional changes. At different times during the healing process, the patient may feel angry, depressed, fearful, anxious, or a combination of these emotions. It is imperative for the nurse to observe the patient's response to the device and provide the patient and family members with emotional support and teaching as indicated. Identifying that the patient appears apprehensive about resuming sexual activity acknowledges the patient's concerns while allowing for further discussion. The remaining responses ignore the patient's feelings and do not facilitate an ongoing conversation or explore the patient's concern.

A patient's ECG tracing reveals a ventricular rate between 250 and 400, with saw-toothed P waves. The nurse correctly identifies this dysrhythmia as which of the following? a) Ventricular fibrillation b) Atrial flutter c) Atrial fibrillation d) Ventricular tachycardia

b) Atrial flutter Explanation: The nurse correctly identifies the ECG tracing as atrial flutter. Atrial flutter occurs in the atrium and creates impulses at a regular atrial rate between 250 and 400 times per minute. The P waves are saw-toothed in appearance. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. The atrial rate is 300 to 600, and the ventricular rate is usually 120 to 200 in untreated atrial fibrillation. There are no discernible P waves. Ventricular fibrillation is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. The ventricular rate is greater than 300 per minute and extremely irregular, without a specific pattern. The QRS shape and duration is irregular, undulating waves without recognizable QRS complexes. Ventricular tachycardia is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per

A nurse is completing a shift assessment on a patient admitted to the telemetry unit with a diagnosis of syncope. The patient's heart rate is 55 bpm with a blood pressure of 90/66 mm Hg. The patient is also experiencing dizziness and shortness of breath. Which of the following medications will the nurse anticipate administering to the patient based on these clinical findings? a) Cardizem b) Atropine c) Lidocaine d) Pronestyl

b) Atropine Explanation: The patient is demonstrating signs and symptoms of symptomatic sinus bradycardia. Atropine is the medication of choice in treating symptomatic sinus bradycardia. Lidocaine treats ventricular dysrhythmias. Pronestyl treats and prevents atrial and ventricular dysrhythmias. Cardizem is a calcium channel blocker and treats atrial dysrhythmias

A patient tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following? a) Request sublingual nitroglycerin. b) Avoid caffeinated beverages c) Lie down and elevate the feet. d) Apply supplemental oxygen

b) Avoid caffeinated beverages Explanation: If PACs are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the patient to avoid caffeinated beverages.

A nurse is providing morning care for a patient in the ICU. Suddenly, the bedside monitor shows ventricular fibrillation and the patient becomes unresponsive. After calling for assistance, what action should the nurse take next? a) Administer intravenous epinephrine. b) Begin cardiopulmonary resuscitation. c) Prepare for endotracheal intubation. d) Provide electrical cardioversion.

b) Begin cardiopulmonary resuscitation. Explanation: In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the patient as soon as possible. If defibrillation is not readily available, CPR is begun until the patient can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention, which includes endotracheal intubation and administration of epinephrine. Electrical cardioversion is not indicated for a patient in ventricular fibrillation.

A nurse is caring for a patient in the cardiovascular intensive care unit (CVICU) following a coronary artery bypass graft (CABG). Which of the following clinical findings requires immediate intervention by the nurse? a) Pain score: 5/10. b) CVP reading: 1 mmHg c) Blood pressure: 110/68 mmHg d) Heart rate: 66 bpm

b) CVP reading: 1 mmHg Explanation: The central venous pressure (CVP) reading of 1 is low (2-6 mmHg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse's priority.

The ability of the cardiac muscle to shorten in response to an electrical impulse is termed which of the following? a) Diastole b) Contractility c) Depolarization d) Repolarization

b) Contractility Explanation: Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.

A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems? a) Acute exacerbation of chronic obstructive pulmonary disease b) Decompensated heart failure with pulmonary edema c) Tuberculosis d) Bilateral pneumonia

b) Decompensated heart failure with pulmonary edema Explanation: Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated HF with pulmonary edema.

A nurse is caring for a patient who experienced an MI. The patient is ordered metoprolol (Lopressor). The nurse understands that the therapeutic effect of this medication is which of the following? a) Decreases cholesterol level b) Decreases resting heart rate c) Decreases platelet aggregation d) Increases cardiac output

b) Decreases resting heart rate Explanation: The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce the myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. Generally the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

A patient with congestive heart failure is admitted to the hospital with complaints of shortness of breath. How should the nurse position the patient in order to decrease preload? a) Prone with legs elevated on pillows b) Head of the bed elevated at 45 degrees and lower arms supported by pillows c) Supine with arms elevated on pillows above the level of the heart d) Head of the bed elevated at 30 degrees and legs elevated on pillows

b) Head of the bed elevated at 45 degrees and lower arms supported by pillows Explanation: Preload is the amount of blood presented to the ventricle just before systole. The patient is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the patient may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the patient's weight on the shoulder muscles.

A patient is being treated in the intensive care unit following an acute MI. During the nursing assessment, the patient states shortness of breath and chest pain. In addition, the patient's blood pressure (BP) is 100/60 mm Hg with a heart rate (HR) of 53 bpm, and the electrocardiogram (ECG) tracing shows more P waves than QRS complexes. Which of the following actions should the nurse complete first? a) Prepare for defibrillation. b) Initiate transcutaneous pacing. c) Administer 1 mg of IV atropine. d) Obtain a 12-lead ECG.

b) Initiate transcutaneous pacing. Explanation: The patient is experiencing a third-degree heart block. Transcutaneous pacing should be implemented first. A permanent pacemaker may be indicated if the block continues. Defibrillation is not indicated; third-degree heart block does not respond to atropine; a 12-lead ECG may be obtained, but is not completed first.

The nurse is observing a patient during an exercise stress test (bicycle). Which of the following findings indicates a positive test and the need for further diagnostic testing? a) Heart rate changes; 78 bpm to 112 bpm b) ST-segment changes on the ECG c) BP changes; 148/80 mm Hg to 166/90 mm Hg d) Dizziness and leg cramping

b) ST-segment changes on the ECG Explanation: During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated when the target heart rate is achieved or if the patient experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the patient develops chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant the testing to be stopped.

The nurse is caring for a patient with diabetes who is scheduled for a cardiac catheterization. Prior to the procedure, it is most important for the nurse to ask which of the following questions? a) "When was the last time you ate or drank?" b) "Are you having chest pain?" c) "Are you allergic to shellfish?" d) "What was your morning blood sugar reading?"

c) "Are you allergic to shellfish?" Explanation: Radiopaque contrast agents are used to visualize the coronary arteries. Some contrast agents contain iodine, and the patient is assessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (e.g., seafood). If the patient has a suspected or known allergy to the substance, antihistamines or methylprednisolone (Solu-Medrol) may be administered before the procedure. Although the other questions are important to ask the patient, it is most important to ascertain if the patient has an allergy to shellfish.

In order to be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)? a) 9 days b) 30 minutes c) 60 minutes d) 6 to 12 months

c) 60 minutes Explanation: The 60-minute interval is known as "door-to-balloon time" for performance of PTCA on a diagnosed MI patient. The 30-minute interval is known as "door-to-needle time" for administration of thrombolytics post MI. The time frame of 9 days refers to the time for onset of vasculitis after administration of streptokinase for thrombolysis in an acute MI patient. The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same patient for acute MI.

The nurse is caring for a patient diagnosed with unstable angina receiving IV heparin. The patient is placed on bleeding precautions. Bleeding precautions include which of the following measures? a) Avoiding the use of nail clippers b) Avoiding continuous BP monitoring c) Avoiding subcutaneous (SQ) injections d) Using an electric toothbrush

c) Avoiding continuous BP monitoring Explanation: The patient receiving heparin is placed on bleeding precautions, which can include: applying pressure to the site of any needle punctures for a longer time than usual, avoiding intramuscular injections, avoiding tissue injury and bruising from trauma or constrictive devices (e.g. continuous use of an automatic BP cuff). SQ injections are permitted; a soft toothbrush should be used, and the patient may use nail clippers, but with caution.

The nurse is caring for a patient with an intra-arterial BP monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which of the following? a) Air embolism b) Hemorrhage c) Catheter-related bloodstream infections (CRBSI) d) Pneumothorax

c) Catheter-related bloodstream infections (CRBSI) Explanation: CRBSIs are the most common preventable complication associated with hemodynamic monitoring systems. Comprehensive guidelines for the prevention of these infections have been published by Centers for Disease Control and Prevention (CDC). Complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. A pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters). Air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.

A middle-aged male presents to the ED complaining of severe chest discomfort. Which of the following patient findings is most indicative of a possible MI? a) Anxiousness, restlessness, and lightheadedness b) Intermittent nausea and emesis for 3 days c) Chest discomfort not relieved by rest or nitroglycerin d) Cool, clammy, diaphoretic, and pale appearance

c) Chest discomfort not relieved by rest or nitroglycerin Explanation: Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with ACS (acute coronary syndrome) or MI, may also occur with angina and, alone, are not indicative of an MI.

A nurse is evaluating a client with a temporary pacemaker. The patient's ECG tracing shows each P wave followed by the pacing spike. The nurse's best response is which of the following? a) Obtain a 12-lead ECG and a portable chest x-ray. b) Check the security of all connections and increase the milliamperage. c) Document the findings and continue to monitor the patient. d) Reposition the extremity and turn the patient to left side

c) Document the findings and continue to monitor the patient. Explanation: Capture is a term used to denote that the appropriate complex is followed by the pacing spike. In this instance, the patient's temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike. The nurse should document the findings and continue to monitor the patient. Repositioning the patient, placing the patient on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture. Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.

The nurse is analyzing the electrocardiogram (ECG) strip of a stable patient admitted to the telemetry unit. The patient's ECG strip demonstrates PR intervals that measure 0.24 seconds. Which of the following is the nurse's most appropriate action? a) Apply oxygen via nasal cannula and obtain a 12-lead ECG. b) Instruct the patient to bear down as if having a bowel movement. c) Document the findings and continue to monitor the patient. d) Notify the patient's primary care provider of the findings.

c) Document the findings and continue to monitor the patient. Explanation: The patient's ECG tracing indicates a first-degree atrioventricular (AV) block. First-degree AV block rarely causes any hemodynamic effect; the other blocks may result in decreased heart rate, causing a decrease in perfusion to vital organs, such as the brain, heart, kidneys, lungs, and skin. The most appropriate action by the nurse is to document the findings and continue to monitor the patient.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? a) Blood urea nitrogen (BUN) b) Serum electrolytes c) Echocardiogram d) Electrocardiogram (ECG)

c) Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed in the initial workup

A nurse is preparing to assess a patient for postural BP changes. Which of the following indicates the need for further education? a) Positioning the patient supine for 10 minutes prior to taking the initial BP and HR b) Taking the patient's BP with the patient sitting on the edge of the bed with feet dangling c) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) d) Obtaining the supine measurements prior to the sitting and standing measurements

c) Letting 30 seconds elapse after each position change before measuring BP and heart rate (HR) Explanation: The following steps are recommended when assessing patients for postural hypotension: Position the patient supine for 10 minutes before taking the initial BP and HR measurements; reposition the patient to a sitting position with legs in the dependent position, wait 2 minutes then reassess both BP and HR measurements; if the patient is symptom free or has no significant decreases in systolic or diastolic BP, assist the patient into a standing position, obtain measurements immediately and recheck in 2 minutes; continue measurements every 2 minutes for a total of 10 minutes to rule out postural hypotension. Return the patient to supine position if postural hypotension is detected or if the patient becomes symptomatic. Document HR and BP measured in each position (e.g., supine, sitting, and standing) and any signs or symptoms that accompany the postural changes.

A patient presents to the ED complaining of anxiety and chest pain after shoveling heavy snow that morning. The patient says that he has not taken nitroglycerin for months but did take three nitroglycerin tablets and although the pain is less, "They did not work all that well." The patient shows the nurse the nitroglycerin bottle and the prescription was filled 12 months ago. The nurse anticipates which of the following physician orders? a) Ativan 1 mg orally b) Chest x-ray c) Nitroglycerin SL d) Serum electrolytes

c) Nitroglycerin SL Explanation: Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired and the nurse should anticipate administering nitroglycerin to assess if the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the patient's chest pain.

A patient admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which of the following electrocardiographic (ECG) characteristics is commonly associated with this laboratory finding? a) Occasional U waves b) Flattened P waves c) Peaked T waves d) Prolonged QT interval

c) Peaked T waves Explanation: The patient's serum potassium level is high. The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or "peaked" if a patient's serum potassium level is high. The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a patient's serum potassium level is low. The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria and is not affected by a patient's serum potassium level. The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization, and is not affected by a patient's serum potassium level.

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient? a) Enlargement of joints b) Vasculitis c) Potassium levels d) Flexion contractures

c) Potassium levels Explanation: A key concern associated with digoxin therapy is digitalis toxicity. Clinical manifestations of toxicity include anorexia, nausea, visual disturbances, confusion, and bradycardia. The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.

The nurse is analyzing the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which of the following findings indicate the need for follow-up? a) QRS complex that is 0.10 seconds long b) PR interval that is 0.18 seconds long c) QT interval that is 0. 46 seconds long d) ST segment that is isoelectric in appearance

c) QT interval that is 0. 46 seconds long Explanation: The QT interval that is 0.46 seconds long needs to be investigated. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 bpm. If the QT interval becomes prolonged, the patient may be at risk for a lethal ventricular dysrhythmia called torsades de pointes. The other findings are normal.

The nurse is caring for a patient presenting to the emergency department (ED) complaining of chest pain. Which of the following electrocardiographic (ECG) findings would be most concerning to the nurse? a) Frequent premature atrial contractions (PACs) b) Isolated premature ventricular contractions (PVCs) c) ST elevations d) Sinus tachycardia

c) ST elevations Explanation: The first signs of an acute MI are usually seen in the T wave and ST segment. The T wave becomes inverted; the ST segment elevates (usually flat). An elevation in ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e. ST elevation myocardial infarction, STEMI). This patient requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.

The nurse is reviewing discharge instructions with a patient who underwent a left groin cardiac catheterization 8 hours ago. Which of the following instructions should the nurse include? a) "Contact your primary care provider if you develop a temperature above 102°F." b) "If any discharge occurs at the puncture site, call 911 immediately." c) "You can take a tub bath or a shower when you get home." d) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."

d) "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." Explanation: The nurse should instruct the patient to complete the following: If the artery of the groin was used, for the next 24 hours, do not bend at the waist, strain, or lift heavy objects; the primary provider should be contacted if any of the following occur: swelling, new bruising or pain from your procedure puncture site, temperature of 101°F or more. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The patient should not drive to the hospital.

A patient is admitted to the emergency department (ED) with complaints of chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph (ECG) monitor. The nurse counts 9 RR intervals on the patient's 6-second rhythm tracing. The nurse correctly identifies the patient's heart rate as which of the following? a) 100 bpm b) 70 bpm c) 80 bpm d) 90 bpm

d) 90 bpm Explanation: An alternative but less accurate method for estimating heart rate, which is usually used when the rhythm is irregular, is to count the number of RR intervals in 6 seconds and multiply that number by 10. The RR intervals are counted, rather than QRS complexes, because a computed heart rate based on the latter might be inaccurately high. The same methods may be used for determining atrial rate, using the PP interval instead of the RR interval. In this instance, 9 × 10 = 90.

A patient is scheduled for an elective electrical cardioversion for a sustained dysrhythmia lasting for 24 hours. Which of the following interventions is necessary for the nurse to implement prior to the procedure? a) Administer anticoagulant therapy as prescribed prior to the procedure. b) Maintain the patient on NPO status for 8 hours prior to the procedure. c) Administer the prescribed digitalis to the patient before the scheduled procedure. d) Administer moderate sedation IV and analgesic medication as prescribed.

d) Administer moderate sedation IV and analgesic medication as prescribed. Explanation: Before an elective cardioversion, the patient should receive moderate sedation IV as well as an analgesic medication or anesthesia. In contrast, in emergent situations, the patient may not be premedicated. Digoxin is usually withheld for 48 hours before cardioversion to ensure the resumption of sinus rhythm with normal conduction. If the cardioversion is elective and the dysrhythmia has lasted longer than 48 hours, anticoagulation performed for a few weeks before cardioversion may be indicated. The patient is instructed not to eat or drink for at least 4 hours before the procedure.

A nurse is providing evening care for a patient wearing a continuous telemetry monitor. While the nurse is giving the patient a back rub, the patient's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response? a) Administer a pericardial thump. b) Call a code and obtain the crash cart. c) Call for assistance and begin CPR. d) Assess the patient and monitor leads

d) Assess the patient and monitor leads. Explanation: The nurse should assess the patient and monitor leads first. It is important that the nurse "treat the patient, not the monitor." Ventricular asystole may often appear on the monitor when leads are displaced. The other interventions are not necessary.

The nurse understands that a patient with which cardiac arrhythmia is most at risk for developing heart failure? a) Sinus tachycardia b) First-degree heart block c) Supraventricular tachycardia d) Atrial fibrillation

d) Atrial fibrillation Explanation: Cardiac dysrhythmias such as atrial fibrillation may either cause or result from HF; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

A patient tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following? a) Lie down and elevate the feet. b) Request sublingual nitroglycerin. c) Apply supplemental oxygen. d) Avoid caffeinated beverages.

d) Avoid caffeinated beverages. Explanation: If PACs are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the patient to avoid caffeinated beverages.

The nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation? a) By checking for cardiac dysrhythmias b) By hemodynamic monitoring c) By observing the patient for bleeding d) By checking peripheral pulses

d) By checking peripheral pulses Explanation: Peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. The nurse observes the patient for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses. Hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.

The nurse identifies which of the following symptoms as a manifestation of right-sided heart failure (HF)? a) Reduction in cardiac output b) Reduction in forward flow c) Accumulation of blood in the lungs d) Congestion in the peripheral tissues

d) Congestion in the peripheral tissues Explanation: Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues.

The nurse is caring for a patient in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the patient's CVP as 8 mm Hg. The nurse understands that this finding indicates the patient is experiencing which of the following? a) Excessive blood loss b) Overdiuresis c) Left-sided heart failure (HF) d) Hypervolemia

d) Hypervolemia Explanation: The normal CVP is 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular preload. Many problems can cause an elevated CVP, but the most common is hypervolemia (excessive fluid circulating in the body) or right-sided HF. In contrast, a low CVP (<2 mm Hg) indicates reduced right ventricular preload, which is most often from hypovolemia.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest? a) II b) I c) III d) IV

d) IV Explanation: Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In Class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In Class II there is a slight limitation of ADLs. In Class III there is marked limitation on ADLs.

A patient diagnosed with a myocardial infarction (MI) has begun an active rehabilitation program. The nurse recognizes an overall goal of rehabilitation for a patient who has had an MI includes which of the following? a) Limiting the effects and progression of atherosclerosis b) Returning the patient to work and a preillness lifestyle c) Prevention of another cardiac event d) Improvement of the quality of life

d) Improvement of the quality of life Explanation: Overall, cardiac rehabilitation is a complete program dedicated to extending and improving quality of life. An immediate objective of rehabilitation of the MI patient is to limit the effects and progression of atherosclerosis. An immediate objective of rehabilitation of the MI patient is to return the patient to work and a preillness lifestyle. An immediate objective of rehabilitation of the MI patient is to prevent another cardiac event.

Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving milrinone? a) Encourage patient to ambulate in room b) Teach patient about safe home use of the medication c) Titrate milrinone rate slowly before discontinuing d) Monitor blood pressure frequently

d) Monitor blood pressure frequently Explanation: Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to patients with severe HF, including patients who are waiting for a heart transplant. Because the drug causes vasodilation, the patient's blood pressure is monitored prior to administration since if the patient is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and following infusions of milrinone.

A nurse is teaching patients newly diagnosed with coronary heart disease (CHD) about their disease process and risk factors for heart failure. Which of the following problems can cause left-sided heart failure (HF)? a) Ineffective right ventricular contraction b) Pulmonary embolus c) Cystic fibrosis d) Myocardial ischemia

d) Myocardial ischemia Explanation: Myocardial dysfunction and HF can be caused by a number of conditions including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of patients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, the death of myocardial cells, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.

The nurse is analyzing a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as which of the following? a) Sinus tachycardia b) First-degree atrioventricular (AV) block c) Junctional tachycardia d) Normal sinus rhythm

d) Normal sinus rhythm Explanation: The ECG tracing shows normal sinus rhythm (NSR). NSR has the following characteristics: ventricular and atrial rate: 60 to 100 beats per minute (bpm) in the adult; ventricular and atrial rhythm: regular; and QRS shape and duration: usually normal, but may be regularly abnormal; P wave: normal and consistent shape, always in front of the QRS; PR interval: consistent interval between 0.12 and 0.20 seconds and P:QRS ratio: 1:1

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following? a) Hyperpnea b) Dyspnea on exertion c) Paroxysmal nocturnal dyspnea d) Orthopnea

d) Orthopnea Explanation: Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler's position. Dyspnea on exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

The nurse recognizes that the treatment for a non-ST elevation myocardial infarction (NSTEMI) differs from that of a patient with a STEMI, in that a STEMI is more frequently treated with which of the following? a) Thrombolytics b) IV nitroglycerin c) IV heparin d) Percutaneous coronary intervention (PCI)

d) Percutaneous coronary intervention (PCI) Explanation: The patient with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

A 28-year-old female patient presents to the emergency department (ED) stating severe restlessness and anxiety. Upon assessment, the patient's heart rate is 118 bpm and regular, the patient's pupils are dilated, and the patient appears excitable. Which action should the nurse take next? a) Prepare to administer a calcium channel blocker. b) Instruct the patient to hold her breath and bear down. c) Place the patient on supplemental oxygen. d) Question the patient about alcohol and illicit drug use.

d) Question the patient about alcohol and illicit drug use. Explanation: The patient is experiencing sinus tachycardia. Since the patient's findings of tachycardia, dilated pupils, restlessness, anxiety, and excitability can indicate illicit drug use (cocaine), the nurse should question the patient about alcohol and illicit drug use. This information will direct the patient's plan of care. Causes of tachycardia include medications that stimulate the sympathetic response, stimulants, and illicit drugs. The treatment goals for sinus tachycardia is usually determined by the severity of symptoms and directed at identifying and abolishing its cause. The other interventions may be implemented, but determining the cause of the tachycardia is essential.

Which of the following is the term for the normal pacemaker of the heart? a) Purkinje fibers b) Atrioventricular (AV) node c) Bundle of His d) Sinoatrial (SA) node

d) Sinoatrial (SA) node Explanation: The sinoatrial node is the primary pacemaker of the heart. The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.