med/surg chapt 35

When obtaining a client's vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse's best intervention?

Teach the client lifestyle modifications to decrease blood pressure.

The nurse is assessing clients at a clinic. Which activity takes priority?

Teaching smoking cessation to a middle-aged woman who smokes

The nurse is assessing a client in the emergency department. Which client statement alerts the nurse to the occurrence of heart failure?

"I get short of breath when I climb stairs."

The client is scheduled for a resting electrocardiography. Which statement by the client indicates a good understanding of the preprocedure teaching?

"I must lie as still as possible during the procedure."

A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means. What is the nurse's best response?

"It is a rushing sound that blood makes moving through narrow places."

The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client alerts the nurse to the presence of edema?

"My shoes fit tighter by the end of the day."

A client who is scheduled for an echocardiography today asks why this test is being performed. What is the nurse's best response?

"This procedure is a noninvasive way to assess the structure of the heart."

A client with a history of renal insufficiency is scheduled for a cardiac catheterization. What does the nurse expect to do for this client before the catheterization? (Select all that apply.)

Administer IV fluids. Assess for allergies to iodine. Assess laboratory results. Assess and mark pulses. Have the client sign the consent.

The nurse is preparing a client for a cardiac catheterization. What assessment is a priority before the procedure?

Allergies to iodine and shellfish

The nurse is assessing clients at a community health center. Which client does the nurse determine is at high risk for cardiovascular disease?

American Indian woman with diabetes mellitus

A client has returned from a cardiac angiography via the left femoral artery. Two hours after the procedure, the nurse notes that the left pedal pulse is weak. What is the nurse's best action?

Assess the color and temperature of the left leg.

A client consistently reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What nursing assessment takes priority at this time?

Blood pressure

The nurse is performing a focused cardiac assessment. What assessment finding should be reported to the health care provider?

Bruit heard on the side of the neck

The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if the client's mean arterial blood pressure decreases below 60 mm Hg?

Chest pain

The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. What is the nurse's first intervention?

Compare the results with previous readings.

The nurse is assessing an older adult client who is experiencing a myocardial infarction. What clinical manifestation does the nurse expect in this client?

Disorientation and confusion

The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected?

Decreased cardiac output

The nurse is auscultating heart tones on an older client and hears the following sound. What is the nurse's best action? (Click the media button to hear the audio clip

Document the finding. (The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.)

The nurse is caring for a client with an 80% blockage of the right coronary artery (RCA). While waiting for bypass surgery, what is essential for the nurse to have available?

External pacemaker

A female client is admitted to the emergency department. Which symptoms cause the nurse to order an electrocardiogram? (Select all that apply.)

Fatigue despite adequate rest Indigestion Abdominal fullness Shortness of breath Feeling of choking

The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What additional assessment finding does the nurse expect?

Heart rate of 120 beats/min

The nurse is auscultating cardiac tones. Where should the nurse listen to best hear a cardiac murmur related to aortic regurgitation?

Location A The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the heart. The client's history includes a previous myocardial infarction and pacemaker implantation. Which action by the nurse is most appropriate?

Notify the health care provider before scheduling the MRI.

The nurse is caring for a client with pericarditis. What assessment finding correlates with this disorder?

Pericardial friction rub

The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the nurse expect?

Pulse decrease from 100 to 80 beats/min

The nurse is obtaining a client's health history. Which illness alerts the nurse to the possibility of abnormal heart valves?

Rheumatic fever

A client is recovering after a coronary catheterization. What assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)

Serum potassium of 2.9 mEq/L Expanding groin hematoma Rhythm changes on the cardiac monitor

The nurse is monitoring a client undergoing an exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped?

Significant ST-segment depression

The nurse is recovering a client after a left-sided cardiac catheterization. What assessment finding requires immediate intervention?

Slurred speech and confusion

The nurse is preparing to measure a client's pulmonary artery wedge pressure (PAWP). In what position will the nurse place the client for the most accurate results?

Supine, with the head elevated to 45 degrees

When reviewing a client's laboratory results, which findings alert the nurse to the possibility of atherosclerosis? (Select all that apply.)

Total cholesterol of 280 mg/dL Triglycerides of 200 mg/dL Low-density cholesterol of 160 mg/dL

A nurse is performing an admission assessment on an older adult client with multiple chronic diseases. The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first?

Assess the client's medications.