Medsurge exam 1
A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session? A. It is relieved by rest. B. It is precipitated by light activity. C.It is described as sharp or knifelike. D. It is unaffected by the administration of vasodilators.
Answer: A Rationale: Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload and oxygen need. Angina usually is precipitated by exertion, emotion, or a heavy meal. Anginal pain usually is described as tightness, indigestion, or heaviness. Nitroglycerin, a vasodilator and a standard treatment for angina, dilates coronary arteries, which increases oxygen to the myocardium, decreasing pain.
The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? A. Stridor B. Crackles C. Wheezes D. Friction rubs
Answer: B Rationale: Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are not heard with heart failure, but with asthma. Friction rubs are not heard with heart failure, but with pleurisy.
What does a nurse who is caring for a client experiencing anginal pain expect to observe about the pain? A. Unchanged by rest B. Precipitated by light activity C. Described as a knifelike sharpness D. Relieved by sublingual nitroglycerin
Answer: D Rationale: Relief by sublingual nitroglycerin is a classic reaction because it dilates coronary arteries, which increases oxygen to the myocardium, thus decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness.
A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. What is an appropriate treatment plan? A. Amiodarone bolus B. Intracardiac epinephrine C. Insertion of a pacemaker D. Cardiopulmonary resuscitation (CPR)
Answer: A Rationale: Amiodarone suppresses ventricular activity; therefore, it is used for treatment of premature ventricular complexes (PVCs) and ventricular tachycardia. It works directly on the heart tissue and slows the nerve impulses in the heart. Epinephrine HCl is not used for ventricular tachycardia (VT) with a pulse; it is used for cardiac arrest and may even precipitate ventricular fibrillation. A pacemaker is used for symptomatic bradycardia and heart blocks. The client has a pulse; CPR is not indicated.
The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? A. A loss of atrial kick B. No physiologic changes C. Increased cardiac output D. Decreased risk of pulmonary embolism
Answer: A Rationale: Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The atrioventricular (AV) node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. This irregularity is called "irregularly irregular." The ineffectual contraction of the atria results in loss of "atrial kick." If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The client may or may not be aware of the atrial fibrillation. If the ventricular response is rapid, the client may show signs of decreased cardiac output or worsening of heart failure symptoms.
A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. How would the nurse expect the client to describe the chest pain? A. Severe, intense B. Burning and of short duration C. Mild, radiating toward the abdomen D. Squeezing, relieved by nitroglycerin
Answer: A Rationale: Blockage of myocardial blood supply causes accumulation of unoxidized metabolites in the muscle; this affects nerve endings and causes severe, intense chest pain. Burning chest pain is not the type of pain associated with a myocardial infarction. Mild chest pain, radiating toward the abdomen, is not the type of pain associated with a myocardial infarction. Nitroglycerin relieves pain associated with angina, not pain associated with myocardial infarction.
A primary healthcare provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse? A. "The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." B. "I wouldn't bother. For this diet all that you need to do is to reduce the amount of salt you use and fry foods in peanut oil." C. "You're right. Be careful to cook a small portion for each of you to eat to not waste food." D. "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen."
Answer: A Rationale: Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals. Fried foods are not advocated on a heart-healthy diet; peanut oil is a monounsaturated fatty acid, and these acids should not exceed 15% of the calories of the diet. The responses "You're right. Be careful to cook a small portion for each of you to eat to not waste food" and "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen" can be discouraging and encourage noncompliance.
A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease? A. Esophageal pain may imitate the symptoms of a heart attack. B. GERD may predispose to heart disease. C. Strenuous exercise may exacerbate reflux problems. D.Similar changes in laboratory studies may occur in both cardiac and reflux problems.
Answer: A Rationale: Symptoms associated with myocardial infarction may be interpreted by a client as esophageal reflux and therefore ignored. GERD does not predispose to heart disease. Exercise does not seem to exacerbate esophageal reflux problems unless the stomach is full when exercising. Exercising to maintain a healthy weight helps reduce esophageal reflux. Laboratory workups help differentiate these two diagnoses. Tests, such as cardiac enzymes, can help to reveal a myocardial infarction, thereby facilitating differentiation between these problems.
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? A. Check for a pulse B. Start cardiac compressions C. Prepare to defibrillate the client D. Administer oxygen via an ambu bag
Answer: A Rationale: The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.
A woman comes to the emergency department reporting signs and symptoms that are determined by the primary healthcare provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? Select all that apply. A. Severe fatigue B. Sense of unease C. Choking sensation D. Chest pain relieved by rest E. Pain radiating down the left arm
Answer: A, B Rationale: A myocardial infarction in women may be asymptomatic, atypical, or mild. Unique symptoms include overwhelming fatigue, a sense of uneasiness, indigestion, and shoulder tenderness. A sense of unease is a unique characteristic of a myocardial infarction in women. The client knows something is not right but cannot identify what it is. This uneasiness often is disregarded by the client. A choking sensation occurs in both men and women with a myocardial infarction. Chest pain relieved by rest occurs in both men and women with angina; it is caused by coronary artery spasms leading to myocardial ischemia. Angina frequently is a precursor to a myocardial infarction. Pain radiating down the left arm occurs in both men and women. It can radiate also to the neck, lower jaw, left arm, left shoulder, and, less frequently, the right arm and back.
A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? Select all that apply. A. Anxiety B. Chest pain C. Irregular pulse D. Fear of losing control E. Feelings of depersonalization
Answer: A, B, C Rationale: Anxiety is associated with both myocardial infarctions and panic attacks. The overwhelming chest pain that usually accompanies a myocardial infarction, due to myocardial ischemia, precipitates a feeling of impending death. Most people who have panic attacks eventually recognize that they are not going to die as a result of the attack. Chest pain is associated with both myocardial infarctions and panic attacks. Chest pain is associated with a myocardial infarction because of myocardial ischemia. It is often described as "viselike" or "crushing" in nature. The chest discomfort during a panic attack usually is not as severe as the pain associated with a myocardial infarction. Fear of losing control usually is not a characteristic associated with a myocardial infarction. Fear of losing control or of going crazy is among the criteria for the diagnosis of panic attacks. A feeling of depersonalization is not a characteristic associated with a myocardial infarction. Depersonalization (feeling detached from the self) and derealization (feelings of unreality) are among the criteria for the diagnosis of panic attacks.
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. A. Dependent edema B. Swollen hands and fingers C. Collapsed neck veins D. Right upper quadrant discomfort E. Oliguria
Answer: A, B, D Rationale: With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.
A client is experiencing tachycardia. Which adverse hemodynamic effects will the nurse consider when planning care for this client? Select all that apply. A. Decreased ventricular filling time B. Increased coronary artery filling C. Decreased cardiac output D. Increased atrial kick E. Increased cardiac output
Answer: A, C Rationale: Tachycardia is a fast heart rate; the fast heart rhythm may cause a decrease in cardiac output because of the decreased filling time for the ventricles. There is also a decreased, not increased, time for coronary artery filling during diastole. During atrial systole, a bolus of atrial blood is ejected into the ventricles; this step is called the atrial kick, and it contributes more blood to the cardiac output of the ventricles. With fast heart rates, there is less time for the atria to fill, and therefore less blood (atrial kick) to pump.
The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS; then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the primary healthcare provider. Which rhythm does the nurse share with the provider? A. First degree atrioventricular (AV) block B. Second degree AV block Mobitz I (Wenckebach) C. Second degree AV block Mobitz II D. Third degree AV block (complete heart block)
Answer: B Rationale: Also called Mobitz I or Wenckebach heart block, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.
What client response must the nurse monitor to determine the effectiveness of amiodarone? A. Absence of ischemic chest pain B. Decrease in cardiac dysrhythmias C. Improvement in fasting lipid profile D. Maintenance of blood pressure control
Answer: B Rationale: Amiodarone is a class III antidysrhythmic used for treating ventricular and supraventricular tachycardia and for conversion of atrial fibrillation. Results of fasting lipid profile are expected with antilipidemics. Degree of blood pressure control is expected with antihypertensives. Incidence of ischemic chest pain is expected with antianginal agents, such as nitrates.Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.
The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? A. Defibrillate B. Assess the client's pulse C. Initiate advanced cardiac life support D. Check another lead to confirm asystole
Answer: B Rationale: Pulse should be immediately assessed because a lead or electrode coming off may mimic this dysrhythmia. Asystole is characterized by complete cessation of electrical activity. A flat baseline is seen, without any evidence of P, QRS, or T waveforms. A pulse is absent, and there is no cardiac output; cardiac arrest has occurred. Once confirmed, Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) protocols are initiated for asystole. Defibrillation is part of the ACLS protocol for ventricular fibrillation.
A client's cardiac monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. The nurse concludes that the client is experiencing what? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular fibrillation D.First-degree atrioventricular block
Answer: B Rationale: The presence of a P wave before each QRS complex indicates a sinus rhythm; a heart rate greater than 100 regular beats per minute is referred to as tachycardia. Atrial fibrillation has no well-defined P waves, there are 350 or more beats per minute, there are random ventricular beats, and the rhythm is irregular. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.
A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority? A. Elective cardioversion B.Immediate defibrillation C. An intramuscular (IM) injection of digoxin D. An intravenous (IV) line for emergency medications
Answer: B Rationale: When ventricular fibrillation is verified, the first intervention is defibrillation; it is the only measure that will terminate this lethal dysrhythmia. Elective cardioversion delivers a shock during the R wave; because there is no R wave in ventricular fibrillation, the dysrhythmia will continue and death will result. Digitalis preparations are not used to treat ventricular dysrhythmias. If not already in place, an IV line should be inserted after the client is defibrillated.
A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of? A. Atrial fibrillation B. Cardiac irritability C. Impending heart block D. Ventricular tachycardia
Answer: C Rationale: Cardioversion involves administration of precordial shock, which is synchronized with the R wave to interrupt the heart rate. It is used for atrial fibrillation, supraventricular tachycardia, and ventricular tachycardia with a pulse when pharmaceutical preparations fail. The heart is stopped by the electrical stimulation, and it is hoped that the sinoatrial (SA) node will take over as pacemaker. Because there are no R waves in a cardiac standstill, defibrillation and not cardioversion should be done. Premature ventricular complexes suggest an irritable myocardium and generally respond to antidysrhythmic agents.
Metoprolol is prescribed for a client. Which condition in the client's electronic medical record will cause the nurse to question the prescription? A. Hypertension B. Angina pectoris C. Sinus bradycardia D. Myocardial infarction
Answer: C Rationale: Metoprolol is a beta blocker; it decreases the heart rate and thus is contraindicated with bradycardia. Metoprolol is an antihypertensive agent and is given for hypertension. By reducing cardiac output, metoprolol reduces myocardial oxygen consumption, which helps prevent ischemia from anginal pain and myocardial infarction.
A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the primary healthcare provider probably will insert a pacemaker? A. Angina B. Chest pain C. Heart block D. Tachycardia
Answer: C Rationale: Heart block is the primary indication for a pacemaker because there is an interference with the electrical conduction of impulses from the atria to the ventricles of the heart. The primary treatment for angina is medication; angina is not an indication for a pacemaker. The primary treatment for chest pain is medication; chest pain is not an indication for a pacemaker. The primary treatment for tachycardia is medication; tachycardia is not an indication for a pacemaker.
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? A. Causes mild perspiration B. Occurs after moderate exercise C. Continues after rest and nitroglycerin D. Precipitates discomfort in the arms and jaw
Answer: C Rationale: When neither rest nor nitroglycerin relieves the pain, the client may be experiencing an acute myocardial infarction. Angina may cause mild diaphoresis; acute myocardial infarction causes profuse diaphoresis, which should be reported. Chest pain after exercise is expected; activity increases cardiac output, which can cause angina. Anginal pain can, and often does, radiate.
Valsartan, an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply. A. Constipation B. Hypokalemia C. Irregular pulse rate D. Change in visual acuity E. Orthostatic hypotension
Answer: C, E Rationale: Dysrhythmias, including second-degree heart block, are cardiovascular side effects of valsartan. It also may precipitate angina pectoris, myocardial infarction, and brain attack (cerebrovascular accident, CVA). Angiotensin II receptor antagonists, such as valsartan, block vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites, including vascular smooth muscle, thus reducing the blood pressure; dizziness, orthostatic hypotension, and excessive hypotension may occur. Diarrhea, not constipation, may occur with valsartan. Hyperkalemia, not hypokalemia, may occur with valsartan. Valsartan does not cause altered visual acuity.
While a pacemaker catheter is being inserted, the client's heart rate drops to 38 beats/min. What medication should the nurse expect the healthcare provider to prescribe? A. Digoxin B. Lidocaine C. Amiodarone D. Atropine sulfate
Answer: D Rationale: Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate. Digoxin slows the heart rate; hence it would not be indicated in this situation. Lidocaine decreases myocardial sensitivity and will not increase the heart rate. Amiodarone is an antidysrhythmic drug used for ventricular tachycardia; it will not stimulate the heart rate.
The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the drug of choice for this client? A. Diazepam B. Meperidine C. Flurazepam D. Morphine sulfate
Answer: D Rationale: For myocardial infarction, morphine sulfate is the drug of choice because it relieves pain quickly and reduces anxiety while decreasing cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the pain of a myocardial infarction. Although meperidine is effective, it is not the drug of choice. Flurazepam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the pain of a myocardial infarction.
A nurse is assessing an ECG rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization? A. P wave B. T wave C. PR interval D. QRS complex
Answer: D Rationale: The QRS complex represents ventricular depolarization. The classic QRS complex begins with a negative, or downward, deflection immediately after the PR interval. The P wave represents atrial depolarization. Normally a P wave indicates that the sinoatrial node initiated the impulse that depolarized the atrium. The T wave represents ventricular repolarization. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval.
Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. Which statement by the client indicates the teaching was effective? A. "I should take the medicine three times a day." B. "I will be sure to take my pulse after I have exercised." C. "It will be important to avoid activities that are too strenuous." D. "I should take one tablet before attempting to climb two flights of stairs."
Answer: D Rationale: The response about taking one tablet before attempting to climb two flights of stairs indicates that the client understands the nurse's teaching. Taking a nitroglycerin tablet before such an activity probably will prevent an episode of angina, which is an example of prophylactic use of a medication. Taking the medicine three times a day is an example of scheduled administration of a medication, not prophylactic use. The statement to avoid activities that are too strenuous indicates avoidance of activity rather than taking medication to prevent angina during the activity. Blood pressure, not pulse, is the parameter most affected by nitroglycerin.
The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip? A. First degree atrioventricular (AV) block B. Second degree AV block Mobitz I (Wenckebach) C. Second degree AV block Mobitz II D. Third degree AV block (complete heart block)
Answer: D Rationale: Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second-degree AV block type I, also called Mobitz I or Wenckebach heart block, is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s).
