MS Cardio Focus Review
which of the following nursing measures is MOST effective for preventing thrombophlebitis for a patient while on bedrest?
instruct the pt to flex and point his toes every two hours.-> flexing and pointing toes will increase venous return and maintain the integrity of his blood vessels and will help prevent thrombophletitis
One week after discharge from the hospital, a client with heart failure (HF) comes to the cardiac clinic for a follow-up visit. which of these statements, if made by the client to the nurse, indicates an improvement in the client's condition?
"i only sleep on one pillow" -> a symptom of HF is orthopnea or the inability to breathe while lying flat; the client's statement that he uses only one pillow to sleep indicates an improvement in his respiratory function
the nurse cares for the client diagnosed with MI. which client statement indicates to the nurse an understanding of lifestyle changes required due to the MI?
" i guess I won't be playing volleyball with the guys for a while. I need to complete my cardiac rehabilitation program." indicates an understanding of needing to participate in a rehabilitation program before activity level can be resumed at the prior level; myocardial infarction (MI) is the formation of localized necrotic areas within the myocardium, usually following the sudden occlusion of a coronary artery and the abrupt decrease of blood and oxygen to the heart muscle; signs and symptoms include severe crushing chest pain that may radiate to arms, jaw, neck, and back, dyspnea, nausea, vomiting, gastric discomfort, indigestion, apprehension, restlessness, and fear of death; nursing care includes providing thrombolytic therapy, relieving family's anxiety, bed rest, monitoring vital signs and intake and output; client instruction about modification of lifestyle includes stop smoking, reduce stress, and regular physical activity
the nurse performs discharge teaching for a patient receiving an antihypertensive medication. the nurse determines that further teaching is necessary when the patient makes which of the following statements?
"I can stop taking the medication when my BP goes down." usually required to take medication for the rest of their lives; reinforce that patients are not stop medication even though they have no symptoms and to report any side effects to the physician
the home care nurse visits a patient with a new permanent pacemaker implanted in the area below the left clavicle. it is most important for the nurse to respond to which of the following?
"I know my wound is healing because I see drainage from the incision site." -> drainage from the incision site in indicative of infection, and physician must be notified; other incision site indications of infection include swelling, warmth, redness, as well as overall fever
The nurse instructs a patient about hypertension. Which of the following statements, if made by the patient to the nurse, indicates teaching is successful?
"I know that I must see my physician on a regular basis." Hypertension is a serious condition that must be constantly monitored.
the nurse cares for the client diagnosed with heart failure. which question in the nursing history will be most helpful in establishing the presence of prior rheumatic fever?
"have you had any sore throats in the past 6-12 weeks?" -> group A beta-hemolytic streptococcus is responsible for the sore throat that almost always precedes the development of rheumatic fever (inflammatory disease that occurs after group A beta-hemolytic streptococcus pharyngitis)
the nurse teaches diagnosed with artherosclerosis about the disease process. which client statement allows the nurse to evaluate the instruction as effective?
"fatty deposits in the arteries make is diameter smaller."
the nurse understands that the pain of angina is caused by:
insufficient oxygen in the heart muscles angina pectoris is caused by ischemia of the myocardium
a patient is diagnosed with angina, and the nurse instructs the patient about care at home. the nurse determines that teaching is effective if the patient makes which of the following statements?
"if i have chest pain, i should stop my activity and take a nitroglycerin tablet." -> angina is chest discomfort caused by the heart's inability to provide oxygen to the cardiac muscle; warning sign of ischemia; anginal pain is relieved by rest and nitroglycerin; the first thing the patient should do is rest, and immediately take a nitrogylcerin tablet
the nurse instructs the client diagnosed with elevated total cholesterol levels. which client statement indicates to the nurse a need for further instructions?
"medication is the best way to lower cholesterol." -> sometimes helps lower cholesterol
the nurse teaches the client diagnosed with coronary artery disease after a MI. the information includes foods on a 2 gram sodium diet. which client statement indicates to the nurse that the client understands the dietary education?
"sodium makes me hold fluid, and with my condition I can't hold too much fluid." -> reason the client needs to limit salt intake is because Na retains water, and excess water in the circulation increases blood pressure
the office nurse prepares a client for a resting EKG. which of the following by the client indicates teaching is successful?
"the more still I can lie, the better the results will be?"-> EKG assesses overall and detailed cardiac function; resting EKG (vs. ambulatory or Holter monitoring or exercise EKG or stress test) requires client to lie as still as possible during the test to ensure the heart is being monitored in its resting or baseline state
the nurse instructs a client in the outpatient clinic about a stress test. which of the following statements by the nurse is BEST?
"the stress test will determine the amount of stress that your heart can tolerate." during the treadmill test, the client runs on a motorized treadmill while rate and B are monitored; physician can determine if cardiac ischemia is occurring, and get an estimate of the workload or stress this person's heart can tolerate
the nurse organizes care for he client who just has a carotid arteriogram. which interventions are important for the nurse to implement?
1. Check the puncture or cutdown site for bleeding and hematoma formation. (client is at risk for bleeding and hematoma formation at the puncture or cutdown site; carotid arteriogram is a visualization of the carotid arteries performed by using a radiopaque contrast medium dye injected via the femoral or brachial artery) 2. Assess vital signs frequently, including apical heart rate. (vital signs need to be checked frequently to assess for signs of bleeding or dysrhythmias) 3. Check distal extremity for color and pulse. (distal extremity should be checked for normal color and intact pulses) 4. Assess urinary output and check for bladder distention. (adequate urine output is important to flush out the dye; bladder distention may produce a vasovagal response with bradycardia, hypotension, and nausea, especially when a femoral site is used)
the nurse supervises the nursing student caring for the client who has a femoropoliteal bypass graft in the R leg 12 hours ago. the nurse should intervene if the nursing student performs which intervention?
1. the nursing student places the client in a chair for 30 minutes. -> bending the hip and knee are contraindicated due to possible thrombus formation 4. the nursing student obtains a Doppler evaluation of the client's right leg every two hours. -> assess hourly
the nurse is monitoring a patient receiving treatment for hypertension. which of the following blood pressure readings indicates to the nurse that the treatment is successful?
120/78 one of the goals of antihypertension therapy is to maintain systole blood pressure of 120 or below, and a diastolic pressure below 80
the nurse assesses the client's telemetry rhythm strip and counts 14 complexes occurring over a period of time between 3 marks at the top of the ECG paper. which is the HR?
140 bpm
the nurse performs a blood pressure screening at the local grocery store. the nurse knows that which of the following blood pressure reading indicates stage 1 hypertension?
142/88 systlic 140-150mm Hg or diastolic 90-99 mmHg
when one nurse is performing CPR on an adult, which is the correct ratio of compressions to breaths?
30 compressions to 2 breaths -> compression- ventilation ration for one to two rescuers
a newborn is transferred to the NICU with persistent tachycardia. at delivery the child's weight was 3250 grams. the health care provider orders an initial dose of digoxin (0.025 mg.kg in 3 doses over 24 hours.? how many mL?
3250/10000= 3.25 kg 0.27 mg= 27 micrograms 100/1= 27 micrograms 100/1 - 27/x answer: .027 mL
the nurse cares for the client diagnosed with HR possibly due to cardiac valvular disease. which is the most appropriate test to diagnose cardiac valvular disease?
A 3-dimensional (3D) echocardiogram it permits visualization of the valves
a patient undergoes a cardiac catheterization. following the procedure, the nurse discovers that the patient is bleeding from the cut-down site. which action should the nurse take first?
Apply pressure to the site The immediate priority at this time is to stop the bleeding; after this is done, the nurse may take the patient's vital signs, notify the physician, and reinforce the dressing over the site; after procedure, the client on bedrest for 4-6 hours and the insertion site is kept straight; assess pulses, sensation, bleeding at insertion site
the nurse admits the client to the unit from the post anesthesia care unit (PACU) immediately after an abdominal aortic aneurysm repair. which is the nurse's priority observation?
BP reading patency of the aortic graft can be assured with maintenance of an adequate systemic blood pressure; abdominal aortic aneurysm is the localized enlargement of the abdominal aorta's wall; may be asymptomatic or complain of abdominal and low back pain
the nurse monitors the cardiac enzymes of the client who has severe chest pain. which enzyme will elevate and peak MOST rapidly if the client experiences a MI?
CK-MB (creatine kinase-MB) appearance of CK-MB in the blood indicates damage to the MI; this enzyme shows a predictable rise and fall following a MI within a period of 3 days
the nurse cares for a client receiving lidocaine. The nurse identifies which medication would possibly cause toxicity if administered with lidocaine?
Cimetidine (Tagamet) -> cimetidine increases the toxicity of lidocaine by decreasing lidocaine metabolism-> side effects include hypotension, tremors, double vision, tinnitus, confusion, blurred vision, drowsiness, and dizziness.
the 350 lbs client is admitted to the medical floor. which information must the nurse obtain to ensure accurate BP reading from the client's right arm?
Circumference of the client's arm. blood pressure (BP) cuff must be the correct width and length for the client's arm; width of the cuff should be 40% of the client's arm circumference between the olecranon and the acromion; cuff should be long enough to encircle the limb and cover two thirds of its circumference; therefore, the nurse must know the arm circumference to choose the correct cuff; primary cause of a falsely elevated BP reading is a BP cuff that is too narrow
the nurse understands that CABs of CPR stand for which?
Compressions, airway, breathing-> CABs (compression, airway, breathing of CPR (airway, breathing, circulating) is a method to help remember CPR priorities; first is to restore circulation through compressions; second, assure a patent airway; third, establish breathing
the nurse expects which of these lab test results to be elevated in a client following an acute MI?
Creatine kinase (CK), troporin T and I, and myoglobin -> values are increased after an MI; creatine kinase (CK-M5) is an enzyme that is cardiac specific; begins to increase in an hour and peaks in 24 hours; troporin is myocardial muscle protein released when heart muscle damaged; any rise indicates MI; myoglobin is protein found in cardiac and skeletal muscle; normal is less than 90 mcg/L
a continuous intravenous infusion of heparin is administered to a patient. it is most important for the nurse to have which of the following medications available?
protamine sulfate -> the action of heparin is to interfere with normal blood coagulation promtamine sulfate is the antagonist to heparin and should be kept on hand at all times
the nurse cares for the client diagnosed with arterial insufficiency in the lower extremities. which assessment finding maybe related to the client's disease?
Intermittent claudication claudication is an indication of arterial insufficiency; it is cramping, pain, or aching experienced in lower extremity muscles during exercise
A client is started on warfarin. the nurse instructs the client to regularly obtain bloodwork to measure which laboratory value?
prothrombin time -> warfarin interfers with prothrombin formation; when client is receiving warfarin, prothrombin times should be closely monitored; therapeutic level is 1.5 times the control
the nurse assesses the post-op client for orthostatic hypotension before ambulating the client for the first time. which action is MOST important for the nurse to take?
Observe the client for a drop in blood pressure and/or an increase in pulse orthostatic hypotension is defined by a drop in blood pressure of 2 mm Hg systolic or 5 mm Hg diastolic and/or by an increase in HR of 20 bpm associated with position change
the cardiac nurse instructs a patient scheduled to receive a pacemaker about how the usual cardiac conduction cycle flows. which of the following should the nurse identify as the natural pacemaker of the heart?
Sinoatrial (SA) node-> it is the pacemaker of the heart, usually initiating impulses (heartbeats) at 60-100 bpm; it is located in the junction of the superior vena cava and the right atrium; it regulates HR, rhythm, and regularly; other components of the conduction pathway have potential to discharge impulses independently, but the SA node releases impulses more rapidly and therefore assumes control over the process
a client receiving verpamil in the sustained-release form complains of a HA. which information should the nurse provide the client?
this medication often causes HA -> varpamil is a calcium channel blocker that sometimes cause HA, constipation, fatigue, and dizziness; non-narotic analgesia is often prescribed to treat the HA; this side effect to diminish over time
the nurse performs discharge teaching for a patient with angina. It is MOST important to report which of the following?
a change in the character of the pain. -> change in the character of the pain in which the pain would radiate or be accompanied by diaphoresis would be an important sign for a patient and family to recognize.
the nurse cares for the client dx with AMI. the client's skin is clammy, BP is 85/50; client appears restless and anxious. which actions should the nurse take first?
administer analgesia as ordered. -> analgesic of choice is IV morphine; reduces pain and anxiety and reduces preload, which decreases the workload of the heart and therefore the pain; pain in this case indicates myocardial ishemia; delaying treatment increases ischemic involvement
the nurse in the student health service of college is planning a series of brief presentations on reducing health risks. One of the topics is going to be toxic shock syndrome (TSS). it is MOST important for the nurse to target which of the following groups in marketing this program?
all females-> since TSS is primarily concerned with tampon use and since this is a college-age campus, all women should be targeted; TSS is a type of distributive shock resulting from inadequate vascular tone due to staphylococcus aureus infection; in addition to tampons, various contraceptive devices, postpartum conditions and nonmenstrual vaginal conditions have been associated with TSS; proper use of tampons, including avoidance of those with super absorbent properties, is a priority; sudden high fever, vomiting, diarrhea, hypotension, and rash are initial symptoms of TSS; preventive education is the focus of the primary care setting
the nurse reviews the care of a post-op client with the nursing student. the nursing student identifies which intervention to prevent thrombembolism?
apply an intermittent compression device to the legs.-> they foster effective circulation
the nurse provides dietary education for the client diagnosed with MI. the client is on a 2-gram sodium diet. which menu choice by the client teaching is effective?
basked potato
The nurse understands that they MOST important factor to maintain adequate circulations is
blood volume -> in order to maintain adequate circulation, an adequate transport medium to carry nutrients and gases throughout the body is needed
the nurse administers a beta blocker and a calcium channel blocker to the client diagnosed with a MI. the nurse should be aware of which factors when planning to administer these medications together?
both medications can cause a decrease in HR and BP and change in rhythm
which artery should the nurse use to assess the pulse rate of an infant during cardiopulmonary resuscitation?
brachial artery-> infant's arteries are naturally small; femoral, carotid, and apical pulses may be difficult to palpate
the nurse observes a person suddenly collapse on the street. the nurse finds the person unresponsive. which action should the nurse take first?
call the emergency number -> for sudden collapse, call the emergency response number and then begin CPR
One week following a MI, a patient complains to the nurse of fatigue. the nurse notes that the patient is slightly short of breath and the pulse rate is 110 bpm. which of the following actions by the nurse is BEST?
check for any edema or weight gain -> assessment; fatigue, shortness of breath, and tachycardia are signs of heart failure; nurse should check for signs of edema or weight gain to determine if the patient is retaining fluid from the heart failure
which nursing measure would be most important immediately following cardiac catheterization?
check the extremities for pulses following catheterization, trauma to the vessels used for cath is the major concern
the nurse cares for a patient immediately after a femoral-to-popliteal bypass graft. the nurse is MOST concerned if which of the following is observed?
clammy skin -> hypovolemic shock is due to an inadequate volume of blood due to hemorrhage, severe dehydration, or burns; skin will be cold and clammy because the body redirects blood from the skin, kidneys, and GI tracts to the brain and heart; urine output decreases; blood pressure will be decreased and pulse will be elevated.
the 6-month-old baby has a cyanotic congenital heart defect. the nurse knows that a cyanotic congenital heart defect is associated with which symptom?
clubbing of the fingers-> other symptoms that occur in clients with congenital heart defects include retractions and failure to thrive
a patient arrives in the emergency room complaining of severe pain in the left leg that is not relieved by rest or medication. on physical examination, the nurse is MOST likely to assess which of the following?
cold, mottled leg -> pain in the lower extremities not relieved by rest indicates peripheral arterial disease; pain may be described as numbness or burning; pain sometimes relieved by placing leg in dependent position; skin is dry, scaly, dusky, pale, mottled, and cold
It is MOST important for the nurse to take which action when administering cardiopulmonary rescuscitation?
compress the chest at least a rate of 100 compressions per minute. -> push hard and push fast" to maintain blood flow; in order for cardiac compressions to be efficient and effective, there should be vertical pressure through the heel of the hand with each compression; only the heel of the hand should be placed on the sternum; the shoulders should be parallel to the sternum and elbows should be locked to generate enough pressure for even a small person to move the sternum an inch to an inch-and-a- half downward, and compress the heart between the sternum and the vertebrae
Which reason does the nurse understand to be the purpose of a coronary artery bypass graft (CABG)?
insert the graft in a bypass procedure, a graft places and anastomosed distally and proximally to bypass the obstuction
Several hours after being admitted to the unit, an IV lidocaine drip is stated for a client diagnosed with acute MI. the nurse understands which outcome is the purpose of this medication?
decrease the myocardial irritability.-> lidocaine, like other anitdysrhythmic drugs, decreases myocardial irritability and decreases myocardial automaticity
the nurse understands that the primary purpose of promoting rest a MI includes which rationale?
decrease the worked on the heart
the nurse understands that the primary purpose of promoting rest following a MI includes which rationale?
decrease the workload on the heart-> client has altered cardiopulmonary tissue perfusion due to MI; rest with limited mobility will decrease the workload of the heart by reducing myocardial oxygen consumption
the nurse cares for a client diagnosed with angina. the nurse understands that nitrolycerin is used in the treatment of angina pectoris for which reason?
decreases preload by dilating the peripheral vessels, blood pressure is decreased thereby decreasing preload; the heart does not have to pump as hard to eject blood and therefore the work load of the heart is decreased relieving angina
the nurse recognizes that the type of edema related to cardiac failure is usually
dependent seen with right-sided heart failure and usually noted in the ankles and in the sacral region
the client comes to the cardiac clinic reporting of anorexia, nausea, and blurred vision. the nurse understands that these symptoms indicate that the client may be experiencing which condition?
digitalis toxicity -> nausea, vomiting, anorexia, and visual distrubances are all signs of digitalis toxicity as well as bradycardia; check apical rate and hold if below 60/mon; normal range for digoxin is 0.5-2.0 ng/mL
the nurse informs a patient with angina that some common side effects of nitroglycerin includes which of the following?
dizziness, HA, and hypotension-> common side effects of nitroglycerin includes dizziness, HA, and hypotension; renew supply every 3 months, avoid alcoholic beverages, protect drug from light
the nurse plans care for the client diagnosed with ulcerations and infections of the feet related to peripheral vascular disease. which interventions should the nurse should include?
elevate the feet if swollen-> feet should be elevated to minimize the symptoms of swelling and edema
the nursing instructor instructs a class about MI. the instructor tells the class oxygen is given to the client experiencing an MI to keep the heart muscle well-oxygenated. this is done to prevent which problem that the ischemic heart muscle is likely to develop?
fatal dysrhyhmias. -> ischemic heart is irritable and may easily develop arrhythmias.
the nurse identifies that the correct area to assess the apical pulse is which of the following?
fifth intercostal space at the left midclavicular line -> mitral area
the nurse cares for the client 12 hours after artofemoral bypass. it is MOST important for the nurse to place the client in which position?
full supine hip must remain straight to prevent bleeding
the nurse cares for a patient following a MI. which of the following information, obtained during the health hx, is most significant when planning for the patient's discharge?
high-stress job is a significant risk factor for cardiac disease
the nurse cares for a client receiving digoxin and hydrochlorothiazide. the nurse understands that a major side effect of hydrochlorothiazide includes which?
hypokalemia -> thiazide diuretics block reabsorption of sodium and increase the excretion of water and potassium from the body, which can result in hypokalemia
the nurse teaching a patient diagnosed with heart failure about the prescribed medication. the nurse explains the purpose of digoxin (Lanoxin) includes which of the following?
increase the strength of the heart's contractions -> deigitalis increases the force of the heart's contractions by slowing the heart rate and conduction through the AV node
the nurse cares for a client receiving a blood transfusion. the nurse observes which symptoms if fluid overload occurs during the transfusion?
increased pulse rate, increased BP, increased respirations
a medical surgical unit is being converted into a cardiac until due to increasing numbers of clients coming to the hospital with cardiac conditions. the nurse manager reviews with staff the difference defib and cardioversion. which should the manager identify as characteristics that these two procedures have in common?
intended action and paddle placement the intended action for both defib and cardioversion is to completely deplarize all the myocardial cells at once so the SA node can reestablish its role as the pacemaker of the hear; paddle placement is the same for both procedures, with one paddle over the right sternal border and the other over the apex of the heart
the nurse cares for the client diagnosed with chronic venous insufficiency. which priority interventions should the nurse include when planning the client's care?
keep legs elevated Chronic venous insufficiency allows retrograde blood flow, client may have persistent edema as well as cyanosis that worsen with dependent positioning
the nurse is caring for a client receiving methyldopa. the nurse instructs the client about common side effects of methyldopa. which information should the nurse include?
loss of libido-> methyldopa is a centrally acting sympatholytic that reduces peripheral vascular resistance; side effects include drowsiness, sedation, orthostatic hypotension, bradycardia, and loss of libido; do not discontinue abruptly may cause hypertensive crisis; monitor for fluid retention
which is the primary goal of the nurse in performing CPR on the client experiencing ventricular dysrhythmias?
maintain circulation to vital organs
the nurse understands that the cause of essential hypertension is
not known essential (primary) hypertension accounts for 90-95% of all cases; hypertension may have no symptoms or HA, dizziness, anginal pain, treatment includes medication and lifestyle changes
the nurse cares for the client diagnosed with coronary artery disease after experiencing a MI. which menu item chosen by the client indicates to the nurse that the client understands appropriate dietary needs?
oatmeal and orange juice for breakfast; a salad for lunch, and grilled chicken with green vegetables for dinner. - low in fat
the nurse cares for the client diagnosed with an acute MI who has a temporary demand pacemaker placed. the nurse observes the rhythm strip and determines that the pacemaker is failing to sense. which type of rhythm does the nurse know that the EKG strip will most likely show?
pacemaker spikes with no relation to the client's own heart beat-> failure to sense occurs when the pacemaker fails to recognize spontaneous atrial or ventricular activity and fires inappropriately; pacemaker functions when the client's heart rate falls below a set rate
the nurse understands that intermittent claudation is
pain caused by walking intermittent claudication is pain felt in the calves when the patient walks and is seen in arterial insufficiency
the nurse cares for the client diagnosed with arterial insufficiency. which sign or symptom should the nurse expect when obtaining the client's hx or performing a physical assessment?
pain in the hip, buttock, thighs, or calf. -> decreased arterial blood flow leads to pain in the hip, buttock, thigh, and calf; classic symptom of arterial disease is intermittent claudication, ischemic muscle disease; indications of PAD include rubor, cool and shiny skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication, and decreased peripheral pulses
the nurse cares for the client reporting numbness in the left arm and intermittent upper substernal pressure that radiates to the neck. the pressure is relieved by rest. the client sates, "I can't explain it, but I feel like i'm about to die." based on the available data, which nursing diagnosis would the nurse select as most important?
pain related to ischemia-> insufficient coronary blood flow results in an inadequate supply of oxygen to the myocardium, this produces pain
which initial action should the nurse perform when the client experiences ventricular fibrillation?
perform cardiopulmonary resuscitation (CPR) -> if client is breathing and is pulseless, implement CPR
the nurse attache a Holter monitor to the client. which nursing action will ensure proper functioning of the Holter monitor?
place a new battery in the monitoring device attaching the unit to the client.
an older man is admitted to the hospital with a diagnosis of heart failure. which of the following findings is most characteristic of heart failure?
pulse 110 respirations 24 BP 100/60-> HF is failure of the cardiac muscle to pump sufficient blood to meet the body's metabolic demands; can have right or left-sided failure; characteristic signs of HF include tachycardia and increased respirations
the nurse performs diet teaching for a client diagnosed with a MI. the nurse determines that teaching is effective if the client selects which of the following menus?
sliced turkey, green beans, pear -> these are all low in cholesterol and low in salt; other meals are high cholesterol and salt
the nurse cares for the client diagnosed with angina. the client is scheduled for a cardiac catherterization and tells the nurse, "I get a rash when I eat strawberries or shellfhis." which interventions should be the nurse perform first?
stop preparations for the test Reaction to shellfish may indicate an allergy to the iodine contrast medium in the test
the nurse recognizes which medication is not used for the treatment of pulmonary emboli?
streptomycin-> an aminoglycoside used to treat various infections; side effects include ototoxicity, anorexia, nausea, vomiting, and diarrhea
an older client has a medical hx that includes hypertension. a public health nurse visits the client regularly and on each visit records the vital signs. the nurse expects which of the following findings for this client?
temperature (96.8F), blood pressure 160/92, pulse 80, respirations 24-> in the elderly body temperature may decrease normal temperature for this client; blood pressure of 160/92 would be expected in a patient who has a medical hx of hypertension; pulse of 8- would be normal; respirations of 24 normal
to assess the pulse during adult cardiopulmonary resuscitation (CPR), which site should the nurse assess?
the carotid artery -> carotid artery is most accessible; if there is a weak pulse, it will most likely be felt in the carotid artery; use for adults and children from the ages 1-8 years
the nurse cares for the client diagnosed with rheumatic carditis. the nurse makes the nursing diagnosis of activity intolerance related to reduced cardiac reserve. which long-term goal is most appropriate for the nurse to work toward when developing the plan of care?
the client climbs one flight of stairs with a HR below 90-> it is a reasonable goal for the client with Rheumatic carditis to strive for an activity of daily living in which the HR remains within normal limits; rheumatic carditis is a result of having previous group A beta-hemoltyic strep pharyngitis (strep throat) as a school-age child
a client diagnosed with iron deficiency anemia receives heparin after a venous thromboembolism (VTE) is diagnosed in the left leg. which observation most concerns the nurse?
the client has a nosebleed. -> bleeding from any body site can indicate hemorrhage, the primary concern with anticoagulant drugs such as heparin; immediate management of the epistaxis and notification of the health care provider should occur; if needed, protamine sulfate, the specific hepain antagonist, may be given
the nurse in the prenatal clinic assesses a client at 31 weeks gestation. the client's BP is 150/96, edema of the face and hands is noted, 3+ protein in the urine, and serum albumin level is 3 mg/dL. which of the following instructions by the nurse is MOST important?
the client should ensure adequate protein. -> client has preeclampsia; bedrest lying on the left side; maintain adequate intake of fluids and proteins; proteins restore osmotic pressure
the nurse cares for the client diagnosed with impaired arterial circulation in the lower extremities. which short-term goal is most appropriate for the nurse to add to the client's plan of care?
the client will report freedom from muscle pain while walking in the room. -> arterial insufficiency is characterized by intermittent claudication caused by the inability of occluded arteries to provide adequate nutrients and oxygen to the tissues during exercise
the nurse cares for a patient after a coronary artery bypass graft (CABG). which observation during the postoperative period MOST concerns to the nurse?
the heavy chest tube drainage suddenly stops sudden cessation of mediastinal chest tube drainage after a CABG, especially when the drainage was heavy, is a hallmark manifestation of cardiac tamponade; in cardiac tamponade blood and/or fluid collects in the pericardial sac, presses on the heart, and prevents atria and ventricles from filling adequately; cardiac output is thus reduced; emergency sternotomy and volume and volume expanders are the treatment of choice
100/1 mg= 27 micrograms
the nurse understands that the purpose of promoting rest following a MI includes which rationale?
the nurse cares for patients on the medical unit. propranolol (Inderal) is ordered for a patient. which of the following information found in the patient's hx should cause the nurse to intervene?
the patient has had asthma since childhood. ->one of the side effects of Inderal is bronchospasm; possible side effect must be avoided in patients with asthma.
the nurse is planning discharge teaching for a patient diagnosed with peripheral vascular disease. it is MOST important for the nurse to address which of the following?
the patient smokes heavily. -> smoking is a predisposing factor for arterial peripheral vascular disease
in formulating a nursing care plan for a patient following a myocardial infraction, the nurse should include which of the following goals?
the patient will be free from pain and dysrhsythmias. -> this goal is realistic, achievable and measurable
when a nurse administers dopamine via IV drip, which of the following factors is MOST important?
the patient's weight in kg -> dopamine is administered according to mcg/kg/hr, administer via pump titrated to a certain dosage
which should the nurse expect when assessing the lab results of the client diagnoses with rheumatic fever?
the presence of C-reactive protein-> presence in serum is not normal and is diagnostic of Rheumatic fever
the nurse discover an unconscious person in the street. the nurse notes that the person is not breathing. the nurse should take which action?
tilt the person's head back and lift chin. -> by tilting head backward and lifting the chin upward so it points straight up, the upper airway will open; this maneuver removes the tongue from obstructing the airway, a common cause of airway obstruction in unconscious people; sometimes by just performing this maneuver, the person will start breathing again.
the nurse cares for a patient admitted to the unit with a diagnosis of AMI. the nurse understands that a cardiac monitor is attached to this patient for which for the following reasons?
to detect any life-threatening changes in the heart rhythm -> cardiac monitor displays the patient's heat rhythm; by observing this, any abnormalities such as PVC or ventricular fibrillation can be detected.
the nurse educator conducts an orientation class for new graduate nurses will be caring for cardiac patients on the medical surgical unit. the educator should remind the nurses that the QRS complex of an EKG reflects which of the following?
ventricular depolarization -> the QRS complex represents depolarization of the ventricles; occurs after the atrial depolarization, represented by the P wave, and the subsequent, which represents the length it takes to travel through the AV node, bundle of His system and Purkinje fibers; ventricular depolarization may be conceptualized as ventricular systole
the nurse understands that the antagonist of warfarin is which medication?
vitamin K -> Vitamin k is a warfarin antagonist because it promotes blood clotting
the health care provider prescribes hydrochlorothiazide 50 mg once a day for a client. when is the best time for the nurse to administer this medication?
with breakfast. -> hydrochlorothiazide should be taken with meals; if given with dinner, duresis would occur while the patient was sleeping, causing interruption in sleep