NCLEX 10000 Cardiac

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In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload? a) Myocardial infarction, fluid overload, and diuresis b) Hemorrhage, sepsis, and anaphylaxis c) Third spacing, heart failure, and diuresis d) Fluid overload, sepsis, and vasodilation

Hemorrhage, sepsis, and anaphylaxis Correct Explanation: Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload increases with fluid overload and heart failure.

What is the major goal of nursing care for a client with heart failure and pulmonary edema? a) Decrease peripheral edema. b) Increase cardiac output. c) Enhance comfort. d) Improve respiratory status.

Increase cardiac output. Correct Explanation: Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema.

What is the major goal of nursing care for a client with heart failure and pulmonary edema? a) Improve respiratory status. b) Enhance comfort. c) Decrease peripheral edema. d) Increase cardiac output.

Increase cardiac output. Correct Explanation: Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level.

The nurse is assessing a client with Buerger's disease. The nurse should determine if the client is experiencing: a) Pain, pallor, and pulselessness. b) Thickening of the intima and media of the artery. c) Inflammation and fibrosis of arteries, veins, and nerves. d) Vasospasm lasting several minutes.

Inflammation and fibrosis of arteries, veins, and nerves. Explanation: Buerger's disease is characterized by inflammation and fibrosis of arteries, veins, and nerves. White blood cells infiltrate the area and become fibrotic, which results in occlusion of the vessels. Signs and symptoms include slowly developing claudication, cyanosis, coldness, and pain at rest.

A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation? a) Orthostatic hypotension b) Irregularly irregular heart rate c) Increased PR interval d) Fourth heart sound (S4)

Irregularly irregular heart rate Correct Explanation: An irregularly irregular heart rate indicates atrial fibrillation and should be investigated further. It's normal for an elderly client to have a prolonged systole, which causes an S4 heart sound. It's also normal for an elderly client to have slowed conduction, causing an increased PR interval. As a person ages, it's normal for baroreceptors in the body to decrease their response to changes in body position, which can cause orthostatic hypotension.

The nurse is caring for a client on hemodialysis who has an arteriovenous (AV) fistula in the right arm. When managing a client's plan of care, which instructions would the nurse determine as a priority is being completed? Select all that apply. a) Maintaining the right arm above the heart b) Wearing tight fitted shirts c) Assessing the shunt by auscultating a bruit d) Utilizing a splint to maintain the right arm in an extended position e) Avoiding all blood pressure readings and trauma to the right arm f) Completing arm and finger exercises

A client was recently diagnosed with a deep vein thrombosis in the right leg. The nurse should incorporate which of the following activities into the client's plan of care? a) Encourage the client to ambulate twice a shift. b) Keep the right leg elevated above heart level. c) Have the client do active leg exercises hourly with both legs. d) Assess the edema of the right leg every 4 hours.

Keep the right leg elevated above heart level. Correct Explanation: The extremity should be kept elevated with heat applied to treat the inflammation and pain. To decrease chances of dislodging a thrombus, the client is typically kept on bed rest during the initial stages of treatment until therapeutic levels of anticoagulation are achieved.

A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instructio

"Client walks 4 miles (6.4 kilometers) in 1 hour every day." Explanation: Four weeks after an MI, a client's walking program should aim for a goal of 2 miles (3.2 kilometers) in less than 1 hour. Walking 4 miles (6.4 kilometers) in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions.

A client with peripheral vascular disease is recovering from surgery to insert an aortofemoral-popliteal bypass graft. When developing a postoperative education plan, which question by the nurse will provide the most helpful information? a) "How did you manage your health before admission?" b) "What is your home environment like?" c) "How far could you walk without pain before surgery?" d) "Do you have problems with urine retention?"

"How did you manage your health before admission?" Correct Explanation: Assessing the individual's health behavior before surgery will help the nurse and client develop strategies to manage the postoperative course. Asking open-ended questions will elicit the most helpful information.

A nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching? a) "I'll have to sign a consent form before the test." b) "I won't eat or drink anything after midnight tonight." c) "I won't smoke for 2 to 3 hours before the test." d) "I'll likely be able to take my regular medications before the test."

"I won't eat or drink anything after midnight tonight." Correct Explanation: The client requires additional teaching if he states that he'll fast from midnight until the test. Clients need to abstain from eating and drinking for only 4 hours before the test.

A middle-aged adult with a family history of CAD has the following fasting blood laboratory test results: Total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/l); HDL cholesterol 58 (3.2 mmol/L); Triglycerides 148 (8.2 mmol/L); Blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why it is necessary to take these medications. Which is the best response by the nurse?

"The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." Explanation: CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk.

A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs? a) Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. b) Decreased renal blood flow causes the renin-angiotensin-aldosterone system to reduce secretion of aldosterone and antidiuretic hormone. c) Low blood pressure triggers the baroreceptors to decrease sympathetic nervous system stimulation. d) Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase aldosterone secretion.

Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. Correct Explanation: In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing an increased heart rate, vasoconstriction, and increased myocardial oxygen consumption.

A nurse is obtaining an ankle-brachial index for a client with arteriosclerosis. Identify the correct order for obtaining the ankle-brachial index.

*Place the client in the supine position. *Record the highest systolic blood pressure readings in both arms. *Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posterior tibial). *Record the ankle systolic blood pressure reading when the Doppler sound returns The nurse should first place the client in a supine position. Next the nurse should assess blood pressures in both arms and record the highest systolic blood pressure as the brachial pressure. To obtain the brachial pressure, the nurse should place the blood pressure cuff around the affected leg just above the malleolus and then place a Doppler probe at a 45-degree angle to the dorsalis pedis or posterior tibial pulse. The nurse should then inflate the blood pressure cuff until the Doppler sound stops and then deflate it until the Doppler sound returns. The point when sound returns is recorded as the ankle systolic pressure. The ankle-brachial index is the ankle (dorsalis pedis or posterior tibial) pressure divided by the highest arm pressure. A pressure above .90 is normal; anything lower indicates obstruction.

A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride, an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within: a) 1 to 2 minutes after continuous I.V. infusion. b) 1 to 2 minutes after I.V. bolus administration. c) 10 to 15 minutes after I.V. bolus administration. d) 10 to 15 minutes after continuous I.V. infusion.

1 to 2 minutes after I.V. bolus administration. Correct Explanation: Lidocaine exerts its antiarrhythmic effect in 1 to 2 minutes after I.V. bolus administration. A continuous I.V. infusion will maintain lidocaine's antiarrhythmic effect for as long as the drip is used. Lidocaine provides antiarrhythmic effects for only 15 minutes after the I.V. infusion is stopped.

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?

The severity of discomfort isn't related to the size of varicosities Explanation: Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities.

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? a) The severity of discomfort isn't related to the size of varicosities. b) Varicose veins are more common in men than in women. c) Sclerotherapy is used to cure varicose veins. d) Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation.

A nurse administers an IV antihypertensive medication to a client with a blood pressure (BP) reading of 210/120 mm Hg, a mean arterial pressure (MAP) of 150 mm Hg, sudden vomiting, and severe headache. Which of the following is an appropriate outcome for treatment? a) No vomiting in 4 hours b) MAP 115 in 1 hour c) BP 120/80 mm Hg in 2 hours d) No headache in 3 hours

MAP 115 in 1 hour Correct Explanation: A hypertensive crisis occurs when the BP suddenly rises above 180/120 mm Hg. Manifestations include headache, nausea, vomiting, seizures, confusion, stupor, and coma. There may also be blurred vision, renal insufficiency, dyspnea, and chest pain. Treatment with intravenous antihypertensive medications aims to reduce BP by no more than 25% in the first hour. Rapid lowering of BP may precipitate a stroke, myocardial infarction, or renal failure. MAP is often used to monitor pressure changes during hypertensive crisis. MAP = (SBP + 2DBP)/3: [SBP = systolic blood pressure, DBP = diastolic blood pressure.] The initial MAP for this client is 150 mm Hg. Twenty-five percent of that is 37.5 mm Hg. So the MAP should not drop below 112.5 mm Hg in the first hour. Within the next 2-6 hours, the MAP should gradually reach 110 mm Hg

A client with suspected acute myocardial infarction is admitted to the coronary care unit. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain?

4 to 6 hours Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.

Which assessment data should a nurse use to monitor the respiratory status of a client with pulmonary edema?

Arterial blood gas (ABG) analysis Explanation: ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy.

Which assessment data should a nurse use to monitor the respiratory status of a client with pulmonary edema? a) Lung sounds b) Arterial blood gas (ABG) analysis c) Skin color assessment d) Pulse oximetry

Arterial blood gas (ABG) analysis Explanation: ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy.

Which assessment data should a nurse use to monitor the respiratory status of a client with pulmonary edema? a) Arterial blood gas (ABG) analysis b) Lung sounds c) Skin color assessment d) Pulse oximetry

Arterial blood gas (ABG) analysis Explanation: ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy. Although a nurse can use any of the options to detect pulmonary changes, assessment of skin color and assessment of lung fields commonly are subject to interpretation by practitioners

A client has been prescribed hydrochlorothiazide to treat heart failure. For which of the following symptoms should the nurse monitor the client?

Muscle weakness. Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of hypokalemia.

The nurse should complete which of the following assessments on a client who has received tissue plasminogen activator or alteplase recombinant therapy?

Neurologic signs frequently throughout the course of therapy. The nurse needs to assess neurologic status throughout the therapy. Altered sensorium or neurologic changes may indicate intracranial bleeding for the client who has received tissue plasminogen activator or alteplase.

The nurse is caring for a client with a third heart sound. Which action is indicated? a) Place the client on a cardiac monitor b) Observe for sluggish skin turgor c) Assess the client's lungs for crackles d) Place the client flat in bed

Assess the client's lungs for crackles Correct Explanation: A third heart sound indicates fluid volume excess (FVE) or heart failure; crackles are an additional finding and will further refine the assessment

The nurse is caring for a client with a third heart sound. Which action is indicated? a) Place the client on a cardiac monitor b) Observe for sluggish skin turgor c) Place the client flat in bed d) Assess the client's lungs for crackles

Assess the client's lungs for crackles Explanation: A third heart sound indicates fluid volume excess (FVE) or heart failure; crackles are an additional finding and will further refine the assessment.

The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client is anxious because he fears he will not be monitored as closely as he was in the CCU. How can the nurse allay his fears? a) Obtain an order for an antianxiety medication. b) Assign the same nurse to the client when possible. c) Move the client to a room far from the nurses' station to reduce his exposure to noise. d) Remind the client he would not have been moved out of CCU if he was not stable.

Assign the same nurse to the client when possible. Explanation: Assigning the same nurse to the client when possible provides continuity of care and stability, thereby reducing his anxiety.

When starting a client on oral or I.V. diltiazem hydrochloride, for which potential complication should the nurse monitor?

Atrioventricular block The chief complications of diltiazem are hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels.

A physician in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema? a) Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours b) Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours c) A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling d) A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling

Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Correct Explanation: Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.

Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal.

A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal? a) Ibuprofen. b) Nicotine. c) Bupropion. d) Nitroglycerin.

Bupropion. Correct Explanation: Bupropion, a non-nicotine medication, is used to promote smoking cessation.

The nurse is developing an education plan for clients with hypertension. The nurse should emphasize which long-term goal? a) Develop a plan to limit stress. b) Monitor blood pressure regularly. c) Participate in a weight reduction program. d) Commit to lifelong therapy.

Commit to lifelong therapy. Explanation: The most appropriate long-term goal for the client with hypertension is to commit to lifelong therapy. A significant problem in the long-term management of hypertension is compliance with the treatment plan. It is essential that the client understand the reasons for modifying lifestyle, taking prescribed medications, and obtaining regular health care.

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? a) Sclerotherapy is used to cure varicose veins. b) Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation. c) Varicose veins are more common in men than in women. d) The severity of discomfort isn't related to the size of varicosities.

The severity of discomfort isn't related to the size of varicosities. Correct Explanation: Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, DVT, or inflammation damages valves.

A physician admits a client with a history of I.V. drug abuse to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has: a) a scratchy pericardial friction rub. b) retrosternal pain that worsens during supine positioning. c) pulsus paradoxus. d) Osler's nodes and splinter hemorrhages.

Osler's nodes and splinter hemorrhages. Explanation: Infective endocarditis occurs when an infectious agent enters the bloodstream, such as from I.V. drug abuse or during an invasive procedure or dental work. Typical assessment findings in clients with this disease include Osler's nodes (red, painful nodules on the fingers and toes), splinter hemorrhages, fever, diaphoresis, joint pain, weakness, abdominal pain, a new or altered heart murmur, and Janeway's lesions (small, hemorrhagic areas on the fingers, toes, ears, and nose).

The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? a) Prothrombin time, 1.5 to 2.5 times the normal control. b) Thrombin clotting time, 10 to 15 seconds. c) International Normalized Ratio, 2 to 3 seconds. d) Partial thromboplastin time, 1.5 to 2.5 times the normal control.

Partial thromboplastin time, 1.5 to 2.5 times the normal control. Correct Explanation: The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of warfarin, oral anticoagulation therapy. The thrombin clotting time is used to confirm disseminated intravascular coagulation.

Upon assessment of third-degree heart block on the monitor, what should the nurse do first? a) Call a code. b) Place transcutaneous pads on the client. c) Prepare for defibrillation. d) Begin cardiopulmonary resuscitation.

Place transcutaneous pads on the client. Correct Explanation: Transcutaneous pads should be placed on the client with third-degree heart block.

The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported? a) Document essential transfer information in the client's electronic health record. b) Give the report face-to-face with both nurses in a quiet room. c) Use a printed checklist with information individualized for the client. d) Audiotape the report for future reference and documentation.

Use a printed checklist with information individualized for the client. Correct Explanation: Using an individualized, printed checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later.

Use a printed checklist with information individualized for the client. Using an individualized, printed checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later.

A nurse is teaching a client about maintaining a healthy heart. The nurse should include which point in her teaching? a) Smoke in moderation. b) Exercise one or two times per week. c) Use alcohol in moderation. d) Consume a diet high in saturated fats and low in cholesterol.

Use alcohol in moderation. Correct Explanation: The nurse should advise the client that alcohol may be used in moderation as long as there are no other contraindications for its use.

hich of the following conditions is a potential consequence of a prolonged QT interval? a) Serious electrolyte imbalance. b) Development of orthostatic hypotension. c) Predisposition to torsades de pointes. d) Predisposition to atrial fibrillation.

Predisposition to torsades de pointes. Correct Explanation: A prolonged QT interval is significant because it can lead to the development of polymorphic ventricular tachycardia, also known as torsades de pointes.

Which of the following conditions is a potential consequence of a prolonged QT interval? a) Predisposition to atrial fibrillation. b) Predisposition to torsades de pointes. c) Serious electrolyte imbalance. d) Development of orthostatic hypotension.

Predisposition to torsades de pointes. Explanation: A prolonged QT interval is significant because it can lead to the development of polymorphic ventricular tachycardia, also known as torsades de pointes

The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:

Preventing fluid volume deficit. Explanation: Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis

A nurse is caring for a client who is on a continuous cardiac monitor. When evaluating the client's rhythm strip, the nurse notes that the QRS interval has increased from 0.08 second to 0.14 second. Based on this finding, the nurse should withhold continued administration of which drug? a) Verapamil b) Procainamide c) Propafenone d) Metoprolol

Procainamide Explanation: Procainamide may cause an increased QRS complexes and QT intervals. If the QRS duration increases by more than 50%, then the nurse should withhold the drug and notify the physician of her finding.

A physician has scheduled a client with mitral stenosis for mitral valve replacement. Which condition may arise as a complication of mitral stenosis? a) Left-sided heart failure b) Myocardial ischemia c) Left ventricular hypertrophy d) Pulmonary hypertension

Pulmonary hypertension Correct Explanation: Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure.

A physician has scheduled a client with mitral stenosis for mitral valve replacement. Which condition may arise as a complication of mitral stenosis? a) Pulmonary hypertension b) Left ventricular hypertrophy c) Left-sided heart failure d) Myocardial ischemia

A client with deep vein thrombosis has been receiving warfarin for 2 months. The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do?

Return to laboratory for analysis of prothrombin times. These symptoms suggest that the client is receiving too much warfarin; the client should return to the laboratory and have a blood sample drawn to determine the prothrombin levels and have the dosage of warfarin adjusted.

A visiting nurse is teaching a client with heart failure about taking his medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? a) Ask the physician if the client can take fewer pills each day. b) Come to the client's house each morning to prepare the daily allotment of medications. c) Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. d) Ask the client's family to take turns coming to the house at each administration time to assist the client with his medications.

Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. Correct Explanation: The nurse should intervene by asking a family member to fill a compliance aid each week with the client's weekly supply of medications in the appropriate time slots

A client with third-degree atrioventricular heart block with a rate of 28 is admitted to the coronary care unit. Which intervention takes priority? a) Teaching the client about a temporary pacemaker b) Reviewing information regarding advanced directives c) Teaching the client to take his pulse d) Applying an apnea monitor

Teaching the client about a temporary pacemaker Explanation: Third degree A-V heart block is manifested by profound bradycardia and may be accompanied by confusion, dizziness, and syncope. This type of heart block will require pacemaker insertion.

The nurse is preparing to do a 12-lead ECG on a client. Indicate the correct area where the V2 electrode should be placed on the figure below.

The V2 electrode should be placed over the fourth intercostal space, at the left sternal border.

A nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first?

The nurse is caring for a client who was admitted to the hospital with severe nausea, vomiting, dyspnea, and substernal chest pain. Cardiac enzymes are positive for myocardial infarction (MI). Prior medical history includes an MI and diabetes. The nursing interventions for this client include the following. Place in order of priority. Use all options. 1 2 3 4 5 Incorporate teaching about diet and health control. Decrease the anxiety and reduce the workload on the heart. Monitor and manage potential complications. Control the pain and support breathing and oxygenation. Reduce the nausea and vomiting and stabilize the blood glucose.

Control the pain and support breathing and oxygenation. Reduce the nausea and vomiting and stabilize the blood glucose. Decrease the anxiety and reduce the workload on the heart. Monitor and manage potential complications. Incorporate teaching about diet and health control. Explanation: A client who is admitted with dyspnea and chest pain needs immediate assistance with breathing and pain to provide oxygen to the heart muscle. The priority is to prevent any further heart damage. Reducing the nausea and controlling the blood glucose is the next step. The client is likely to be very anxious, thus decreasing anxiety will also decrease the workload on the heart. Once the client is stabilized, then ongoing monitoring for complications would be appropriate, with teaching as the last priority.

A nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first? a) The client who has his call light on. b) The client who suffered an acute myocardial infarction (MI) who is complaining of constipation. c) The client who had a pacemaker inserted yesterday and who is complaining of incisional pain. d) The client admitted with unstable angina pectoris who wants to be discharged.

The client who suffered an acute myocardial infarction (MI) who is complaining of constipation. Explanation: The client who suffered an acute MI who is complaining of constipation should be addressed first. If the client strains at stool after an MI, the vagal response may be stimulated, causing bradycardia thereby provoking arrhythmias. After addressing the MI client with constipation, the nurse should promptly address the pain-relief needs of the client who had a pacemaker inserted the previous day.

After the client has a temporary pacemaker inserted, the nurse should verify that which of the following has been documented?

The client's cardiovascular status Explanation: The cardiovascular status of the client is the first information documented, and will validate the effectiveness of the temporary pacemaker.

A nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation. Why is this check so important? a) The shock must be synchronized with the client's T wave. b) The defibrillator will not deliver a shock if the shock delivery is set at 400. c) The delivered shock must be synchronized with the client's QRS complex. d) The defibrillator will not deliver a shock if the synchronizer switch is turned on.

The defibrillator will not deliver a shock if the synchronizer switch is turned on. Correct Explanation: The nurse needs to check the synchronizer switch to ensure the switch is turned off. The defibrillator will not deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on.

A nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation. Why is this check so important?

The defibrillator will not deliver a shock if the synchronizer switch is turned on. Explanation: The nurse needs to check the synchronizer switch to ensure the switch is turned off. The defibrillator will not deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on

Two female nursing assistants approach a nurse on a cardiac step-down unit to report that a client who they have cared for earlier in the week, who experienced an acute myocardial infarction, made sexual comments to them. What is the best guidance for the nurse to offer to the nursing assistants? a) The nurse should let the nursing assistants know that the incident will be reported to the supervisor immediately. b) The nurse should instruct the nursing assistants to ignore his advances. c) The nurse should explain that the client might have concerns about resuming sexual activity, but is afraid to ask. d) The nurse should explain that the client most likely wants extra attention.

Correct response: The nurse should explain that the client might have concerns about resuming sexual activity, but is afraid to ask. Explanation: The nurse, as a leader, has the education and responsibility to provide guidance to the nursing assistants by listening to their concerns, offering them support, and explaining why the client may be exhibiting this behavior. Sometimes clients are concerned about resuming sexual activity, but are afraid to ask. Making inappropriate sexual comments provides a forum for asking questions. It is not necessary to report the incident to the nursing supervisor immediately without investigating the situation further.

The nurse is preparing to interpret an ECG rhythm strip. Place the following steps for ECG rhythm analysis from first to last, in chronological order. Use all of the options.

Determine the rate and rhythm. Analyze the P waves. Measure the P-R interval. Measure the QRS duration. Interpret the rhythm. Explanation: ECG rhythm strip analysis requires a systematic approach using a five-step method. First, determine the rate and rhythm of both the atria and the ventricles. Then, analyze the P waves for consistency. Next, measure the P-R interval and then the QRS duration. Finally, you can interpret the rhythm with all of the information that has been collected. If the nurse has answered all five steps within normal limits, the client is in sinus rhythm. The greater number of questions that the nurse notes inconsistent with normal limits, the greater the abnormal conduction through the heart.

A client, hospitalized with heart failure, is receiving digoxin and furosemide intravenously and now has continuous ringing in the ears. What is the appropriate action for the nurse to take at this time?

Discontinue the furosemide and notify the physician. The nurse should recognize the ringing in the ears, or tinnitus, as a sign of ototoxicity probably caused by the furosemide. The appropriate action is for the nurse to stop the furosemide and notify the physician. If the drug is stopped soon enough, permanent hearing loss can be avoided and the tinnitus should subside.

A client with chronic obstructive pulmonary disease (COPD) develops signs of cor pulmonale. What assessment data would alert the nurse to this condition? a) Decreased urine output because of decreased arterial blood flow b) Irregular radial pulse and decreased pulse rate c) Edema of the extremities and distended neck veins d) Difficulty breathing and crackles in the lungs

Edema of the extremities and distended neck veins Correct Explanation: Cor pulmonale is right-sided heart failure caused by lung problems, so the symptoms outlined indicate edema and venous congestion, which are backup signs from right-sided failure.

A client with venous thrombus reports having pain in the legs. What should the nurse do first?

Elevate the foot of the bed. Venous stasis can increase pain. Therefore, proper positioning in bed with the foot of the bed elevated or when sitting up in a chair can help promote venous drainage, reduce swelling, and reduce the amount of pain the client might experience.

The nurse is taking a nursing history on a client prior to surgery. Which of the following would have a significant impact on the client's recovery postoperatively? The client: a) Is 10 lbs (4.5 kg) overweight. b) Has smoked 1 pack of cigarettes a day for 12 years. c) Drinks about two beers a week on a regular basis. d) Had a cold 6 weeks ago.

Has smoked 1 pack of cigarettes a day for 12 years. Correct Explanation: A client who smokes is at increased risk for atelectasis postoperatively; thus, smoking is the most significant risk factor listed in this item.

Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? a) Massage the client's feet and ankles regularly. b) Place the client's feet against a firm footboard. c) Have the client wear ankle-high tennis shoes at intervals throughout the day. d) Reposition the client every 2 hours.

Have the client wear ankle-high tennis shoes at intervals throughout the day. Correct Explanation: The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (foot drop) because they add support to the foot and keep it in the correct anatomic position. F

Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? a) Reposition the client every 2 hours. b) Massage the client's feet and ankles regularly. c) Have the client wear ankle-high tennis shoes at intervals throughout the day. d) Place the client's feet against a firm footboard

Have the client wear ankle-high tennis shoes at intervals throughout the day. Explanation: The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (foot drop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended.

A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol, 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located?

Heart Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.

In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload? a) Fluid overload, sepsis, and vasodilation b) Third spacing, heart failure, and diuresis c) Myocardial infarction, fluid overload, and diuresis d) Hemorrhage, sepsis, and anaphylaxis

A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The health care provider (HCP) has prescribed 60 mg of enoxaparin subcutaneously. Before administering the drug, the nurse checks the client's laboratory results. (See image.) Based on these results, what should the nurse do? a) Withhold the dose of the medication and contact the health care provider (HCP). b) Administer the medication as prescribed. c) Assess the client for signs of bruising on the extremities. d) Contact the pharmacist for a lower dose of the medication.

Withhold the dose of the medication and contact the health care provider (HCP). Correct Explanation: Based on the laboratory findings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin and contact the HCP. The nurse should not administer the drug until the HCP has been contacted.

Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision. The nurse's response should reflect the understanding that the client may be experiencing? a) anxiety related to altered body image b) altered tissue perfusion c) lack of knowledge regarding the postoperative course d) depression related to altered health status

anxiety related to altered body image Correct Explanation: Verbalized concerns from this client may stem from anxiety over the changes in the body after open heart surgery. Although the client may experience depression related to altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in the body image.

The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram strip). The nurse should: a) assess the client for changes in the rhythm. b) administer lidocaine as prescribed. c) notify the health care provider (HCP). d) call the rapid response team.

assess the client for changes in the rhythm. Explanation: The client is experiencing a single PVC. PVCs are characterized by a QRS of longer than 0.12 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted. PVCs are potentially serious and can lead to ventricular fibrillation or cardiac arrest when they occur more than 6 to 10 in an hour in clients with myocardial infarction.

A client with unstable angina is scheduled to have a cardiac catheterization. The nurse explains to the client that this procedure is being used to: a) assess the extent of arterial blockage. b) assess the functional adequacy of the valves and heart muscle. c) bypass obstructed vessels. d) open and dilate blocked coronary arteries.

assess the extent of arterial blockage. Correct Explanation: Cardiac catheterization is done in clients with angina primarily to assess the extent and the severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results.

A client is admitted to an acute care facility with pneumonia. When auscultating heart sounds, the nurse notes a fixed split of the second heart sound (S2) — a pathological split that doesn't vary with respirations. A fixed S2 split is the hallmark of:

atrial septal defect. A fixed S2 split is the hallmark of atrial septal defect. This split, which is continuous and doesn't vary with respirations, results from prolonged emptying of the right ventricle.

A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide to treat pulmonary congestion and begins a nitroprusside drip as prescribed. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. The nurse should first assess:

blood pressure. The nurse should immediately assess the blood pressure since nitroprusside and furosemide can cause severe hypotension from a decrease in preload and afterload.

In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to:

bradyrhythmia. Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope.

When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?

coldness of the left foot and ankle Explanation: Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor.

A client has undergone an amputation of three toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which leg position is contraindicated while sitting in a chair? a) extending the knees b) flexing the ankles c) elevating the legs d) crossing the legs

crossing the legs Correct Explanation: Leg crossing is contraindicated because it causes adduction of the hips and decreases the flow of blood into the lower extremities. This may result in increased pressure in the graft in the affected leg.

A young adult has been diagnosed with hypertrophic cardiomyopathy. The nurse should further assess the client for: a) abdominal pain. b) fatigue and shortness of breath. c) angina. d) hypertension.

fatigue and shortness of breath. Correct Explanation: Cardiomyopathy is a broad term that includes three major forms: dilated, hypertrophic, and restrictive cardiomyopathies. The underlying etiology of hypertrophic cardiomyopathy is unknown; it is typically observed in young men but is not limited to them. Common symptoms are fatigue, low tolerance to activity related to the low ejection fraction, and shortness of breath. Angina may be observed if coronary artery disease is present.

To prevent pulmonary emobolism in a client who has had abdominal surgery, the nurse should:

have the client perform leg exercises every hour while awake. Performing leg exercises, including ankle pumping, ankle rotation, and quadriceps setting exercises, will help prevent stasis of blood in the lower extremities, which can lead to blood clot formation.

A client has risk factors for coronary artery disease, including smoking cigarettes, eating a diet high in saturated fat, and leading a sedentary lifestyle. The nurse can coach this client to improve health by: a) withholding praise until the client changes the risky behavior. b) explaining how the risk factors lead to poor health. c) instilling mild fear into the client about the potential outcomes of the risky health behaviors. d) helping the client establish a wellness vision to reduce the health risks.

helping the client establish a wellness vision to reduce the health risks. Correct Explanation: In health coaching, unlike traditional client education techniques in which the nurse provides information, the goal of coaching is to encourage the client to explore the reasons for the behavior and establish a vision for health behavior and the way he or she can make changes to improve their health behavior and reduce or eliminate health risks. When coaching a client, the nurse does not provide information, withhold praise, or instill fear.

he nurse monitors the serum electrolyte levels of a client who is taking digoxin. Which electrolyte imbalance is a common cause of digoxin toxicity? a) hypomagnesemia b) hypokalemia c) hypocalcemia d) hyponatremia

hypokalemia Correct Explanation: Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

A client has had a stasis ulcer of the left ankle with 2+ pitting edema for 2 years. The client is taking chlorothiazide. The desired outcome of this drug for the client is: a) decreased blood pressure. b) improved capillary circulation. c) absence of infection. d) wound healing.

improved capillary circulation. Explanation: The result of chronic venous stasis is swelling and edema and superficial varicose veins. Diuretics will help reduce the swelling, thus improving capillary circulation. Although diuretics may decrease blood pressure, that is not the intended outcome of this drug.

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected? a) thin, soft toenails b) edema around the ankle c) loss of hair on the lower leg d) warmth in the foot

loss of hair on the lower leg Correct Explanation: The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin

The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention? a) low-sodium diet b) walking for 20 minutes 3 times a week c) restricting fluid intake d) elevating the feet

low-sodium diet Correct Explanation: In clients with fluid retention, sodium restriction may be necessary to promote fluid loss.

A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following prescription would pose the greatest health hazard to this client at this time? a) medication therapy b) dental care c) diet modification d) activity restrictions

medication therapy Correct Explanation: Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprosthesis are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery.

The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg, and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has: a) no apparent occlusion in the left lower extremity. b) moderate peripheral artery disease. c) mild peripheral artery disease. d) severe peripheral artery disease.

mild peripheral artery disease. Explanation: The ABI test is a noninvasive test that compares the systolic blood pressure in the arm with that of the ankle. It may be done before or after exercise. The client's highest brachial systolic pressure is divided by the left ankle systolic blood pressure to get 0.81. This score is between 0.71 and 0.90, which suggests mild peripheral artery disease. Moderate peripheral artery disease would yield a score of 0.41 to 0.70. Severe peripheral artery disease would result in a score of 0.00 to 0.40.

The nurse walks into the room and finds that a client who has just had surgery is diaphoretic, appears to have no respirations, and has a barely palpable pulse. The nurse should first: a) start cardiac compressions. b) start rescue breathing. c) open the airway. d) call a code.

open the airway. Correct Explanation: The most appropriate immediate response is to open the airway. The nurse then should look, listen, and feel for respirations. Noting none, the nurse calls a code and attempts ventilations with a bag mask or mask with a one-way valve until the full code team responds. Using standard precautions with the mask protects the nurse from exposure to possible client microorganisms.

A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:

press the right upper abdomen. Explanation: As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle

The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to prevent: a) nausea or vomiting. b) sleep disturbances during the night. c) electrolyte imbalances. d) excretion of excessive fluids accumulated during the night.

sleep disturbances during the night. Correct Explanation: When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed

Which is the most appropriate diet for a client during the acute phase of myocardial infarction?

small, easily digested meals Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated.

Considering a client's atrial fibrillation, a nurse must administer digoxin with caution because it: a) stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. b) can induce a hypertensive crisis by constricting arteries. c) affects the sympathetic division of the autonomic nervous system, decreasing vagal tone. d) can trigger proarrhythmia by increasing stroke volume.

stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. Correct Explanation: A nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, increasing the potential for new arrhythmias to develop. Digoxin doesn't constrict arteries. Although digoxin can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).

The nurse is preparing a teaching plan for a client who is being discharged after being admitted for chest pain. The client has had one previous myocardial infarction 2 years ago and has been taking simvastatin 40 mg for the last 2 years. After reviewing the lab results for the client's cholesterol levels (see chart), the nurse should: a) review the chart for lab reports of hemoglobin and hematocrit. b) ask if the client is taking the simvastatin regularly. c) instruct the client to lower the saturated fat in the diet. d) tell the client that the cholesterol levels are within normal limits.

tell the client that the cholesterol levels are within normal limits. Explanation: The serum cholesterol is within normal range for this client indicating the medication is effective. Since the cholesterol levels are within normal limits, it is likely that the client is taking the medication and asking may indicate the nurse has doubts or mistrusts that the client is taking the medication. The client does not need to change the diet at this point.

A client is in the compensatory stage of shock. Which finding indicates the client is entering the progressive stage of shock? a) heart rate of 110 bpm b) blood pressure of 110/70 mm Hg c) temperature of 99° F d) urinary output of 20 ml per hour

urinary output of 20 ml per hour Correct Explanation: In the compensatory stage of shock, the client exhibits moderate tachycardia, but as the shock continues to the progressive stage the client will have a decreased urinary output, hypotension, and mental confusion as a result of failure to perfuse and ineffective compensatory mechanisms.

As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: a) improved conductivity in the myocardium. b) antispasmodic effects on the pericardium. c) vasodilation of peripheral vasculature. d) causing an increased myocardial oxygen demand.

vasodilation of peripheral vasculature. Correct Explanation: Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart.

When assessing a client for early septic shock, the nurse should assess the client for which finding? a) cool, clammy skin b) hemorrhage c) increased blood pressure d) warm, flushed skin

warm, flushed skin Explanation: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase)

An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written a prescription to: a) limit the amount of protein in the diet prior to the cardiac catheterization. b) administer the metformin with only a sip of water prior to the cardiac catheterization. c) give the metformin before breakfast. d) withhold the metformin prior to the cardiac catheterization.

withhold the metformin prior to the cardiac catheterization. Correct Explanation: The nurse should verify that the HCP has requested to withhold the metformin prior to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system.

The nurse is developing a teaching plan for a client who will be starting a prescription for simvastatin 40 mg/day. What instructions should the nurse give the client? Select all that apply. a) "Report muscle pain or tenderness to your health care provider." b) "Take once a day in the morning." c) "Be sure to take the pill with food." d) "If you miss a dose, take it when you remember it." e) "Continue to follow a diet that is low in saturated fats."

• "Continue to follow a diet that is low in saturated fats." • "If you miss a dose, take it when you remember it." • "Report muscle pain or tenderness to your health care provider." Correct Explanation: Simvastatin is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take simvastatin in the evening, and the nurse should instruct the client that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next scheduled dose.

A client with high blood pressure is prescribed a new medication for an antihypertensive drug. When developing a client teaching plan to minimize orthostatic hypotension, which instructions should the nurse include? Select all that apply:

• "Flex your calf muscles and change positions slowly." • "When getting up from a lying position, sit for 3 to 5 minutes before standing." • "Wear elastic stockings and hold onto a stationary object when rising." Explanation: Measures that minimize orthostatic hypotension include flexing the calf muscles to boost blood return to the heart, changing positions slowly, eating a high-protein snack at night, wearing elastic stockings, and holding onto a stationary object when rising.

The nurse is developing a teaching plan for a client who will be starting a prescription for simvastatin 40 mg/day. What instructions should the nurse give the client? Select all that apply. a) "Continue to follow a diet that is low in saturated fats." b) "Report muscle pain or tenderness to your health care provider." c) "Be sure to take the pill with food." d) "If you miss a dose, take it when you remember it." e) "Take once a day in the morning."

• "If you miss a dose, take it when you remember it." • "Report muscle pain or tenderness to your health care provider." • "Continue to follow a diet that is low in saturated fats." Explanation: Simvastatin is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take simvastatin in the evening, and the nurse should instruct the client that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next scheduled dose.

A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements shows an understanding of the nurse's teaching about this disorder? Select all that apply. a) "I don't need to report any other skin problems with my fingers or hands to my practitioner." b) "I can't continue to wash dishes and do my cleaning because of this problem." c) "My hands get pale, bluish, and feel numb and painful when I'm really stressed." d) "This problem is caused by a temporary lack of circulation in my hands." e) "Medication might help treat this problem." f) "I probably got this disorder because I have lupus."

• "Medication might help treat this problem." • "My hands get pale, bluish, and feel numb and painful when I'm really stressed." • "I probably got this disorder because I have lupus." • "This problem is caused by a temporary lack of circulation in my hands." Correct Explanation: Raynaud's phenomenon causes blanching, cyanosis, coldness, numbness, and throbbing pain in the hands when the client is exposed to cold or stress. It is caused by episodic vasospasm in the small peripheral arteries and arterioles and can affect the feet as well as the hands. The phenomenon is commonly associated with connective tissue diseases such as lupus and may be alleviated by calcium channel blockers or adrenergic blockers. It does not limit the client's ability to function, although the symptoms are bothersome. Keeping the hands warm and learning to manage stressful situations effectively reduces the frequency of episodes. The disorder can progress to skin ulcerations and even gangrene in some clients, so all skin changes should be reported to the practitioner promptly

The nurse is developing a teaching plan for a client who will be starting a prescription for simvastatin 40 mg/day. What instructions should the nurse give the client? Select all that apply.

• "Report muscle pain or tenderness to your health care provider." • "If you miss a dose, take it when you remember it." • "Continue to follow a diet that is low in saturated fats." Explanation: Simvastatin is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take simvastatin in the evening, and the nurse should instruct the client that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next scheduled dose. It is not necessary to take the pill with food. The client does not need to limit greens (limiting greens is appropriate for clients taking warfarin, but the nurse should instruct the client to avoid grapefruit and grapefruit juice, which can increase the amount of the drug in the bloodstream. A serious side effect is myopathy, and the client should report muscle pain or tenderness to the health care provider (HCP)

A nurse is caring for a client who has had gastric bypass surgery. The physician encourages the client to increase mobility as soon as possible. The nurse notes edema to the right leg with skin color changes to the right lower extremity. The client reports pain at the incision site as 3 on a 0- to 10-point scale and pain to the right calf as 7 on a 0- to 10-point scale. The nurse reports the findings to the physician and suspects that the client has a deep vein thrombosis. Which intervention should she include in the plan of care? Select all that apply. a) Apply ice to the right calf. b) Elevate the right lower extremity. c) Ambulation as tolerated. d) Prepare the client for evacuation of the thrombus. e) Administer heparin infusion.

• Administer heparin infusion. • Elevate the right lower extremity. • Ambulation as tolerated. Explanation: The plan of care for clients diagnosed with a deep vein thrombosis include: anticoagulant therapy, elevation of affected extremity when sitting or lying down, application of moist heat to the affected extremity and ambulation as tolerated. Traditional approach was to keep clients on bedrest, but that is a component of Virchow's triad. There is no evidence that ambulation is contraindicated or that surgery would be included in the plan of care

The nurse is planning care for a group of elderly clients affected by orthostatic hypotension. What should the nurse should do? Select all that apply. a) Assist the clients to stand to help prevent falls. b) Place clients on bed rest. c) Teach the clients how to gradually change their position. d) Request a prescription for antihypertensive medications for clients at high risk. e) Conduct "fall risk" assessments. f) Consider the use of sequential compression devices (SCDs) for high-risk clients.

• Assist the clients to stand to help prevent falls. • Conduct "fall risk" assessments. • Consider the use of sequential compression devices (SCDs) for high-risk clients. • Teach the clients how to gradually change their position. Correct Explanation: Orthostatic hypotension is a drop in blood pressure that occurs when changing position, usually to a more upright position. Orthostatic hypotension often occurs in elderly clients, and it is a common cause of falls. Nurses must assess clients for orthostatic hypotension and assist all clients with orthostatic hypotension in standing to help prevent falls. Lower limb compression devices aid in prevention of decreased orthostatic systolic blood pressure and reduce symptoms in elderly clients with progressive orthostatic hypotension. Nurses must teach clients how to gradually change their position, and they must conduct "fall risk" assessments. Sequential compression devices may be helpful to high-risk clients and should be considered when developing the care plan. Antihypertensive medications are not necessary for clients with orthostatic hypertension and may precipitate dangerous drops in blood pressure. The clients should be encouraged to be ambulatory.

The nurse is caring for a client on hemodialysis who has an arteriovenous (AV) fistula in the right arm. When managing a client's plan of care, which instructions would the nurse determine as a priority is being completed? Select all that apply. a) Assessing the shunt by auscultating a bruit b) Avoiding all blood pressure readings and trauma to the right arm c) Wearing tight fitted shirts d) Utilizing a splint to maintain the right arm in an extended position e) Completing arm and finger exercises f) Maintaining the right arm above the heart

• Avoiding all blood pressure readings and trauma to the right arm • Assessing the shunt by auscultating a bruit • Completing arm and finger exercises Explanation: An AV fistula is a connection between an artery and a vein creating a ready source with a rapid flow of blood. The fistula is located under the skin and is used during dialysis to access the bloodstream. When managing the care of the client, instruction is needed to ensure the patency of the fistula. The client would not have any blood pressure readings, labwork drawn or trauma to the right arm. To check the fistula for adequate blood flow, the client would feel the thrill of the blood moving through the vessels and auscultate a bruit hearing the swish in the vessels. Arm and finger exercises are encouraged for blood flow.

Which of the following instructions should the nurse give to a a client with peripheral arterial occlusive disease? Select all that apply. a) Warming the fingers or toes by using an electric heating pad. b) Wearing extra socks in the winter. c) Limiting walking to one block at a time. d) Wearing clean, loose, soft cotton socks. e) Avoiding sunburn during the summer.

• Avoiding sunburn during the summer. • Wearing extra socks in the winter. • Wearing clean, loose, soft cotton socks. Explanation: A client with peripheral arterial occlusive disease is at high risk for injury. Thus, the client should be able to recognize the signs of potential thermal dangers to prevent skin breakdown. The individual should be instructed to wear clean, loose, soft cotton socks so that the feet are comfortable, air is allowed to circulate, and moisture is absorbed. In the winter or if the client reports "cold feet," the client should be encouraged to wear an extra pair of socks and a larger shoe size. Getting a sunburn during the summer puts the client at risk for tissue injury and skin breakdown.

The nurse is preparing a teaching plan for a client who recently underwent surgery for insertion of a permanent pacemaker. Which instructions should the nurse include in the teaching plan? Select all that apply.

• Check heart rate for 1 minute daily. • Report redness, swelling, or discharge at insertion site. • Avoid magnetic resonance imaging (MRI) diagnostic studies. The client with an implanted pacemaker should assess heart rate daily and report too fast or too slow rates. The nurse should instruct the client to inspect the insertion site and report signs and symptoms of infection, such as redness, swelling, and discharge. MRI studies are contraindicated in the client with a permanent pacemaker, because the magnet may move the metal pacemaker within the body, causing injury.

A client is admitted to the emergency department after complaining of acute chest pain radiating down his left arm. Which laboratory studies would be indicated? Select all that apply. a) Myoglobin b) Creatinine phosphokinase (CPK) c) Hemoglobin and hematocrit d) Troponin T and troponin I e) Serum glucose f) Blood urea nitrogen (BUN)

• Creatinine phosphokinase (CPK) • Myoglobin • Troponin T and troponin I Correct Explanation: Levels of CPK, troponin T, and troponin I elevate because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage.

A nurse is caring for a client in the immediate post-cardiac catheterization period. Which interventions should the nurse include in the client's care? Select all that apply. a) Assess the insertion site. b) Assess all peripheral pulses frequently. c) Monitor vital signs every 15 minutes for the first hour. d) Restrict the client to bed rest for 2 to 6 hours. e) Perform range-of-motion (ROM) exercises.

• Monitor vital signs every 15 minutes for the first hour. • Restrict the client to bed rest for 2 to 6 hours. • Assess the insertion site. Explanation: The key word is "immediate," indicating that care may be different throughout the recovery period. In the immediate period, the client's vital signs are typically monitored every 15 minutes for the first hour, then every 30 minutes for 2 hours or until vital signs are stable, and then every 4 hours or according to facility policy. All peripheral pulses do not require frequent assessment. (Always reflect on the word "all" in the selection.) The pulses in the affected extremity are usually assessed with every vital signs check. Clients typically remain in bed for 2 to 6 hours unless a special closure is used. The insertion site extremity is kept straight following the procedure, so ROM exercises would not be performed.

A client is admitted to the emergency department after complaining of acute chest pain radiating down his left arm. Which laboratory studies would be indicated? Select all that apply. a) Troponin T and troponin I b) Creatinine phosphokinase (CPK) c) Blood urea nitrogen (BUN) d) Serum glucose e) Myoglobin f) Hemoglobin and hematocrit

• Myoglobin • Creatinine phosphokinase (CPK) • Troponin T and troponin I Correct Explanation: Levels of CPK, troponin T, and troponin I elevate because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage.

When assessing a client for postoperative peripheral nerve damage the nurse should determine if the client has which of the following? Select all that apply. a) Swelling b) Bleeding c) Pulselessness. d) Pain. e) Altered sensation.

• Pulselessness. • Altered sensation. • Pain. Correct Explanation: Neurovascular damage may be indicated by the presence of any of the "five Ps": pain, pallor, pulselessness, paresthesia, and paralysis. Bleeding does not indicate neurovascular damage. Swelling is not a sign of peripheral nerve damage. Pain can indicate nerve damage. A thorough evaluation of the pain should help distinguish if it is expected postoperative pain or is indicative of nerve damage. Altered sensation is indicative of nerve dysfunction and needs to be fully evaluated to determine the cause. Decreased or absent pulses are indicative of vascular compromise and need to be evaluated immediately.

The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply: a) Serum myoglobin b) Serum bilirubin c) 24-hour creatinine clearance d) Serum troponin e) Electroencephalogram f) Urinalysis

• Serum myoglobin • Serum troponin Correct Explanation: Troponin and myoglobin are enzymes that are released when cardiac muscle is damaged. Serum troponin levels increase within 2 to 4 hours after MI. Serum myoglobin levels increase within ½ hour to 2 hours after MI.

• Serum myoglobin • Serum troponin Explanation: Troponin and myoglobin are enzymes that are released when cardiac muscle is damaged. Serum troponin levels increase within 2 to 4 hours after MI. Serum myoglobin levels increase within ½ hour to 2 hours after MI.

The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply: a) Urinalysis b) Serum troponin c) Serum bilirubin d) 24-hour creatinine clearance e) Serum myoglobin f) Electroencephalogram

• Serum troponin • Serum myoglobin Correct Explanation: Troponin and myoglobin are enzymes that are released when cardiac muscle is damaged. Serum troponin levels increase within 2 to 4 hours after MI. Serum myoglobin levels increase within ½ hour to 2 hours after MI.

A client has been diagnosed with Raynaud's phenomenon on the tip of the nose and fingertips. The healthcare provider (HCP) has prescribed reserpine to determine if the client will obtain relief. The client often works outside in cold weather and also smokes two packs of cigarettes per day. Which directions should be included in the discharge plan for this client? Select all that apply.

• Stop smoking. • Wear a face covering and gloves in the winter. • Report signs of orthostatic hypotension. Explanation: Vasospastic disorder (Raynaud's disease) is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips, toes, or tip of the nose, and a rebound circulation with redness and pain. The nurse should instruct the client to stop smoking because nicotine is a vasoconstrictor. An adverse effect of reserpine is orthostatic hypotension. The client should report dizziness and low blood pressure as it may be necessary to consider stopping the drug. The client should prevent vasoconstriction by covering affected parts when in cold environments

A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI? Select all that apply. a) Notched T-wave b) Pathologic Q-wave c) Prolonged PR-interval d) T-wave inversion e) Presence of a U-wave f) ST-segment elevation

• T-wave inversion • ST-segment elevation • Pathologic Q-wave Explanation: T-wave inversion, ST-segment elevation, and a pathologic Q-wave are all signs of tissue hypoxia which occur during an MI. Ischemia results from inadequate blood supply to the myocardial tissue and is reflected by T-wave inversion. Injury results from prolonged ischemia and is reflected by ST-segment elevation. Q-waves may become evident when the injury progresses to infarction.

A client who has diabetes is taking metoprolol for hypertension. What should the nurse instruct the client to do? Select all that apply. a) Take the tablets with food at same time each day. b) Report any fainting spells to the health care provider (HCP). c) Use an appropriate decongestant if needed. d) Do not crush or chew the tablets. e) Have a blood glucose level drawn every 6 to 12 months during therapy. f) Notify the health care provider (HCP) if pulse is 82 beats/minute.

• Take the tablets with food at same time each day. • Do not crush or chew the tablets. • Have a blood glucose level drawn every 6 to 12 months during therapy. • Report any fainting spells to the health care provider (HCP). Explanation: Metoprolol is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The HCP should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, and tremor.

When collaborating who has decreased arterial blood flow to the lower extremity, which goals would be most appropriate? Select all that apply.

• The extremities are warm to touch. • There are no signs of ulcer formation. • Muscle pain with activity has decreased. Explanation: The temperature of the involved lower extremity is an important outcome for a client with peripheral vascular disease. The temperature will indicate the degree to which the blood supply is getting to the extremity. Warmth indicates adequate blood supply. Pain is an indication of ischemia and lack of oxygen that results when the oxygen demand becomes greater than the supply. Therefore, a decrease in pain would indicate that oxygen is being delivered to the tissues. With adequate tissue perfusion, there are no signs of ulcer formation.

Several clients have come to the emergency department after a possible terrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply.

• Violent vomiting. • Severe diarrhea. • Abdominal pain. When arsenic overexposure occurs, the symptoms include violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis. Dehydration can lead to shock and death. After the acute phase, bone marrow depression, encephalopathy, and sensory neuropathy occur.

The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply.

• Vitamin B6. • Folate. • Vitamin B12. Vitamin B6, folate, and vitamin B12 have been shown to reduce homocysteine levels.

A client is taking clonidine for treatment of hypertension. The nurse should teach the client about which common adverse effects of this drug? Select all that apply. a) sleep disturbance b) hyperkalemia c) dry mouth d) pancreatitis e) impotence

• dry mouth • impotence • sleep disturbance Explanation: Clonidine is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects.

The nurse should assess the client with left-sided heart failure for which findings? Select all that apply. a) decreased oxygen saturation levels b) oliguria c) crackles d) dyspnea e) jugular vein distention (JVD) f) right upper quadrant pain

• dyspnea • crackles • oliguria • decreased oxygen saturation levels Explanation: Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure.

A client is taking clonidine for treatment of hypertension. The nurse should teach the client about which common adverse effects of this drug? Select all that apply.

• impotence • dry mouth • sleep disturbance Clonidine is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects.

A client with acute chest pain is receiving I.V. morphine sulfate. Which is an expected effect of morphine? Select all that apply. a) promotes reduction in respiratory rate b) reduces anxiety and fear c) prevents ventricular remodeling d) reduces blood pressure and heart rate e) reduces myocardial oxygen consumption

• reduces myocardial oxygen consumption • reduces blood pressure and heart rate • reduces anxiety and fear Explanation: Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate.

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