NUR 242 Exam 2
Which criterion is an indicator that the nitroglycerin sublingual tablets have lost their potency?
The tablets are more than 3 months old.
Which activity would the nurse teach clients to avoid after having implantation of a permanent cardiac pacemaker?
Touring a power plant
A client who has had a myocardial infarction is being discharged. The client asks the nurse when sexual activity can be resumed. Which response by the nurse is correct?
"Have you discussed this with your primary health care provider?"
Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The nurse advises the client to anticipate pain relief will begin within which period of time?
1-3 minutes
According to developmental norms for a 5-year-old child, the nurse would hold digoxin if an apical heart rate falls below which number?
70 beats/min
A client who had a myocardial infarction has runs of ventricular tachycardia. Which medication will the nurse prepare to administer?
Amiodarone
Which clinical finding indicates that a client taking digoxin may have developed digoxin toxicity?
Cardiac dysrhythmias
Which client response must the nurse monitor to determine the effectiveness of amiodarone?
Decrease in cardiac dysrhythmias
When a client who is admitted for coronary artery bypass graft (CABG) surgery asks the nurse about the purpose of pacemaker wires inserted during surgery, which explanation will the nurse give?
Prevention of slow heart rate after surgery
After a client has had a permanent demand pacemaker implanted, which finding by the nurse would be of most concern?
Pulse rate 40 beats/minute
Which action by the nurse is best when a client who had a myocardial infarction 2 days previously has a temperature of 100.2°F (37.9°C)?
Record the temperature reading and continue to monitor it
Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation?
Take pulse apically for a full minute.
When a client who has had a myocardial infarction asks the nurse about why a thallium scan has been prescribed, which answer would the nurse provide?
To establish viability of heart muscle
A client with a diagnosis of myocardial infarction asks the nurse, "What is causing the pain I am having?" Which explanation would the nurse give?
inadequate oxygenation of myocardium
After the nurse has completed discharge teaching for a client who has had a myocardial infarction, which client statement indicates that more teaching is needed?
"I will avoid physical activity"
A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." Which response would the nurse provide?
"The medication may need to be discontinued. Come to the clinic this afternoon."
A health care provider prescribes an initial loading dose of 75 mcg of oral digoxin for a child. The medication is supplied as an elixir, 50 mcg/mL. How many milliliters of solution would the nurse administer?___ mL
1.5 ml
An antidysrhythmic needs to be administered intravenously (IV) at 1000 mcg/min. The medication is available as 500 mg in 500 mL of DW. The nurse will set the volume control device to administer the medication at how many milliliters per hour?___ mL/h
60 ml
When caring for a client who has just arrived in the emergency department with possible acute coronary syndrome, which prescribed action would the nurse take first?
Ask the client about level of intensity of the chest pain
Which instructions about the use of nitroglycerin to prevent angina will the nurse provide to a client?
Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs.
Which instruction would the nurse include when teaching the client about sublingual nitroglycerin?
Common side effects include headache and low blood pressure
When the nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor, which intervention is the priority?
Defibrillate the client.
When planning discharge teaching for a client who had coronary artery bypass graft (CABG) surgery using a vein graft, which information will the nurse include?
Elevate the leg that provided the vein graft whenever you are sitting.
When caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI), which laboratory result will the nurse expect?
Elevated serum troponins I and T
When a client has a newly implanted demand pacemaker and the nurse observes spikes on the cardiac monitor at a regular rate but no QRS following the spikes, how will the finding be documented?
Failure to capture
A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats/minute. After treatment with diltiazem, which assessment indicates to the nurse that the diltiazem is effective?
Heart rate of 98 beats/minute
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the medication, the client complains of feeling dizzy. Which action will the nurse take?
Place the client in the supine position and take the vital signs
Which advice will the nurse include when teaching a client about digoxin for left ventricular failure?
Report increasing fatigue
Which information is most important to include when the nurse is teaching a client who has had an ST segment elevation myocardial infarction (STEMI) about the purpose of salt restriction?
Salt intake increases the work of the heart
When assisting with cardioversion, which action will the nurse take before delivering the prescribed shock?
Shout "clear" to all persons at the bedside
A client with heart failure is to receive digoxin. Which therapeutic effect is associated with this medication?
Slows and strengthens cardiac contractions
A client is discharged with a prescription for sustained-release nitroglycerin. Which information will the nurse provide to the client?
Swallow the capsule whole
Which finding in a client who has been admitted with myocardial infarction is most important to communicate to the health care provider?
Urine output 15 mL/h
A preterm infant is started on digoxin and furosemide for persistent patent ductus arteriosus. Which nursing assessment provides the best indication of the effectiveness of the furosemide?
Urine output exceeds fluid intake
A beta blocker is prescribed for the client with persistent ventricular tachycardia. Which response indicates that the beta blocker is working effectively?
decreased heart rate
When a client who has had a myocardial infarction suddenly develops a heart rate of 120 beats/minute, which action would the nurse take first?
Check blood pressure
A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. Which statement would the nurse identify as the purpose of the nitroglycerin patch?
Decreased cardiac preload reduces cardiac workload
A client who takes furosemide and digoxin reports to the nurse that everything looks yellow. Which response by the nurse is most appropriate?
I will hold the medication until I consult with your health care provider."
Digoxin is prescribed for a client. Which therapeutic effect of digoxin would the nurse expect?
Increased contractile force of the myocardium
When caring for a client who has had contrast medium injected into the brachial artery during a cerebral angiogram, which action will the nurse take after the procedure?
Monitor bilateral radial pulse quality
A client who has type 1 diabetes and chronic bronchitis is prescribed atenolol for the management of angina pectoris. Which clinical manifestation will alert the nurse to the fact that the client may be developing a life-threatening response to the medication?
Paroxysmal nocturnal dyspnea
A client who has paroxysmal supraventricular tachycardia reports a mild "fluttering feeling" in the chest and has a blood pressure of 110/55 mm Hg. Which potential treatment by the health care provider would the nurse question?
Synchronized cardioversion
Which finding in a client who had coronary artery bypass graft (CABG) surgery 1 day previously is most important for the nurse to communicate to the health care provider?
Temperature of 102°F (38.9°C)
The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding?
Unifocal
A client with a myocardial infarction is admitted to the cardiac intensive care unit. Which pain relief medication would the nurse expect to find on the plan of care for this client?
morphine
When teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin?
yellow vision
A client with hypertensive heart disease who had an acute episode of heart failure is to be discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate when metoprolol is administered with digoxin?
Bradycardia
The nurse teaches the parents of a 4-year-old child about the administration of digoxin elixir twice a day. Which statement indicates to the nurse the parents need further teaching?
"We should give the digoxin twice a day, at breakfast and dinner
A client is to receive 0.25 mg of digoxin intramuscularly. The ampule is labeled 0.5 mg = 2 mL. How many milliliters will the nurse administer?___ mL
1 ml
Which nursing intervention is the priority action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation?
initiating defibrillation
A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats/minute. Which action is indicated?
Administer amiodarone
When a client in the coronary care unit develops ventricular tachycardia, which action will the nurse take first?
Assess client pulse and blood pressure
When a client is experiencing acute coronary syndrome, which factor would the nurse identify as the cause of the pain experienced by a client?
Heart muscle ischemia
When a client with peripheral arterial disease returns to the nursing unit after a femoral angiogram, which action will the nurse take first?
Assess the client's affected leg
A client with left ventricular heart failure and supraventricular tachycardia is prescribed digoxin 0.25 mg daily. Which changes would the nurse expect to find if this medication is therapeutically effective? Select all that apply. One, some, or all responses may be correct.
Diuresis Decreased edema Decreased pulse rate
Which action would the nurse perform when a client is in ventricular fibrillation? Select all that apply. One, some, or all responses may be correct.
Initiating CPR Assessing the EKG Using a defibrillator Obtaining electrolytes Administering epinephrine
The nurse provides medication discharge instructions to a client who received a prescription for digoxin. Which statement by the client leads the nurse to conclude that the teaching was effective?
It will be important to check my pulse rate daily.
Digoxin is prescribed for a client with heart failure. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply. One, some, or all responses may be correct.
Nausea Yellow vision Irregular pulse
Which action would the nurse take to decrease a client's risk for sensory and cognitive disturbances after coronary artery bypass surgery?
Plan to minimize interruption of sleep at night
A client, who is currently taking digoxin 0.125 mg in the morning and alprazolam 0.5 mg twice a day, is prescribed donepezil 5 mg daily for early dementia of the Alzheimer type. Which instruction would the nurse include when teaching the client's spouse about medication administration?
Prefill a weekly medication box with the medications for the client to self-administe
Which information would be included in the discharge planning for a client who has had a new permanent pacemaker implanted above the left clavicle? Select all that apply. One, some, or all responses may be correct.
Take your pulse daily and report changes to the health care provider. Notify the health care provider about swelling or drainage at the incision. Inform airport security about the presence of a pacemaker if you are traveling.
The nurse is reviewing medication instructions with parents of an infant receiving digoxin and spironolactone. Which parental response indicates instructions have been understood?
Vomiting should be reported to the health care provider
Which activities might cause chest pain in a client with stable angina? Select all that apply. One, some, or all responses may be correct.
Walking outside on a cold day Sexual activity Smoking a cigarette Use of an oral decongestant
When teaching about prevention of coronary artery disease (CAD) for a 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg), smokes 1 pack a day of cigarettes, and has siblings with CAD, which topics are most important for the nurse to include? Select all that apply. One, some, or all responses may be correct.
Weight Tobacco use
Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin?
Potassium level of 2.3 mEq/L (2.3 mmol/L)
Which client statement indicates understanding of the side effects of nitroglycerin ointment?
"I may experience a headache."
Which action would the nurse include in the postprocedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram?
Check pedal pulses every 15 minutes postprocedure
The health care provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond?
"It decreases cardiac oxygen demand.
When a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first?
Assess pulse
An infant with congenital heart disease is prescribed digoxin and furosemide upon discharge. Which sign would the nurse instruct the parents to be alert for?
Difficulty feeding with vomiting
A client presents to the emergency department with chest pain. A myocardial infarction is suspected, and 500 mL of 5% dextrose in water (D 5W) with 50 mg of nitroglycerin intravenously (IV) has been prescribed. The nurse will monitor the client for which common side effect of nitroglycerin?
Hypotension
Which is the priority nursing intervention immediately after a client has a ventricular demand pacemaker inserted?
Monitor the heart rate and rhythm
Digoxin and verapamil are prescribed to manage a client's cardiac dysrhythmia. The nurse will monitor the client for signs and symptoms of which adverse effect?
Myocardial depression
When caring for a client with acute coronary syndrome who has frequent premature ventricular complexes (PVCs), the nurse will be most concerned about PVCs occurring in which phase of the cardiac cycle?
T wave
Which information would the nurse include when teaching a client with coronary artery disease about aspirin therapy? Select all that apply. One, some, or all responses may be correct.
Take aspirin with food. Report ringing in the ears. Monitor and report excessive bleeding and bruising. Avoid over-the-counter pain medications that contain aspirin.
The nursing manager issued orders to take the utmost care of a client with myocardial infarction and expects the staff to obey and follow the rules immediately. Which type of decision-making is the manager using?
The autocratic method results in rapid decision-making and is more appropriate in a crisis situation. Optimizing decision making is when the nurse considers both pros and cons of each position. Laissez-faire is a "hands-off" approach, which is taken by manager who chooses to do nothing when intervention is indicated. The bureaucratic style is focused on organizational rules and policies.
Which physiological process causes temperature elevation after a client has had a myocardial infarction?
Tissue necrosis and inflammation
The nurse is preparing to apply nitroglycerin ointment. Before applying the ointment, which action will the nurse take?
Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount.
When a client with angina is scheduled to have a cardiac catheterization, which explanation would the nurse give about the purpose of the procedure?
Visualize the disease process in the coronary arteries
When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin?
Vitamin K
A health care provider prescribes digoxin for a client. The nurse teaches the client to be alert for which common early indication of acute digoxin toxicity?
Vomiting
After the nurse has presented a staff education session on the use of adenosine for supraventricular tachycardia, which statement by a staff member indicates that the teaching has been effective?
We will need a crash cart available at the client's bedside.
Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct.
Wearing a medical alert bracelet Initiating bleeding precautions Refraining from estrogen therapy Obtaining routine prothrombin times Notifying providers of anticoagulation
Three days after having a myocardial infarction, a client displays an outburst of anger and tells the nurse to get out of the room. Which is the most appropriate nursing action?
Agree to leave and check back with the client later
Which certification would the emergency nursing staff member possess to perform defibrillation or cardioversion and special resuscitation for clients who sustained injuries in a tsunami?
Advanced Cardiac Life Support (ACLS)
A client's cardiac monitor indicates multiple multifocal premature ventricular complexes (PVCs). Which medication is indicated for treatment of ventricular dysrhythmias?
Amiodarone
When caring for an older adult with coronary artery disease, which modification in the plan of care would the nurse make because of the client's age?
Assess for less common anginal symptoms like shortness of breath and gastric discomfort.
Which client would be at an increased risk for coronary artery disease (CAD)? Select all that apply. One, some, or all responses may be correct.
Client with total cholesterol 250 mg/dL and LDL cholesterol 120 mg/d
After a myocardial infarction, a client asks the nurse, "What's the chance of my having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse?
Identifying the concerns and helping the client explore feelings
To determine whether a client is experiencing acute coronary syndrome (ACS), which component of the electrocardiogram would the nurse analyze?
ST segment
When a client has supraventricular tachycardia that has persisted despite treatment with vagal maneuvers and medications, which collaborative intervention will the nurse anticipate to treat the dysrhythmia?
Synchronized cardioversion
The nurse is monitoring a 6-year-old child for toxicity precipitated by digoxin. Which sign of digoxin toxicity would the nurse monitor for?
Vomiting
When a client comes to the emergency department with moderate substernal chest pain that is unrelieved by rest and nitroglycerin, which prescribed action has the highest priority?
Obtain a 12-lead electrocardiogram (ECG).
Sublingual nitroglycerin has been prescribed for a client with unstable angina. Which client response indicates that nitroglycerin is effective?
Pain subsides as a result of arteriole and venous dilation.
Which lifestyle advice does the nurse give to a client when oral digoxin therapy is initiated? Select all that apply. One, some, or all responses may be correct.
Bran can decrease digoxin absorption. Digoxin should not be taken with hawthorn supplements. Ginseng may cause a dangerous increase in digoxin levels in the blood. Medications that lower serum potassium or magnesium can cause digoxin toxicity
The nurse is discussing discharge instructions with a client who had a myocardial infarction. The client asks, "When will it be safe to have sex again?" Which response by the nurse is best?
"One indication that your heart has healed enough for sexual activity is being able to climb two flights of stairs."
Which action will the nurse take when caring for a client who has just returned from having a femoral angiogram?
Assess the catheter insertion site at frequent intervals
Which information about a client who is being discharged 3 days after having an ST segment elevation myocardial infarction (STEMI) and coronary artery stent placement indicates that a home health referral may be needed at discharge?
Client reports frequently forgetting to take medications
When a client is diagnosed with microvascular angina, which topics would the nurse include in client teaching? Select all that apply. One, some, or all responses may be correct.
Use of daily aspirin Tobacco cessation techniques Management of usual daily activities to avoid symptoms Use of nitroglycerin to prevent and treat anginal symptom
When caring for a client in the third trimester of pregnancy with a history of myocardial infarction, which statement made by the client would concern the nurse the most?
"I have been using cough drops to try and get rid of my cough.
After the nurse has finished teaching a 50-year-old female client about symptoms of coronary artery disease in women, which statement indicates that the teaching has been effective?
"I will call my health care provider about any unusual fatigue"
Which response by the nurse is best when a client who has had an ST segment elevation myocardial infarction (STEMI) asks about the resumption of sexual activity?
"Sexual activities can be safely resumed after an exercise stress test with no heart symptoms"
A client with heart block who requires implantation of a permanent pacemaker expresses concern about having an increased risk of accidental electrocution. How would the nurse respond?
"The voltage emitted is not strong enough to electrocute."
A child is prescribed 1.2 mL of digoxin twice a day. The medication label reads "Digoxin 0.125 mg/mL." What is the total amount of medication, in milligrams, the child takes each day?____ mg
0.3
After an admission for acute coronary syndrome (ACS), a client is asked to notify the nursing staff before getting out of bed. After finding the client up walking alone in the hallways an hour later, which response by the nurse is best?
Sometimes after ACS, people feel dizzy and fall.
A client with midsternal pain presents to the emergency department. Vital signs are stable. Which form of nitroglycerin would the nurse anticipate giving initially?
Sublingual spray
Which assessment finding by the nurse caring for a client with new-onset atrial fibrillation would be most important to communicate to the health care provider?
Sudden vision change
A client with coronary artery disease and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of shortness of breath. Which action by the nurse is best?
Suggest that the client call 911
After the home health nurse obtains a radial pulse rate of 136 beats/minute in a client with chronic atrial fibrillation, which action would the nurse take next?
Take the client's apical pulse for a full minut
Which topics would be included when teaching a client with heart failure who will be discharged with a new prescription for digoxin? Select all that apply. One, some, or all responses may be correct.
Take your radial pulse daily and write it down Notify the health care provider if you develop any vision changes Call the health care provider if your pulse is irregular or less than 60 beats/minute
When a client with a possible past history of myocardial infarction has an electrocardiogram (ECG) prescribed and asks the nurse the purpose of the ECG, which response by the nurse is accurate?
The ECG will show if there has been damage to the heart muscle
Which finding in a client who has just arrived in the cardiac intensive care unit after having coronary artery bypass grafting (CABG) requires the most rapid action by the nurse?
The serum potassium level is 3.1 mEq/L (3.1 mmol/L).
When a client who is scheduled to have coronary artery bypass graft surgery asks the nurse what benefit can be expected from the surgery, which response would the nurse make?
This surgery significantly decreases symptoms in most clients
Which laboratory value will be most important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)?
Troponin T (cTnT)
A client is given a loading dose of digoxin and placed on a maintenance dose of digoxin 0.25 mg by mouth daily. Which responses would the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved?
Resolution of heart failure
Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the health care provider?
Right arm weakness
Which information would the nurse include when teaching a client about resumption of sexual activity after having a myocardial infarction?
Select familiar settings for sexual activity.
Which action by the nurse is most important when preparing for cardioversion of a client with atrial fibrillation?
Set synchronizer switch on defibrillator to the "on" position
Which clinical manifestations are more likely to occur in women with coronary artery disease compared with men? Select all that apply. One, some, or all responses may be correct.
Severe fatigue Sense of unease Shortness of breath
When a client is admitted to the coronary care unit with a diagnosis of ST segment elevation myocardial infarction, how will the nurse expect the client to describe the pain?
Severe, intense chest pain
The nurse is providing discharge medication teaching to a client who will be taking furosemide and digoxin after discharge from the hospital. Which information is important for the nurse to include in the teaching plan?
Signs and symptoms of digoxin toxicity
Which assessment finding indicates a need for the nurse to consult with the health care provider before administering the prescribed metoprolol to a client with stable angina?
Sinus bradycardia, rate 54 on monitor
After experiencing acute coronary syndrome, a client who has begun an exercise program asks the nurse how to tell whether the exercise is helping. Which response would the nurse make?
You will be able to walk progressively longer distances before tiring.
The nurse is instructing a community group regarding risk factors for coronary artery disease. Which risk factor cannot be modified?
Heredity
Which nursing action has the highest priority when caring for a client who has had an acute myocardial infarction (MI)?
Monitor for cardiac dysrhythmias.
When a client with type 1 diabetes develops heart failure, digoxin is prescribed. Which nursing action is important to include when planning care?
Monitor the client for cardiac dysrhythmias.
The nurse preceptor is evaluating the nurse who is preparing to administer digoxin intravenously (IV) to a client. Which intervention by the nurse would require the preceptor to stop the nurse?
Piggybacking the digoxin in an existing infusion
The nurse is preparing a teaching plan for a client prescribed nitroglycerin sublingual. Which would the nurse include in the teaching?
Place the tablet under the tongue or between the cheek and gums.
When the pulse rate for a client with a recent myocardial infarction increases from 70 beats/minute to 135 beats/minute while climbing the stairs, which instruction would the cardiac rehabilitation nurse give to the client?
Stand still and rest.
Which object would the nurse teach the client with a newly implanted pacemaker to avoid?
Strong magnet (can change setting and function of the pm) Microwave is not a concern remote control devices are not contraindicated Mobile phones should be used in the ear opposite the pacemaker.
Which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain?
Relieved by sublingual nitroglycerin
Which instruction would the nurse include in a teaching plan for nitroglycerin patches?
Remove a previous patch before applying the next one."
A 20-year-old client seen in the emergency department reports frequent "skipped heart beats," and the nurse notes frequent premature ventricular complexes (PVCs) on the cardiac monitor. Which action would the nurse take first?
Ask the client about use of caffeine or stimulant drugs
Which nursing action has the highest priority when caring for a client receiving nitroglycerin for the treatment of angina?
Asking the client to sit or stand slowly
The cardiac monitor reveals several runs of ventricular tachycardia. Which medication is used to treat this dysrhythmia?
Amiodarone
When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first?
Attach the cardiac monitor
Which physiological response explains why elevation in body temperature occurs in clients who experience acute coronary syndrome?
Inflammatory response
Which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker?
Third degree heart block
When treating clients for osteoporosis, which medication has a side effect of atrial fibrillation when infused too quickly?
Zoledronic acid
Which clinical finding would the nurse expect for a client with hypertensive emergency?
severe, pounding headache
Which laboratory test is most important for the nurse to monitor when a client is admitted with acute coronary syndrome?
troponin
When preparing to give medications to a client, the nurse notes a prescription for digoxin 2.5 mg by mouth daily. The digoxin is supplied as 0.125 mg tablets. Which action would the nurse take?
Consult with the primary health care provider.
Which instructions will the nurse give a client for whom nitroglycerin tablets are prescribed?
Ensure that the medication is stored in its original dark container
A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The registered nurse identifies that which items on the client's care plan are appropriate for a licensed practical nurse (LPN) to perform? Select all that apply. One, some, or all responses may be correct.
Help the client ambulate when required. Monitor the client's vitals every 30 minutes. Administer adequate oral fluids to the client.
Which nursing interventions are important when caring for clients receiving intravenous (IV) digoxin? Select all that apply. One, some, or all responses may be correct.
Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level.
A client with myocardial infarction is brought to the emergency department, and the primary health care provider recommends the placement of a stent. The client is incompetent to understand the situation. Which model would the nurse manager think would be beneficial in this situation?
Patient-benefit model
The clinic nurse receives a call from the mother of an infant prescribed digoxin. The mother reports she forgot whether she gave the morning dose of digoxin. Which response by the nurse is most appropriate?
Skip this dose and give it at the next prescribed time
When discharging a client who has had insertion of a coronary artery stent, the nurse will instruct the client to seek immediate medical attention for which signs and symptoms? Select all that apply. One, some, or all responses may be correct.
Unexplainable profuse diaphoresis Indigestion not relieved by antacids Fatigue the day after a rigorous walk Acute chest pain after rigorous exercise Continued chest pain after nitroglycerin use
After the nurse teaches a group of women about coronary artery disease (CAD) and myocardial infarction (MI), which statement by the women indicates that the teaching has been effective?
Unusual fatigue is a common symptom of CAD in women.
A health care provider prescribes morphine for a client being treated for myocardial infarction. Which physiological response will occur if the client experiences the intended therapeutic effect of morphine?
decreased workload of the heart
A client has a prescription for a sublingual nitroglycerin tablet. Which technique will the nurse teach the client to use?
Place the pill under the tongue and let it dissolve.
A client has been given a prescription for furosemide 40 mg every day in conjunction with digoxin. Which concern would prompt the nurse to ask the health care provider about potassium supplements?
Digoxin toxicity occurs rapidly in the presence of hypokalemia
When teaching a group of female clients about clinical manifestations of coronary artery disease that are more common in women, which symptoms would the nurse include? Select all that apply. One, some, or all responses may be correct.
Dyspnea Indigestion Unusual fatigue
Which finding on an electrocardiogram for a client complaining of chest pain indicates possible acute myocardial infarction?
Elevated ST segments
The nurse is examining the nails of four different clients. Which client would the nurse anticipate having a myocardial infarction?
Generalized pallor of the nail bed and white-colored nails are signs of a myocardial infarction, as noted in client A. Diffuse yellow to brown discoloration and yellow-brown nail color are signs of jaundice, as noted in client B. Dark red nails are signs of polycythemia vera, as noted in client C. Diffuse blue discoloration that blanches with pressure and blue nail color are signs of methemoglobinuria, as noted in client D.
A client with a myocardial infarction receives intravenous nitroglycerin to relieve pain. The nurse will assess for which medication side effect?
Hypotension
The onset of action of sublingual nitroglycerin tablets is rapid (1-3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.
Hypotension
The nurse provides discharge teaching to a client who has received prescriptions for digoxin, furosemide, and a 2-g sodium diet. Which statement from the client indicates that further teaching is needed?
I can use a little table salt on my food as long as I do not use it when cooking food.
Which action would the nurse take before developing the teaching plan for a client who has had a myocardial infarction?
Identify the learning needs of the client
A health care provider prescribes tissue plasminogen activator (t-PA) to be administered intravenously over 1 hour for a client experiencing a myocardial infarction. Which assessment component can identify problems caused by this medication's effect?
Intravenous insertion site
A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day?
Maintaining potassium levels
Metoprolol
Metoprolol is indicated for the control of a blood pressure of 176/96 and a pulse of 100, which increases the cardiac workload and may lead to myocardial ischemia. Albuterol, a bronchodilator, is not the priority at this time; its administration may be delayed until the blood pressure is controlled because side effects of this medication include tachycardia and hypertension. Warfarin, an anticoagulant, is not the priority at this time; the international normalized ratio (INR) is within the therapeutic range of 2 to 3. A slight temperature increase is an expected response to a myocardial infarction; however, the administration of the antipyretic acetaminophen is not the priority. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the hospital record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and nurse/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
When the emergency department nurse is caring for a client with acute coronary syndrome who reports severe crushing chest pressure, which prescribed medication is best for the nurse to administer?
Morphine sulfate 4 mg intravenously
After the nurse teaches a client with coronary artery disease about healthy food choices, which dietary choices by the client indicate that the teaching was effective? Select all that apply. One, some, or all responses may be correct.
Olive oil Whole-grain bread Vegetables and fruits
When caring for a client who is hospitalized for an acute myocardial infarction, which prescription by the health care provider would the nurse question?
Rectal suppository as needed for constipation
The nurse has administered sublingual nitroglycerin. Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin?
Relief of anginal pain
Which action would the nurse take first when using an automated external defibrillator (AED) for a pulseless and unresponsive client?
Remove any medication patches
Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider?
Premature ventricular contractions
Which diagnostic test is most important to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome (ACS)?
12-lead electrocardiogram (ECG)
The spouse of a client who has been newly diagnosed with angina tells the nurse, "I guess I'm going to have to cook 2 meals, one for my spouse and one for myself." Which response would the nurse make?
A heart-healthy diet includes foods that most people would enjoy eating.
The spouse of a client who had coronary artery bypass graft (CABG) surgery asks why there is a dressing on the client's left leg. Which explanation would the nurse give?
A vein in the leg was used to bypass the coronary artery
When a client with acute coronary syndrome (ACS) is admitted to the coronary intensive care unit, which topic is a priority to include in teaching?
Need to report any chest discomfort to the nurses
Which behavior by a client who has had an ST-segment-elevation myocardial infarction indicates that the nurse's actions to improve client autonomy have been successful?
Active participation in providing self-care
A client who has atrial fibrillation with rapid ventricular response is started on a continuous heparin infusion. Which clinical finding enables the nurse to conclude that the heparin therapy is effective?
An activated partial thromboplastin time (aPTT) is twice the usual value.
Which finding in a client with a diagnosis of stable angina is most important for the nurse to communicate to the health care provider?
Angina episodes are occurring more frequently
Which assessment will the nurse conduct before administering digoxin to a client?
Apical heart rate
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. Which medication is indicated to prevent progression to a myocardial infarction?
Aspirin
The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. Which action would the nurse take?
Assess for obstructions in the chest tube
When the nurse is caring for a client who has just arrived in the intensive care unit after coronary artery bypass graft surgery, which finding would be of most concern?
Atrial fibrillation, rate 112 beats/minut
Which finding for a client with acute coronary syndrome who is walking in the hallway will be most important to communicate to the health care provider?
Blood pressure drops from 130/72 mm Hg to 122/60 mm Hg with ambulation
A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item would the nurse teach the mother to use when administering the medication?
Calibrated syringe
Which nursing interventions promote safe administration of digoxin in a child diagnosed with heart failure? Select all that apply. One, some, or all responses may be correct.
Checking for compliance with the client's medication regimen Monitoring the client's serum potassium and magnesium levels regularly Calculating the correct dosage form, prescribed amounts, and the prescriber's prescription Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly
Which finding about a client's angina is most important for the nurse to communicate to the health care provider?
Continues after rest and nitroglycerin
Which action would the nurse take when assessing an infant on digoxin who has an apical pulse of 88 beats per minute?
Notify the health care provider immediately
Which is the priority intervention for the unconscious client in ventricular fibrillation?
Defibrillation
One week after being hospitalized for an acute myocardial infarction, a client reports nausea and loss of appetite. Which of the client's prescribed medications would be withheld and the health care provider notified?
Digoxin
When planning care for a client who has just returned to the nursing unit after placement of a coronary artery stent that was accomplished via access through the femoral artery, which complication is a priority for the nurse to prevent?
Hematoma formation
Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. Which statement by the client indicates the teaching was effective?
I should take one tablet before attempting activity that has caused angina."
A client who has been diagnosed with a myocardial infarction receives digoxin, fluoxetine, morphine, and docusate sodium. Which medication would the nurse identify as a risk factor for straining due to constipation?
Morphine
The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the medication of choice for this client?
Morphine sulfate
A client, admitted to the cardiac care unit with a myocardial infarction, complains of chest pain. Which intervention will be most effective in relieving the client's pain?
Morphine sulfate 2 mg IV