UWorld Cardiovascular

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation? 1. B-type natriuretic peptide (BNP) 1382 pg/mL [1382 pmol/L] 2. Flat jugular veins when seated at a 45-degree angle 3. Sodium 150 mEq/L [150 mmol/L] 4. Urine output greater than 100 mL/hr

1 Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of left ventricular filling pressure elevation and mortality. A normal BNP level is <100 pg/mL [<100 pmol/L]. The nurse would expect a high BNP in a client exhibiting symptoms of acute decompensated heart failure. (Option 2) Jugular veins should normally flatten and disappear as the client is raised to an upright position. Jugular venous distension present above a 45-degree seated position indicates fluid volume excess and elevated cardiac filling pressures that occur with heart failure. (Option 3) Normal sodium level is 135-145 mEq/L [135-145 mmol/L]. Serum sodium can be normal or low in heart failure clients. Low levels are due to dilution from excess free water. (Option 4) Urine output of 100 mL/hr should be adequate to maintain fluid volume status. Inadequate urine output may cause fluid retention and volume overload, precipitating an exacerbation of heart failure. A state of low cardiac output may also decrease renal perfusion, resulting in renal dysfunction and decreased urine output. Diuretic therapy is the mainstay treatment for fluid volume overload. The nurse should expect to see an increase in urine output in response to diuretic administration. Educational objective: The nurse should assess the BNP level in clients admitted with heart failure exacerbations. Elevated BNP levels indicate increased ventricular stretch and correlate with severity of heart failure and fluid volume overload. Heart failure clients may also present with jugular venous distension, low serum sodium, and decreased urine output.

The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1. Chest tube output of 175 mL in past hour [40%] 2. International Normalized Ratio (INR) of 1.5 [14%] 3. Temperature of 100.3 F (37.9 C) [14%] 4. Total urine output of 85 mL over past 3 hours [30%]

1 Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products. (Option 2) Clients who receive a mechanical valve replacement will be started on anticoagulants. A therapeutic INR is 2.5-3.5. This client just had surgery and so has not received enough anticoagulation to get the INR to a therapeutic level. (Option 3) Although this is an abnormal temperature, it is not as high a priority as the blood loss. The nurse should continue to monitor and administer prescribed postoperative antibiotics. (Option 4) Normal urine output is 30 mL/hr. This urine level is just 5 mL below normal. The nurse should continue to monitor. Educational objective: Postoperative blood loss >100 mL/hr should be reported to the HCP immediately. The client may have a compromised suture site and can rapidly become hemodynamically unstable.

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency? 1. Brownish, hardened skin on lower extremities 2. Diminished peripheral pulses 3. Nonhealing ulcer on lateral surface of great toe 4. Shiny, hairless lower extremities

1 Chronic venous insufficiency (CVI) occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and into the surrounding tissues, where tissue enzymes break down red blood cells. The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery (Option 1). Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. (Options 2, 3, and 4) Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with peripheral arterial disease due to hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues. Educational objective: Chronic venous insufficiency occurs when the valves in the veins of the lower extremities fail to keep blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on the extremities and venous leg ulcers (commonly on the inside of the ankle).

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD? 1. Head of the bed elevated to a 45-degree angle 2. Head of the bed elevated to a 60-degree angle 3. Head of the bed elevated to a 90-degree angle 4. Head of the bed flat

1 Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a 30- to 45-degree angle. The nurse will observe for distension and prominent pulsation of the neck veins. The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload. (Options 2 and 3) JVD may still be present at 60- and 90-degree angles if marked fluid overload is present. Placement this high might miss mild to moderate JVD. (Option 4) JVD may be present while the client is flat. This is not considered abnormal, and the client with possible fluid overload or respiratory issues may not be able to lie flat. Educational objective: The nurse should position the client with the head of the bed at a 30- to 45-degree angle to assess for the presence of JVD.

The nurse receives hand-off report on assigned clients. Which client should the nurse assess first? 1. Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler 2. Client with chronic venous insufficiency who has edema and brown discoloration of the lower extremities 3. Client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless extremity 4. Client with peripheral arterial disease who reports severe cramping pain in the calf with activity such as walking

1 Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately. (Option 2) Chronic venous insufficiency is the inability of the leg veins to efficiently pump blood back to the heart. It can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected manifestations, so this is not the priority assessment. (Option 3) Gangrene of the foot is a complication of peripheral arterial disease (PAD) associated with decreased blood flow to the extremity. Coolness of the skin and shiny, hairless legs, feet, and toes are expected manifestations of PAD, so the nurse would not assess this client first. (Option 4) Intermittent claudication is leg pain caused by decreased blood flow to the muscles that reoccurs during activity such as walking and dissipates with rest. It is an expected manifestation of PAD of the lower extremities, so the nurse would not assess this client first. Educational objective: Absent or decreased volume in the peripheral pulses distal to the graft can indicate compromised circulation or graft occlusion and should be reported to the health care provider immediately.

A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? 1. If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP 2. Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the HCP 3. It will be 6 months before the heart is healthy enough for sexual activity 4. The client will be ready for sexual activity after completion of cardiac rehabilitation

1 Sexual counseling is important for cardiac clients, yet can be difficult for clients and HCPs to discuss and is often neglected. Clients' concern about resumption of sexual activity can prove to be more stressful than would be the activity itself. The nurse should encourage clients to discuss concerns with the HCP; in general, if a client can walk 1 block or climb 2 flights of stairs without symptoms, the client can resume sexual activity safely. (Option 2) The use of erectile agents is contraindicated if the client is consuming any form of nitrates. (Option 3) Resumption of sexual activity depends on the emotional readiness of the client and the client's partner and on the HCP's assessment of recovery. In general, it is safe to resume sexual activity 7-10 days after an uncomplicated MI. (Option 4) The client may participate in cardiac rehabilitation, but this should not impact the ability to engage in sexual activity, especially if the client remains asymptomatic. Educational objective: It is important to educate clients and their partners about sexual activity after an MI. Generally, it is safe for clients to consider resumption of sexual activity when they can walk 1 block or climb 2 flights of stairs without symptoms.

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline 2. 2 days postcoronary bypass graft surgery with a white blood cell count of 18,000/mm3 (18.0 × 109/L) 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

1 The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival. (Option 2) An elevated white blood cell count (>11,000/mm3 [11.0 x 109/L]) could be caused by an underlying infection or the stress of the surgery. This needs to be assessed as soon as possible, but it does not take priority over the possible limb loss with graft occlusion. (Option 3) A decreased ejection fraction (normal 55%-70%) results in decreased cardiac output and inability to meet oxygen demand, leading to shortness of breath and activity intolerance. The nurse should assess lung sounds. However, this is an expected finding, so the nurse does not need to assess this client first. (Option 4) Subcutaneous emphysema is air in the tissue surrounding the chest tube insertion site and can occur in a client with a pneumothorax. The nurse should assess lung sounds and palpate to determine the degree of emphysema. However, this is an expected finding, so the nurse does not need to assess this client first. Educational objective: A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity in a client who is postoperative abdominal aortic aneurysm repair can indicate the presence of an arterial or graft occlusion and poses the greatest threat to survival.

The nurse observes the rhythm shown in the exhibit on a client's cardiac monitor. The client reports palpitations and lightheadedness. Which intervention does the nurse anticipate? Click on the exhibit button for additional information. ECG: SVT 1. Adenosine IVP 2. Atropine IVP 3. Defibrillation 4. External pacing

1 This client is experiencing paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced cardiac output such as hypotension, palpitations, dyspnea, and angina. Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of choice for PSVT treatment. Due to its very short half-life, adenosine is administered rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be given twice if previous administration is ineffective. Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used. (Option 2) Atropine is an anticholinergic agent used to increase heart rate in clients with symptomatic bradycardic (<60/min) rhythms. (Option 3) Defibrillation is used only in clients with ventricular fibrillation and pulseless ventricular tachycardia. Cardioversion would be considered if drug therapy is ineffective for PSVT. (Option 4) External pacing is indicated in symptomatic bradycardic (<60/min) rhythms. Educational objective: The drug of choice in clients with PSVT is adenosine. It is given rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be administered 2 more times if previous administration is ineffective.

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply. 1. "I need to eat less red meat and more fresh vegetables." 2. "I'll limit drinking soda to only one at a time as an occasional treat." 3. "I'm going to replace potato chips with fruit during meals and snacking." 4. "I'm really going to miss drinking as much milk as I normally do." 5. "Taking the salt shaker off the table should be enough to reduce my sodium intake."

1, 2, 3 The Dietary Approaches to Stop Hypertension (DASH) diet is often suggested to clients with hypertension due to its ability to reduce blood pressure. The diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats, which all contribute to increased blood pressure. The DASH diet focuses on: - Including fresh fruits and vegetables, and whole grains in the daily diet - Choosing fat-free or low-fat dairy products - Choosing meats lower in cholesterol (eg, fish, poultry) and alternate protein sources (eg, legumes) instead of red meats (Option 1) - Limiting intake of sweets, foods high in sodium (eg, potato chips, frozen meals, canned foods), and sugary beverages to the occasional treat (Options 2 and 3) (Option 4) Limiting milk intake is unnecessary; however, the nurse may need to educate the client about choosing low-fat or skim milk over whole milk. (Option 5) Taking the salt shaker off the table may be a good first step in reducing sodium intake. However, it will not be enough as salt is found in many foods. Educational objective: The Dietary Approaches to Stop Hypertension (DASH) diet is often recommended to reduce blood pressure in clients with hypertension. The client is taught to limit intake of sugar, sodium, cholesterol, and trans or saturated fats, and instead choose healthier options (eg, fresh fruit and vegetables, low-fat dairy products).

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply. 1. Amphetamine use 2. Cigarette smoking 3. Cold exposure 4. Deep sleep 5. Sexual intercourse

1, 2, 3, 5 Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: - Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) - Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload - Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) - Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release - Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction - Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium (Option 4) Deep sleep doesn't increase oxygen demand. Educational objective: Angina pectoris is chest pain caused by myocardial ischemia. Any factor that increases oxygen demand or decreases oxygen supply may deprive the myocardium of necessary oxygen needed to function effectively.

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply. 1. Client may be required to lie flat for several hours following the procedure 2. Client may feel warm or flushed when contrast dye is injected during the procedure 3. Client should expect to stay in the hospital for 1-3 days following the procedure 4. Client should not eat or drink anything for 6-12 hours before the procedure 5. Client will receive general anesthesia and will not be awake during the procedure

1, 2, 4 A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: 1. Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) (Option 4) 2. The client may feel warm or flushed while the contrast dye is being injected (Option 2) 3. Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis (Option 1) (Option 3) If the procedure is just a diagnostic study, the client often goes home the same day. Hospitalization for 1-3 days may be required if angioplasty or stent placement is performed. (Option 5) General anesthesia is not used during coronary angiography. Sedating medications are given during the procedure. Educational objective: Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed.

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. 1. Capillary refill is less than 3 seconds 2. Pulse pressure is narrowed 3. Systolic blood pressure drops only when standing 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020

1, 4, 5 This client's initial vital signs show tachycardia and hypotension, which are classic signs of hypovolemia. Normal capillary refill is less than 3 seconds and is an indication of normal hydration and perfusion (Option 1). Obligatory urine output is 30 mL/hr, and this client has 90 mL/hr. Urine output is one of the best indicators of adequate rehydration (Option 4). The urine specific gravity is within a normal range (1.003 to 1.030), which can indicate normal hydration (Option 5). (Option 2) Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock and would not indicate adequate rehydration. The client arrived with a narrow pulse pressure already. (Option 3) This is indicative of orthostatic vital signs. When a client stands, the body normally vasoconstricts to maintain the blood pressure from the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted, and there is no compensatory mechanism left to adjust to the position change. Educational objective: Signs of adequate hydration are normal urine specific gravity (1.003 to 1.030), adequate volume of urine output (>30 mL/hr), and capillary refill of less than 3 seconds. Pulse pressure narrows in shock, and positive orthostatic vital signs (decreasing systolic blood pressure and rising heart rate) with position change indicate dehydration.

The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client? 1. How to transmit the readings over the phone 2. Keep a diary of activities and any symptoms experienced 3. Refrain from exercising while wearing the monitor 4. The monitor may be removed only when bathing

2 A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities. Client instructions include the following: 1. Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances 2. Do not bathe or shower during the test period (Option 4) 3. Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record (Option 3) (Option 1) The data are not generally transmitted over the phone. The client simply takes the monitor back to the HCP's office. Educational objective: The nurse should instruct the client with a Holter monitor to keep a diary of activities and any symptoms that occur while wearing it. The client should also be taught not to bathe during the testing period but to continue all other normal activities.

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse? 1. Client reports chest pain that is worse with deep inspiration 2. Distant heart tones and jugular venous distension 3. ECG showing ST-segment elevations in all leads 4. Pericardial friction rub auscultated at the left sternal border

2 Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). Increased pericardial fluid places pressure on the heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-threatening without immediate intervention. When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest. (Option 1) In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside table) to lean on for comfort. (Option 3) ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in only localized leads (depending on which vessel is occluded). (Option 4) Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium rubbing together to create a characteristic high-pitched, leathery, and grating sound. Educational objective: Nurses caring for clients with pericarditis should monitor for, and immediately report, signs of cardiac tamponade (eg, jugular venous distension, distant heart sounds, hypotension), a life-threatening complication occurring from increased pericardial fluid volume.

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? 1. "I'm not worried about the device firing now because I know it won't hurt." 2. "I will let my daughter fix my hair until my health care provider says I can do it." 3. "I will look into public transportation because I won't be able to drive again." 4. "I will notify my travel agent that I can no longer travel by plane."

2 An implantable cardioverter defibrillator (ICD) can sense and defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias that may occur after defibrillation. The ICD consists of a lead system placed into the endocardium via the subclavian vein. The pulse generator is implanted subcutaneously over the pectoral muscle. Postoperative care and teaching are similar to those for pacemaker implantation. Clients are instructed to refrain from lifting the affected arm above the shoulder (until approved by the health care provider) to prevent dislodgement of the lead wire on the endocardium (Option 2). (Option 1) Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest. (Option 3) Driving may be approved by the health care provider after healing has occurred. Long-term decisions are based on the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs. (Option 4) Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications while traveling. Educational objective: After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system.

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply. 1. "Do not take car rides longer than 4 hours for at least 3-4 weeks." 2. "Drink plenty of fluids every day and limit caffeine and alcohol intake." 3. "Elevate legs on a footstool when sitting and dorsiflex the feet often." 4. "Resume your walking program as soon as possible after getting home." 5. "Sit in a cross-legged position for 5-10 minutes to improve circulation."

2, 3, 4 A deep venous thrombosis (DVT) is a blood clot (ie, thrombus) formed in large veins, generally of the lower extremities. Risk factors for DVT include venous stasis, blood hypercoagulability, and endothelial damage. Therefore, discharge teaching for a client with resolved DVT emphasizes interventions to promote blood flow and venous return (eg, exercise, smoking cessation) to prevent reoccurrence. Interventions to prevent DVT reoccurrence include: - Obtain adequate fluid intake and limit caffeine and alcohol intake to avoid dehydration because dehydration increases the risk for blood hypercoagulability (Option 2). - Elevate the legs when sitting and dorsiflex the feet often to reduce edema and promote venous return (Option 3). - Resume an exercise program (eg, walking, swimming) and change positions frequently to promote venous return (Option 4). - Stop smoking to prevent endothelial damage and vasoconstriction. - Avoid restrictive clothing (eg, tight jeans), which interferes with circulation and promotes clotting. - Consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels. (Option 1) Clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour). (Option 5) Clients should avoid crossing the legs at the knees or ankles because this compresses the veins and limits venous return. Educational objective: Discharge teaching for a client with resolved deep vein thrombosis includes interventions to prevent reoccurrence (eg, take in adequate fluids, elevate the extremities, exercise regularly, change positions frequently, stop smoking).

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply. 1. Decaffeinated coffee or tea can be consumed 2. Do not consume caffeine for 24 hours before the test 3. Do not smoke on the day of the test 4. Do not take beta blockers on the day of the test 5. Take diabetic medications as usual before the test

2, 3, 4 A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected so that a special camera can produce images of the heart. Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion. Pre-procedure client instructions include the following: - Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications (Option 3). - Avoid caffeine products 24 hours before the test (Option 2). - Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option 1). - Do not take theophylline 24-48 hours prior to the test (if tolerated). - If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 5). - Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: > Nitrates (nitroglycerine or isosorbide) > Dipyridamole > Beta blockers (Option 4) Educational objective: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; avoid both caffeinated and decaffeinated products for 24 hours before the test; and avoid taking theophylline or antianginal medications unless otherwise instructed by the health care provider.

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? Select all that apply. 1. Blue, cyanotic toes 2. Calf pain 3. Dry, shiny, hairless skin 4. Lower leg warmth and redness 5. Unilateral leg edema

2, 4, 5 A deep venous thrombosis (DVT) is a blood clot (ie, thrombus) formed in large veins, generally of the lower extremities. DVTs occur commonly as a result of decreased activity or mobility (eg, prolonged travels, bed rest) or as a complication of hospitalization or surgery. Although clients with a DVT may have no symptoms, typical clinical manifestations include unilateral edema, localized pain (eg, calf pain) or tenderness to touch, warmth, erythema, and occasionally low-grade fever (Options 2, 4, and 5). Recognition of a potential DVT is critical because the thrombus can dislodge from the vessel and cause life-threatening pulmonary embolism. (Option 1) Blue, cyanotic toes is an indicator of impaired arterial blood perfusion to the extremity, which may occur with acute arterial occlusion (eg, arterial embolism) or severely reduced blood flow (eg, vasopressor-induced vasoconstriction, atherosclerosis). (Option 3) Dry, shiny, hairless skin are common clinical manifestations of chronic peripheral arterial disease. These characteristic skin alterations occur from long-term impairment of blood flow to the extremity. Educational objective: A deep venous thrombosis (DVT) is a blood clot formed in large veins, typically of the lower extremities, that occurs commonly from decreased activity or mobility. Clinical manifestations of a lower-extremity DVT include unilateral edema, calf pain or tenderness to touch, warmth, erythema, and low-grade fever.

A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse include for this client? 1. Avoid aerobic exercise 2. Ensure you receive antibiotics prior to dental work 3. Stay well hydrated and avoid caffeine 4. Wear a medical alert bracelet

3 Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: - Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) - Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms - Reduce stress and avoid alcohol use (Option 1) Clients should be taught to begin or maintain an exercise program, preferably aerobic exercise, to achieve optimal health. (Option 2) Although MVP may place the client at an increased risk for infective endocarditis, there is no clinical evidence to support the need for prophylactic antibiotics prior to dental procedures. Antibiotic prophylaxis is indicated for clients who have prosthetic valve replacement, repaired valves, or a history of infectious endocarditis. (Option 4) There is no need for a medical alert bracelet. MVP is usually a benign condition. Educational objective: The nurse should teach the client with MVP to stay hydrated, avoid caffeine and alcohol, exercise regularly, reduce stress, and take beta blockers as prescribed for palpitations and chest pain. Nitrates are usually not effective for chest pain from MVP.

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday 2. The client has a painful red area on the buttocks 3. The client has new dependent edema of the feet 4. The client has strong, foul smelling urine

3 New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment. (Option 1) Loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening. (Option 2) A painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly. (Option 4) Strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly. Educational objective: New onset of dependent edema in an elderly client could be due to heart failure; the client needs further assessment for characteristic signs such as lung crackles and increased body weight (fluid retention).

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information. ECG: pacemaker spikes that are not followed by QRS complexes 1. Administer atropine 0.5 mg IV 2. Administer dopamine 5 mcg/kg/min IV 3. Initiate transcutaneous pacing 4. Notify the health care provider

3 The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client. (Option 1) Atropine is administered to clients with symptomatic bradycardia; however, this client's symptoms are caused by failure to capture. Therefore, obtaining capture via transcutaneous pacing should resolve the client's symptoms. (Option 2) Dopamine is an inotrope used to treat hypotension due to bradycardia. This client is bradycardic and hypotensive due to failure to capture. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. (Option 4) The health care provider needs to be notified, but the nurse should first use the transcutaneous pacemaker to stabilize the client. Educational objective: Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension. The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced.

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse? 1. Nurse has client lie supine for 5-10 minutes prior to starting procedure 2. Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding 3. Nurse starts by measuring BP and heart rate (HR) with the client standing 4. Nurse takes BP and HR after standing at 1- and 3-minute intervals

3 The experienced nurse should intervene if the new RN starts BP measurement with the client in the standing position. Orthostatic BP measurement may be done to detect volume depletion or postural hypotension caused by medications or autonomic dysfunction. Procedure for measurement of orthostatic BP 1. Have the client lie down for at least 5 minutes (Option 1) 2. Measure BP and HR 3. Have the client stand 4. Repeat BP and HR measurements after standing at 1- and 3-minute intervals (Option 4) A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal (Option 2). Educational objective: To measure orthostatic BP, the nurse should have the client lie supine for 5-10 minutes and then measure BP and HR. The nurse should then have the client stand for 1 minute, measure BP and HR, and repeat the measurements at 3 minutes. Findings are significant if the systolic BP drops ≥20 mm Hg or the diastolic BP drops ≥10 mm Hg.

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform? 1. Assess for dry, scaly skin on the lower legs 2. Assess for presence or absence of hair growth on lower extremities 3. Check for presence and quality of posterior tibial and dorsalis pedis pulses 4. Obtain a dietary history

3 This client is exhibiting symptoms of intermittent claudication or ischemic muscle pain that can be due to peripheral artery disease (PAD). PAD impairs circulation to the client's extremities. The nurse should first check for the adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality. Poor circulation to the extremities can place the client at increased risk for development of arterial ulcers and infection. The quality of circulation to the extremities will guide the treatment plan for this client; management will include risk factor modification for cardiovascular disease, drug therapy, and possibly surgical revascularization. (Option 1) Dry, scaly skin can be present in the client with PAD. It is a chronic condition of PAD and is not the priority assessment. (Option 2) When circulation to the extremities is impaired, the skin on the lower legs becomes thin, shiny, and taut; hair loss also occurs on the lower legs. This develops over time and would indicate that PAD has been present for a period of time and is not the priority assessment. (Option 4) The nurse should obtain a dietary history to assess for risk factors associated with cardiovascular disease. However, this is a lower level priority in this situation. Educational objective: The nurse caring for a client with intermittent claudication from PAD should assess the adequacy of circulation to the extremities by palpating and assessing the quality of posterior tibial and dorsalis pedis pulses. The quality of circulation will guide the treatment plan including risk factor modification, drug therapy, and possible surgical revascularization.

The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. ECG: irregular waveforms of varying shapes and amplitudes; irregular, chaotic rhythm 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation (VF) 4. Ventricular tachycardia

3 VF is characterized on the ECG by irregular waveforms of varying shapes and amplitudes. This represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover. VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization procedures due to catheter stimulation of the ventricle. Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine, vasopressin, amiodarone). (Option 1) Asystole is the total absence of ventricular electrical activity. (Option 2) Atrial fibrillation is characterized by total disorganization of atrial, not ventricular, activity. QRS complexes are usually normal in morphology. P waves are not seen. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. Educational objective: The nurse should recognize VF, a potentially lethal dysrhythmia. The ECG shows irregular waveforms of varying shapes and amplitudes. The client is unresponsive, pulseless, and apneic. Rapid treatment should include CPR, defibrillation, and drug therapy (eg, epinephrine, vasopressin, amiodarone).

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis? 1. Bounding peripheral pulses 2. Diastolic murmur 3. Loud second heart sound 4. Syncope on exertion

4 Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot overcome the worsening obstruction, and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures) and weak, thready peripheral pulses. With exertion, the volume of blood that is pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope. (Option 1) In aortic stenosis, pulses are weak due to obstruction of outflow from the left ventricle. Pulses would be bounding in aortic regurgitation due to more blood being pumped each time (blood accumulation from regurgitation of the previous systole). (Option 2) On auscultation, aortic stenosis produces a loud, ejection systolic murmur over the aortic area as blood is ejected from the left ventricle through the stenosed aortic valve during systole. (Option 3) The second heart sound (S2) is produced by the closure of aortic and pulmonic valves. When these valves are stiff and difficult to close (as with aortic stenosis), S2 is soft or absent. Educational objective: Aortic stenosis obstructs blood flow during systole from the left ventricle to the aorta. Clients will develop exertional dyspnea, chest pain, and syncope as the heart is unable to overcome the obstruction to pump enough blood to meet metabolic demands. A systolic ejection murmur over the aortic area, soft or absent second heart sounds, and weak peripheral pulses are characteristic.

A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Click on the exhibit button for additional information. Laboratory results: Sodium 134 mEq/L (134 mmol/L) Potassium 3.4 mEq/L (3.4 mmol/L) Chloride 108 mEq/L (108 mmol/L) Magnesium 0.9 mEq/L (0.45 mmol/L) 1. Atrial fibrillation 2. Atrial flutter 3. Mobitz II 4. Torsades de pointes

4 Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate. (Option 1) Characteristics of atrial fibrillation (AF) include an irregularly irregular rhythm and replacement of P waves by fibrillatory waves. Although electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening. (Option 2) Atrial flutter is characterized by sawtooth-shaped flutter waves. There is no clinical evidence suggesting that hypomagnesemia leads to atrial flutter, which is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale). (Option 3) Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers). Educational objective: In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).

The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse? 1. Glucose 200 mg/dL (11.1 mmol/L) 2. Hematocrit 38% (0.38) 3. Potassium 3.4 mEq/L (3.4 mmol/L) 4. Troponin 0.7 ng/mL (0.7 mcg/L)

4 Serum cardiac markers are proteins released into the bloodstream from necrotic heart tissue after a myocardial infarction (MI). Troponin is a highly specific cardiac marker for the detection of MI. It has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. Serum levels of troponin increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline after 10-14 days. A troponin value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority and immediate focus of the nurse. Normal values: troponin I <0.5 ng/mL (<0.5 mcg/L); troponin T <0.1 ng/mL (<0.1 mcg/L). (Option 1) The glucose is elevated (normal random glucose 70-110 mg/dL [3.9-6.1 mmol/L]) but is not the priority in this situation. The nurse will need to assess whether the client has a history of diabetes and time of the last meal. (Option 2) Normal hematocrit for a male is 39%-50% [0.39-0.50] and 35%-47% [0.35-0.47] for a female. The hematocrit value is not the priority. (Option 3) The potassium is slightly below normal (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). This should be the nurse's second priority. A low potassium level can precipitate dysrhythmias. Educational objective: An elevated troponin value holds the highest priority for intervention when a client is experiencing chest pain. Positive troponin levels are indicative of myocardial injury and require immediate attention by the nurse. Normal values are <0.5 ng/mL (<0.5 mcg/L) for troponin I and <0.1 ng/mL (<0.1 mcg/L) for troponin T.

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client? 1. Diet recall for this current week 2. Fluid intake for the past 2 days 3. Medications and dosages taken over the past 2 days 4. Presence of shortness of breath, coughing, or edema

4 The client with chronic heart failure is at risk for exacerbations that may require hospitalization. The priority for the nurse on the phone is to ascertain if the client is experiencing any physiological symptoms such as shortness of breath, coughing, or edema (Option 4). These could indicate fluid overload. This information can help the nurse direct the client to come in for further assessment, follow a protocol to make changes in medications/dosages, or restrict fluids. (Options 1, 2, and 3) These are all important in assessment of the possible cause of the weight gain. They should be addressed after the nurse has questioned the client about physiological symptoms. Educational objective: The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.

The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? 1. A 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives 2. A 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% 3. A 72-year-old client with a fever who is 2 days post coronary stent placement 4. An 80-year-old client who is 4 days postoperative from repair of a fractured hip

4 Venous thromboembolism includes both DVT and pulmonary embolism (PE). DVT is the most common form and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: - Trauma (endothelial injury and venous stasis from immobility) - Major surgery (endothelial injury and venous stasis from immobility) - Prolonged immobilization (eg, stroke, long travel) causing venous stasis - Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) - Oral contraceptives (estrogen is thrombotic) - Underlying malignancy (cancer cells release procoagulants) - Smoking (produces endothelial damage by inflammation) - Old age - Obesity and varicose veins (venous stasis) - Myeloproliferative disorders (increase blood viscosity) The 80-year-old 4-day postoperative client has the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age, and is at greatest risk for developing a DVT. (Option 1) Smoking cigarettes and using oral contraceptives increase plasma fibrinogen and coagulation factors and cause hypercoagulability of blood, but the client is not at greatest risk. Hormonal contraceptives are not recommended if the client is age >35 and also smokes. (Option 2) Elevated hemoglobin/hematocrit level (erythrocytosis) causes increased blood viscosity and hypercoagulability of blood, which increases the risk for DVT. However, the client is not at greatest risk. (Option 3) Anticoagulants and antiplatelet agents are administered before and after coronary stent placement. This client is at increased risk due to endothelial damage and advanced age but is not at greatest risk. Educational objective: DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzymes (CK-MB) 4. Chest x-ray

2 BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test. Educational objective: Elevation of BNP to >100 pg/mL is seen in heart failure. It aids in the assessment of the severity of heart failure and helps distinguish cardiac from respiratory causes of dyspnea.

A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action? 1. Attach defibrillator pads to the client's chest 2. Check the lipid profile laboratory results 3. Obtain a 12-lead electrocardiogram (ECG) 4. Prepare to administer a heparin drip

3 It is very important to rapidly diagnose and treat the client with chest pain and potential myocardial infarction to preserve cardiac muscle. Initial interventions in emergency management of chest pain are as follows: - Assess airway, breathing, and circulation (ABCs) - Position client upright unless contraindicated - Apply oxygen, if the client is hypoxic - Obtain baseline vital signs, including oxygen saturation - Auscultate heart and lung sounds - Obtain a 12-lead electrocardiogram (ECG) - Insert 2-3 large-bore intravenous catheters - Assess pain using the PQRST method - Medicate for pain as prescribed (eg, nitroglycerin) - Initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor) - Obtain baseline blood work (eg, cardiac markers, serum electrolytes) - Obtain portable chest x-ray - Assess for contraindications to antiplatelet and anticoagulant therapy - Administer aspirin unless contraindicated (Option 1) The defibrillator may be used if the 12-lead electrocardiogram (ECG) or cardiac monitoring shows a lethal and shockable rhythm, such as ventricular fibrillation; however, the 12-lead electrocardiogram (ECG) is priority. (Option 2) Elevated cholesterol (lipids) are indicative of long-term lifestyle behaviors and eating habits; a fasting lipid panel needs to be checked within 24 to 48 hours in all clients with presenting coronary artery disease, but this is not an emergency. (Option 4) Anticoagulation with heparin is indicated if the client's pain is determined to be due to acute coronary syndrome. There are many other causes of chest pain that do not require anticoagulation or may be contraindicated (eg, aortic dissection). Educational objective: Nurses must take presenting cardiac symptoms seriously until the cause is determined. Assess airway, breathing, and circulation, and obtain baseline pulse oximetry and vital signs. Then obtain electrocardiogram (ECG) results.

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply. 1. Avoid excessive caffeine 2. Immerse hands in cold water 3. Practice yoga or tai chi 4. Refrain from using tobacco products 5. Wear gloves when handling cold objects

Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: - Wear gloves when handling cold objects (Option 5). - Dress in warm layers, particularly in cold weather. - Avoid extremes and abrupt changes in temperature. - Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). - Avoid excessive caffeine intake (Option 1). - Refrain from use of tobacco products (Option 4). - Implement stress management strategies (eg, yoga, tai chi) (Option 3). If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes. (Option 2) Cold water will cause vasoconstriction and worsen the condition. Educational objective: Raynaud phenomenon is a vasospastic disorder triggered by exposure to cold or stress. Key elements of client teaching include management of acute attacks, avoidance of vasoconstrictive substances (eg, tobacco, cocaine, caffeine), stress reduction, and appropriate clothing (eg, gloves, warm layers).