6201 Adults Exam 2

A nurse is teaching a middle-age client about hypertension. Which of the following information should the RN include in the teaching?

"Diuretics are the first type of medication to control hypertension."

A nurse is reviewing the laboratory results for a client who has a hx/o atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the RN should plan follow-up teaching on low-cholesterol diet?

"I eat two eggs for breakfast each morning."

A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching?

"I must stop smoking." "I need to monitor my weight." "I am limiting my intake of fast foods"

a nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

The client experiences sudden weakness of one arm and leg.

A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?

"It requires lying quietly on one side."

A nurse is providing discharge instructions for a client who has Congestive HF. Which of the following client statements indicates to the nurse that the teaching was effective?

"I plan to slow down if I am tired the day after exercising"

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the RN make?

"I will need to apply electrodes to your chest and extremities."

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the RN include?

"Place the tablet under your tongue, and then take a small sip of water."

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

"Tell me more about these fears of dying from a heart attack."

A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the RN make regarding cardiac enzymes studies?

"These tests help determine the degree of damage to the heart tissues."

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? -pupil clarity - visual fields - visual acuity -lacrimal glands -appearance o f bulbul at conjecctivae

-pupil clarity - visual fields - visual acuity

INR (International Normalized Ratio)

0.8-1.1 or 0.75-1.25 Therapeutic Value 2-3 VTE, 2.5-3.5 mechanical valve; may vary based on comorbidities Standardizes PT results for monitoring anticoagulant therapy

A nurse is admitting a client who has acute heart failure following myocardial infarction. The nurse recognizes that which of the following prescriptions by the provider requires clarification?

0.9% normal saline IV at 50 mL/hr continuous

BUN (Blood Urea Nitrogen)

10-20 mg/dL (2.5-7.1 mmol/L) Assesses kidney function and protein breakdown in the body

PT (Prothrombin Time)

11-12.5 seconds Evaluates the clotting ability of blood

aPTT (Activated Partial Thromboplastin Time)

30-40 seconds Therapeutic value: 46-70 Measures the time it takes for blood to clot

Troponin T (cTnT) Troponin I (cTnI)

<0.1 ng/mL <0.03 ng/mL Assesses heart damage, particularly related to cardiac injuries

C-reactive protein (CRP)

<10 mg/L Indicates inflammation levels in the body

BNP (B-type Natriuretic Peptide)

<100 pg/mL Evaluates heart failure and cardiac stress

A nurse is caring for a client who has a history of heart failure: Nurses' notes: 13:00 A client with a history of coronary artery disease, hypertension, and heart failure is admitted to the cardiac telemetry unit with a diagnosis of new onset atrial fibrillation Client reports 3 days of increasing dyspnea and weight gain. He states he took an extra dose of Lasix the last two mornings. The client received 40 mEq of IV potassium in the emergency department and his current potassium level is 4.1 mEq. Complete the following sentence: The client is a t risk for developing _____ due to _______

A stroke d/t incomplete emptying of the atrium

AMI, commonly known as a heart attack, occurs when blood flow to a part of the heart is blocked, often by a blood clot.This blockage can damage or destroy part of the heart muscle. The blockage is usually due to atherosclerosis, which is the buildup of fatty deposits (plaques) in the coronary arteries. When a plaque breaks, a blood clot can form around it, blocking blood flow.

Acute Myocardial Infarction (AMI) Pathophysiology:

Chest pain or discomfort, often described as pressure, squeezing, or heaviness. The pain may radiate to the arm, jaw, neck, back, or shoulder. Pain or discomfort in the arms, back, neck, jaw, or stomach. Shortness of breath. Fatigue and weakness: feeling excessively tired or weak Cold sweat: some individuals may experience profuse sweating. Nausea or vomiting. Lightheadedness or fainting. Palpitations: Sensation of irregular, rapid, or pounding heartbeat. Anxiety or a sense of impending doom.

Acute Myocardial Infarction (AMI) S/Sxs:

A nurse is preparing to administer an ask a print subcutaneously to a client. Which of the following actions should the nurse take? Administer the medication with the needle at a 45° angle Administer the medication in the clients non-dominant arm Pull the client skin laterally or down prior to administration Massage the injection after administration

Administer the medication with the needle at a 45° angle

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? Advocate advocacy, ensures, clients, safety, health and rights. Advocacy, ensures that nurses are able to explain their own actions Advocacy, ensures, that nurses follow through on their promises Advocacy, ensures, fairness in client, care, delivery, and uses of resource.

Advocate advocacy, ensures, clients, safety, health and rights.

Atrial fibrillation occurs due to chaotic and rapid electrical signals in the atria, leading to irregular and often rapid heartbeats. It can be caused by underlying heart conditions (such as hypertension, heart failure, or coronary artery disease), thyroid problems, excessive alcohol consumption, stimulant use, or other factors.

Atrial Fibrillation (AFib): Cause:

Irregular and often rapid heartbeat, palpitations (feeling of fluttering or racing heart), shortness of breath, fatigue, dizziness or lightheadedness, chest discomfort.

Atrial Fibrillation (AFib): S/Sxs:

is characterized by rapid and regular electrical signals in the atria, causing a characteristic sawtooth pattern. It is often associated with underlying heart conditions, such as coronary artery disease or heart valve problems

Atrial Flutter: Cause:

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness

Hematoma or bleeding at the catheter insertion site. Infection. Damage to the blood vessels. Arrhythmias. Allergic reaction to contrast dye. Kidney damage due to contrast dye. Myocardial infarction. Stroke.

Cardiac Catheterization Complications

Explain the procedure to the patient, including its purpose and what to expect. Inform the patient that they will need to fast (NPO) for 6-12 hours before the procedure. Explain the importance of remaining still during the procedure. Inform the patient that they may feel a warm sensation or flushing when the contrast dye is injected. Advise the patient to report any chest pain or discomfort immediately. Explain that after the procedure, it's important to keep the leg straight and to avoid bending it to prevent bleeding from the insertion site. Encourage the patient to drink fluids after the procedure to help flush out the contrast dye, unless contraindicated.

Cardiac Catheterization Nursing Teachings

Cardiac catheterization is an invasive procedure used to diagnose and treat cardiovascular conditions. It involves threading a catheter through a blood vessel to the heart. This procedure can be used to perform angioplasty, stent placement, and evaluate heart function. It provides detailed information about the heart's structure, function, and blood flow.

Cardiac Catheterization Purpose

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for HTN. The RN notes that the client's K+ level is 3.3 mEq/L. The RN should monitor the client for which of the following complications?

Cardiac dysrhythmias

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the RN include in the client's plan of care? (select all that apply)

Check peripheral pulses in the affected extremity Keep the client's hip and leg extended Have the client remain in bed up to 6 hr

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? Check the client for injuries move hazardous objects away from the client notify the provider

Check the client for injuries

CAD is characterized by the narrowing or blockage of the coronary arteries (which supply oxygen-rich blood to the heart muscle) due to the buildup of atherosclerotic plaques. This buildup restricts blood flow to the heart muscle. When the heart muscle is deprived of oxygen and nutrients, it can lead to angina (chest pain) and myocardial infarction (heart attack).

Coronary Artery Disease (CAD): Pathophysiology

Angina: Chest pain or discomfort, Shortness of breath, Indigestion or heartburn-like symptoms: Discomfort or burning sensation in the upper abdomen or lower chest. Shortness of breath Fatigue Dizziness or fainting Sweating Nausea

Coronary Artery Disease (CAD): S/Sxs

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?

Defibrillation

is characterized by an irregularly irregular rhythm with no discernible P waves on an electrocardiogram (ECG) and irregular QRS complexes.

Description of Rhythm: Atrial fibrillation

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and SOB. Which of the following assessments should indicate to the nurse that the client may have developed a. fib?

Different apical and radial pulses

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? Select all that apply.

Dyspnea Jugular vein distention Confusion

There are generally no complications associated with an echocardiogram as it is non-invasive.

Echocardiogram: Complications

Explain that the echocardiogram is a non-invasive test that uses sound waves to create images of the heart. Inform the patient that the test is painless and does not involve radiation. Explain that they will need to remove clothing from the waist up and wear a hospital gown. Inform the patient that they may be asked to change positions or hold their breath briefly during the test to obtain clear images. Reassure the patient that the healthcare provider will explain the results and any necessary follow-up.

Echocardiogram: Nursing Teachings

An echocardiogram is a non-invasive diagnostic test that uses ultrasound waves to create images of the heart. This test can evaluate the size, shape, and movement of the heart's chambers and valves, and measure the ejection fraction.

Echocardiogram: Purpose

A nurse is caring for a client who reports taking heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Elective cardioversion

Your client is experiencing V. tach and the provider will treat with Elective cardioversion over Radiofrequency catheter ablation, why?

Elective cardioversion is the priority intervention when the client is awake and responsive. Radiofrequency catheter ablation is a procedure used to destroy the area of the heart (irritable focus) that causes the VT. It is used to treat clients who have repeated episodes of stable VT, but it is not used in initial treatment.

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Exercise at least three times per week

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The RN should give the Ct which of the following information about anginal pain?

Exertion and anxiety can trigger the pain.

Your client reports intense pain at the IV catheter site. Area is tot, blanched, cool to the touch with the Dema present. Ivy Vanco myosin has been discontinued and the catheter removed. Your provider has been notified. The nurse should identify that the client is experiencing want?

Extravasation as evidenced by the clients IV catheter site

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of teh following manifestations should the nurse identify as indicating the client is hypokalemic?

Fatigue

A nurse is teaching a client who takes aspirin daily for coronary artery disease without herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin?

Feverfew

A nurse is caring for an older client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough

Heart failure is a complex syndrome characterized by the inability of the heart to pump blood effectively to meet the body's demands. Reduced Cardiac Output: Heart failure can result from impaired systolic function (reduced contractility) or diastolic dysfunction (impaired ventricular relaxation and filling). Both conditions lead to decreased cardiac output and inadequate tissue perfusion.

Heart Failure Pathophysiology:

Diuretics (e.g., furosemide) to reduce fluid overload. ACE inhibitors (e.g., lisinopril) to reduce blood pressure and decrease the heart's workload. Beta-blockers (e.g., carvedilol) to slow the heart rate and reduce blood pressure. Digoxin to strengthen the heart's contractions. Aldosterone antagonists (e.g., spironolactone) to reduce fluid retention and improve heart function.

Heart Failure: Medications:

Shortness of breath or dyspnea, especially with exertion or when lying flat Fatigue and weakness often due to inadequate blood flow and oxygen delivery to the body. Fluid retention: Swelling in the legs, ankles, and feet (edema) Reduced exercise tolerance Weight gain Persistent cough or wheezing Increased urination at night Chest pain (if caused by ischemic heart disease) Rapid or irregular heartbeat

Heart Failure: S/Sxs

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly

Often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it reaches severe levels or complications arise. However, some individuals may experience symptoms like headaches, dizziness, blurred vision, chest pain, or shortness of breath.

Hypertension: S/Sxs

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving medication?

Hypotension

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Hypotension

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements from the client indicates an understanding of the teaching? I can place an extension cord across my living room to plug in my television. I will hire someone to trim the tree that hangs low over the stairs of my front porch. I will place my alarm clock on my bedroom dresser across the room I will replace the old throw rug in the kitchen with a new one

I will hire someone to trim the tree that hangs low over the stairs of my front porch.

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discussed is the treatment options and leave the clients room. When the nurse asks if the client would like to discuss any concerns, a client declines. Which of the following statements should the nurse make.? I will return shortly after and document this in your record. Most men live a long time with prostate cancer. I'm available to talk if you should change your mind. I will make a referral to a cancer support group for you.

I'm available to talk if you should change your mind.

A nurse at a provider's office receives a phone call from a client who reports nausea an unrelieved chest pain after taking a nitroglycerin tablet 5 minutes ago. Which of the following is an appropriate response by the nurse?

Instruct the client to call 911.

What are the signs of sudden onset A. Fib?

Irregular palpitations, rapid and irregular heart rate with significant pulse deficit, fatigue, and dizziness

A nurse on telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client feeling reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Irregular pulsations

A nurse is admitting a client who has acute heart failure following myocardial infarction. What makes 0.9% normal saline IV bolus at 50 mL/hr continuous CI?

It is isotonic and will not cause the fluid shift needed to reduce circulatory overload.

A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the clients room has at least six air exchangers per hour. Make sure the client wears a mask when outside her room if she if there is a construction area Place the client in a private room with negative airflow pressure Wear an N 95 respirator, when giving the claim direct care

Make sure the client wears a mask when outside her room if she if there is a construction area

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh length sequential compression sleeves. Which of the following actions should the nurse take? Assist the client into a prone position. Place a sleeve over the top of each leg with the opening at the knee. Make sure to fingers can fit under the sleeves. Set the angle pressure at 65 mm per mercury.

Make sure to fingers can fit under the sleeves.

Cr (Creatinine)

Males: 0.6-1.2 mg/dL (53-106 µmol/L) Females: 0.5-1.1 mg/dL (44-97 µmol/L) Measures kidney function and muscle breakdown

A nurse is providing teaching discharge to a client about self administering heparin. Which of the following instructions should the nurse include in the teaching? Aspirate for blood return prior to administration. In certain need a lot of 15° angle Minister the medication into the abdomen. Massage the site following injection.

Minister the medication into the abdomen.

MONA protocol

Morphine, Oxygen, Nitroglycerin, and Aspirin. For AMI

A nurse is caring for a client who is postoperative, and Evan is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and report back in one hour. Which of the following action should the nurse take next? Document the provider statement in the medical record Completed incident report Consult the facilities, risk manager Notify the nursing manager.

Notify the nursing manager.

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of HTN?

Obstructive sleep apnea (OSA)

A nurse is caring for a client who has HTN and has a K+ level of 6.8 mEq/L. Which of the following actions should the RN take?

Obtain a 12-lead ECG

A nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?

PT 45 seconds

A nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? Pad clients risk before applying the restraints. Evaluate the clients circulation every eight hours after application Remove the restrains every four hours to evaluate the client status. Secure the restrains to the beds, side rails.

Pad clients risk before applying the restraints.

A nurse is caring for a client who repots a new onset of severe chest pain. Which of the following actions should the RN take to determine if the client is experiencing myocardial infarction?

Perform a 12-lead ECG

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the RN plan to take?

Perform neurovascular checks with vital signs

Furosemide is a loop diuretic that requires monitoring what laboratory value?

Potassium

A nurse is reviewing a clients fluid and electrolyte status which of the following findings should the nurse report to the provider? BUN 15 mg / DL creatinine 0.8 mg / deal. Sodium 143MEQ per L Potassium 5.4 MEQ Dash L.

Potassium 5.4 MEQ Dash L.

A nurse is providing teaching to a client who has a family hx/o HTN. The nurse should inform the client that his blood pressure 124/84 mm Hg places him in which of the following categories?

Prehypertension

Premature ventricular contractions are caused by early electrical impulses originating in the ventricles. They can be triggered by increased irritability of the ventricles, electrolyte imbalances, stimulant use, or underlying heart conditions.

Premature Ventricular Contractions (PVCs): Causes

Premature ventricular contractions can feel like skipped or extra heartbeats, palpitations (feeling of irregular heartbeats), and occasionally may cause symptoms like dizziness or lightheadedness.

Premature Ventricular Contractions (PVCs): S/sxs

ECG characteristics: On an electrocardiogram (ECG), PVCs typically appear as wide and bizarre QRS complexes (representing ventricular depolarization) that occur earlier than expected in relation to the underlying sinus rhythm. The T wave may be in the opposite direction to the QRS complex.

Premature Ventricular Contractions (PVCs): description

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications?

Pulmonary embolism

occurs when the heart rate originating from the sinoatrial (SA) node is elevated. It is usually a normal physiological response to physical or emotional stress, fever, pain, or stimulant use.

Sinus Tachycardia Cause:

Sinus tachycardia manifests as a rapid heartbeat, palpitations, anxiety, shortness of breath, and sometimes dizziness or lightheadedness.

Sinus Tachycardia S/Sxs:

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the RN include as a modifiable risk factor for this d/o? (select all that apply) Smoking Hypercholesterolemia Genetic predisposition Obesity Smoking

Smoking Hypercholesterolemia Obesity

The nurse should instruct the client to avoid the use of NSAIDs to patients with heart failure d/t what side effects that can worsen the client's condition?

Sodium which can contribute to fluid retention

Aspiration. Esophageal perforation. Reaction to sedatives or anesthetics. Respiratory depression.

Transesophageal Echocardiogram (TEE): Complications

A nurse is evaluating the clients use of a cane which of the following actions should the nurse identify as an indication of correct use The top of the cane is parallel to the clients waist When walking the client was the king 46 cm or 18 inches forward. The client holds the cane on the stronger side of the body. The clients are stronger than forward with the cane.

The top of the cane is parallel to the clients waist

Explain the procedure, including its purpose and what to expect. Inform the patient that they will need to fast (NPO) for at least 6 hours before the procedure. Explain that a sedative and a local anesthetic will be used to help them relax and numb the throat. Inform the patient that they will need to remove dentures or oral prostheses. Explain that they may have a sore throat after the procedure. Advise the patient not to eat or drink until the gag reflex returns, to prevent aspiration. Explain that they will need someone to drive them home due to the sedation.

Transesophageal Echocardiogram (TEE): Nursing Teachings

TEE is a specialized type of echocardiogram that uses a probe passed down the esophagus to obtain images of the heart. It provides a closer look at the heart's structures and is often used when standard echocardiogram images are not sufficient. Assessing Valvular Function: TEE allows for a closer evaluation of heart valve structure and function. It is especially useful in detecting conditions such as infective endocarditis or prosthetic valve dysfunction. Detecting Blood Clots: TEE can detect the presence of blood clots within the heart, particularly in the atria. It helps in diagnosing conditions like atrial fibrillation or thrombus formation.

Transesophageal Echocardiogram (TEE): Purpose

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a MI? (select all that apply.)

Troponin I Troponin T CPK Myoglobin

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? Use the complete name of the medication magnesium sulfate Delete the space between the numerical dose in the unit of measure. Write the letter U in noting the dosage of insulin Use the abbreviation SC1 indicating an injection.

Use the complete name of the medication magnesium sulfate

A nurse is caring for a client who has a new diagnosis of essential HTN. The RN should monitor the CT for which of the following findings that is consistent w/this dx?

Vertigo

A nurse is caring for a client who is on warfarin therapy for a. fib. The Client's INR i s5.2. Which of the following medications should the nurse prepare to administer?

Vitamin K

A nurse is educating a client who has a terminal illness by declining resuscitation in a LivingWell. The client asked, what would happen if I arrived at the emergency department and I had difficulty breathing? Which of the following responses should the nurse make? We will consult the person appointed by your healthcare proxy to make decisions. We will give you oxygen through tube in your nose. You would be unable to change your previous wishes about your care. We would insert a breathing tube while we evaluate your condition

We will give you oxygen through tube in your nose.

Atrial Flutter: S/Sxs

can cause a rapid and regular heartbeat, palpitations, shortness of breath, fatigue, and dizziness.

A nurse is admitting a client who's having exacerbation of heart failure. And planning the clients care, what should the nurse initiate discharge planning? during the admissions process As soon as the clients condition is stable During the initial team conference After consulting with the clients family.

during the admissions process

Atrial Flutter: Description

presents as a regular rhythm with atrial rate typically between 250-350 beats per minute and a ventricular rate depending on the conduction ratio.