ATI Targeted Medical-Surgical 2016: Cardiovascular
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? A. Dyspnea on exertion B.Tracheal deviation C. Pericardial rub D. Weight loss
A. Dyspnea on exertion explanation: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find? A. Jugular venous neck distention B. Weak peripheral pulses C. Increased abdominal girth D. Dependent edema
B. Weak peripheral pulses Explanation: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. All other options are a result of right sided HF
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? A."I can'y get rid of these hiccup B. "I feel dizzy when I stand." C."My incision site stings." D."I have a headache."
A. "I can'y get rid of these hiccups" Explanation: Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction (MI)? A. Myoglobin B. C-reactive protein C. Creatine kinase-MB D. Homocysteine
C. Creatine kinase-MB Explanation: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the clients's condition? A.Absence of adventitious breath sounds B. Presence of a nonproductive cough C. Decrease in respiratory rate at rest D. SaO2 86% on room air
A. Absence of adventitious breath sounds Explanation: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.
A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. The nurse should identify that which of the following findings indicates the medication is effective? A. INR 2.0 B. Decreased blood pressure C. Hemoglobin 14 g/dL D. Minimal bruising of extremities
A. INR 2.0 Explanation: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke. The nurse should recognize that decreased blood pressure is a manifestation of bleeding, which is an adverse effect of warfarin. The nurse should recognize that minimal bruising or no bruising is desired and that a hemoglobin level of 14 g/dL is within the expected reference range. However, this is not evidence of effective warfarin therapy.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. the nurse should report which of the flowing findings to the provider immediately? A. Slurred speech B. Irregular pulse C. Dependent edema D. Persistent fatigue
A. Slurred speech explanation: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
A nurse in an emergency room is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for? A. Confusion B. Friction rub C. Hypertension D. Dry skin
A. confusion Explanation: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? A. Hemoglobin 14.4 g/dL B. History of peripheral arterial disease C. Previous allergic reaction to shellfish D. Urine output 200 mL/4 hr
C. Previous allergic reaction to shellfish Explanation: The contrast medium used is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine. A hemoglobin level of 14.4 g/dL is within the expected reference range. This procedure involves access through large arteries or veins into the heart and is not affected by peripheral arterial disease. An output of 200 mL in 4 hr is within the expected reference range.
A nurse is caring for a client who s being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication? A. Lightheadedness B. Shortness of breath C. Metallic taste D. Dry cough
A. Lightheadedness Explanation: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness. Furosemide is used to manage shortness of breath secondary to heart failure. This is not an adverse reaction to this medication. A metallic taste and dry cough is not an adverse reaction to furosemide.
A nurse is providing health teachings for a group of clients. Which of the following clients us at high risk for developing peripheral arterial disease? A. A client who has hypothyroidism B. A client who has diabetes mellitus C. A client whose daily caloric intake consists of 25% fat D. A client who consumes two 12-oz bottles of beer a day
B. A client who has diabetes mellitus Explanation: Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.
A nurse is teaching a client who is starting to take ACE inhibitors to treat hypertension. the nurse should instruct the client to notify his provider if he experiences which of the following adverse effects of his medication? A. Tendon pain B. Persistent cough C. Frequent urination D. Constipation
B. Persistent cough EXPLANATION: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.
A nurse is caring for a client who was admitted for treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. the client is experiencing weakness and an irregular heart rate. which of the following actions should the nurse take first? A. Obtain client's current weight. B. Review serum electrolyte values. C. Determine the time of the last digoxin dose. D. Check the client's urine output.
B. Review serum electrolyte values. Explanation: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
A nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values? A. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL B. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL C.Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL D. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
C. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL Explanation: The expected reference range of cholesterol is less than 200 mg/dL, HDL above 45 mg/dL for men and above 55 mg/dL for women, and LDL less than 130 mg/dL.
A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Initiate seizure precautions. B.Tell the client to report vision changes. C. Elevate the head of the client's bed. D.Start a peripheral IV.
C. elevate the head of the client's bed. Explanation: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.
a nurse is caring for a post operative client 1 hr following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? A. serosanguinous dranage on dressing B. severe pain with coughing C. urine output od 20 mL/hr D. Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F)
C. urine output of 20 mL/hr Explanation: Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
A nurse is caring for a client who is 8 hr postoperatice following a coronary artery bypass graft (CABG). Which of the following client findings should the nurse report? A. Potassium 4.0 mEq/L B. Temperature 37.1 C (98.8 F) C. Mediastinal drainage 100 mL/hr D. Blood pressure 160/80 mm Hg
D. Blood pressure 160/80 mm Hg Explanation: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites. Mediastinal drainage of up to 150 mL/hr is expected during this time. A potassium level of 4.0 mEq/L is the desired goal in the postoperative period after CABG. A body temperature within the expected reference range is desired following a CABG.
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? A. "My arthritis is really bothering me because I haven't taken my aspirin in a week" B. "My blood pressire shouldm'y be high because I took my blood pressure medication this morning" c. " I took my warfarin last night according to my usual schedule " D. "I will check my blood sugar because I took a reduced dose of insulin this morning"
c. " I took my warfarin last night according to my usual schedule " Explanation: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.
A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Which of the following areas of the strip should the nurse examine to observe for atrial depolarization? A. P B. QRS C. T
A is correct Explanation: A is correct. The nurse should examine this area, the P wave, of the rhythm strip to evaluate for atrial depolarization. B is incorrect. The nurse should examine this area, the QRS complex, of the rhythm strip to evaluate for ventricular depolarization. C is incorrect. The nurse should examine this area, the T wave, of the rhythm strip to evaluate for ventricular repolarization
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I smoked a cigarette this morning to calm my nerves about having this procedure" B. "I have had chest pain a couple of times since I saw my doctor in the office last week." C. "I'm still hungry after the bowl of cereal I ate at 7 a.m." D. "I didn't take my heart pills this morning because my doctor told me not to"
A. "I smoked a cigarette this morning to calm my nerves about having this procedure" Explanation: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test. Episodes of chest pain are not a contraindication to this test. It is not necessary for the client to be NPO prior to this procedure. The provider might withhold cardiovascular medications prior to this procedure to effectively monitor cardiovascular response to stress.
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 0.9 kg (2 lb) in 24 hr B. Dyspnea with exertion C. Increase of 10 mm Hg in systolic blood pressure D. Dizziness when rising quickly
A. Weight gain of 0.9 kg (2 lb) in 24 hr Explanation: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately. Dyspnea with exertion is a nonurgent finding that is expected for a client who has heart failure. An increase of 10 mm Hg in systolic blood pressure is a nonurgent finding. Dizziness when rising quickly is a nonurgent finding that is expected for a client who is taking medications to treat heart failure. Although the client should report these, there is another finding the client should report immediately.
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Ask if the client has had a recent infection B. Explore the client's family history of peripheral vascular disease C. Note the presence or absence of pain at the ulcer site D. Inquire about the presence or absence of claudication
D. Inquire about the presence or absence of claudication Explanation: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not. Both arterial and venous ulcers have the potential to become infected. Family history is important, but it does not help to differentiate between arterial and venous ulcers. Both arterial and venous ulcers cause varying degrees of pain or discomforT.
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse A. Aortic B. Pulmonary C. Tricuspid D. Mitral
D. Mitral D is correct. Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line. A is incorrect. The nurse should inspect this location to assess for pulsations of the aortic area of the heart, which is located in the second intercostal space to the right of the sternum. B is incorrect. The nurse should inspect this location to assess for pulsations of the pulmonic area of the heart, which is located in the second intercostal space to the left of the sternum. C is incorrect. The nurse should inspect this location to assess for pulsations of the tricuspid area of the heart, which is located in the fifth intercostal space to the left of the sternal border.
A nurse is providing teaching for a client who is 2 days post operative following a heart transplant. which of the following statements should the nurse include in the teaching? A. "You might no longer be able to feel chest pain." B. "Your level of activity intolerance will not change." C. "After 6 months, you will no longer need to restrict your sodium intake." D. "You will be able to stop taking immunosuppressants after 12 months."
A. "You might no longer be able to feel chest pain." Explanation: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Valvular disease B. Ventricular depolarization C. Myelodysplastic syndrome D. Guillain-Barre syndrome
A. Valvular disease Explanation: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium. Ventricular depolarization occurs during a normal cardiac cycle and is not a potential complication of endocarditis. Myelodysplastic syndrome is a disorder of the bone marrow and is not a potential complication of endocarditis. Guillain-Barré syndrome is associated with certain bacterial and viral infections but is not a potential complication of endocarditis.
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions? A. Defibrillation B. Vagal stimulation C. Administration of atropine IV D. Delivery of a precordial thump
B. Vagal stimulation Explanation: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.The nurse should identify that cardioversion, rather than defibrillation, is used to treat supraventricular tachycardia. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia. The nurse should identify that atropine is used to treat bradydysrhythmias. Supraventricular tachycardia does not require atropine. The nurse should identify that a precordial thump is used for witnessed ventricular tachycardia if a defibrillator is unavailable. Supraventricular tachycardia does not require a precordial thump.
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? A. Replace the patch at the onset of angina. B. Apply the new patch to the same site as the previous patch C. Place the patch on an area of skin away from skin folds and joints D. Keep the patch on 24 hr per day
c. Place the patch on an area of skin away from skin folds and joints Explanation: The client should apply the patch to an area of intact skin that has enough room for the patch to fit smoothly.
A nurse is planning a presentation for a group of clients who have hypertension which of the following lifestyle modifications should the nurse include ( select all that apply) A. Limited alcohol intake B. Regular exercise program C. Decreased magnesium intake D. Reduced potassium intake E. Tobacco cessation
A. Limited alcohol intake B. Regular exercise program E. Tobacco cessation explanation: a. Limited alcohol intake is correct. Clients who have hypertension should limit alcohol intake. b. Regular exercise program is correct. A regular exercise program will help reduce blood pressure e. Tobacco cessation is correct. Tobacco use exacerbates hypertension. c.Decreased magnesium intake is incorrect. Low magnesium intake is associated with hypertension. d.Reduced potassium intake is incorrect. Low potassium intake is associated with hypertension
A nurse is an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week postoperative following an open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? A. Helping the client to the bedside commode B. Assisting with thrombolytic therapy C. Administering oxygen at 2L/min via nasal cannula D. Administering IV morphine sulfate
B. Assisting with thrombolytic therapy Explanation: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy. Using a bedside commode is less stressful than using a bedpan, and most clients are allowed to use a commode following a myocardial infarction. The nurse should administer supplemental oxygen to the client to increase myocardial tissue perfusion. The nurse should administer IV morphine to the client to relieve pain and reduce myocardial oxygen demand
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds? A. increase the heparin infusion flow rate by 2 mL/hr B. continue to monitor the heparin infusion as prescribed C. request a prothrombin time (PT) D. stop the heparin infusion
D. STOP THE HEPARIN INFUSION Explanation: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury
