Cardiac Practice Questions

Asystole

Absence of contractions of the heart

A 44-year-old male client was admitted to the emergency department following a motor vehicle accident. He has an extensive injury to the chest wall that is open and bleeding. In addition, the client has flank bruising and reports intense abdominal pain. The client is awake and alert and vitals are: temperature 98.9° F; HR 133 beats/min; BP 100/48; oxygen saturation 96% on room air. The client's spouse is present and at the bedside and reports that the client is diabetic and has a history of seizures. Select the nursing action that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the client's care at this time. 1. Insert a 24 gauge IV into the left forearm. 2. Apply oxygen via facemask. 3. Administer crystalloid fluids. 4. Assess client's blood type and crossmatch availability 5. Monitor vital signs every 5 to 15 minutes. 6. Prepare to administer broad spectrum antibiotics. 7. Assess the client's blood sugar 8. Pad the side rails of the stretcher in the ED.

1. Contraindicated, 2. Contraindicated, 3. Indicated, 4. Indicated, 5. Indicated, 6. Contraindicated, 7. Indicated, 8. Nonessential It is important for the nurse to establish IV access. However, this client is likely hemorrhaging and is hypovolemic. They will need large amounts of fluid and possible blood products. A 24 gauge IV is not large enough for this client. A minimum of a 20 gauge is needed and a larger bore (16 to 18 g) is preferred. The client's oxygen saturation is currently 96% and there is no evidence to support providing oxygen via facemask with the oxygen levels are normal. The nurse will anticipate administering crystalloid fluids and blood products. Vital signs are required every 5 to 15 minutes depending on overall client status. The most likely concern is hypovolemic shock. Broad spectrum antibiotics are indicated for septic shock—not hypovolemic shock. Given the history of diabetes, the nurse should assess the blood sugar. While it may be important to pad the side rails in the client's room, this is not the priority at this time as the client has a history of seizures, but no active seizure activity at this time.

The nurse is caring for a male client who was admitted through the emergency department in atrial fibrillation. The client does not have a history of atrial fibrillation, but does have a positive history for hypertension, high cholesterol, and anxiety. Current assessment data includes: BP 109/58 mm Hg; HR 144 beats/min; troponin 0.0 ng/mL. Current medications include: atorvastatin, cetirizine, lisinopril, and paroxetine. The client denies chest pain, but feels "very anxious" and like his heart is "beating out of my chest." The client is currently alone as his wife was unable to accompany him in the emergency department due to visiting restrictions associated with the global pandemic of Covid-19. Select to indicate the nursing action that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the client's care at this time. 1. Prepare for cardioversion immediately. 2. Assess coagulation status. 3. Prepare for transesophageal echocardiogram. 4. Make sure the client is wearing a facemask. 5. Administer atropine per standing order. 6. Keep the client in a supine position with the head of the bed lower than 30 de

1. Contraindicated, 2. Indicated, 3. Indicated, 4. Indicated, 5. Contraindicated, 6. Contraindicated, 7. Indicated The nurse will not prepare for cardioversion immediately. This is contraindicated at this time as the time of atrial fibrillation onset is unknown. When the onset of atrial fibrillation is greater than 48 hours, the client must either take anticoagulants or have a TEE to make sure there are no clots in the atrium that could dislodge with cardioversion. Since the client is symptomatic and has a rapid HR, it is most likely that the TEE would be performed to visualize the atrium. If no clots are present, then a cardioversion can be done in an attempt to restore normal conduction. The nurse would assess coagulation status and given the current pandemic and risk of exposure to COVID-19; the nurse would also ensure the client was wearing a facemask. To decrease anxiety, which can elevate the HR even further, it is important for the nurse to be present with the client and communicate clearly. It is contraindicated to keep the client in a supine position. The client can assume a comfortable position.

A client presents to the hospital with persistent flank pain. The client reports that pain started as an ache 2 days and has progressively gotten worse, and is almost unbearable. The client is taking atorvastatin 20 mg daily, metformin 500 mg daily, and paroxetine 12.5 mg daily. The client's pain is currently rated as a 9 on a 0-10 pain scale. The client is diaphoretic, shortness of breath, heart rate is 130, blood pressure is 100/64 and the nurse assesses a pulsatile mass in the client's abdomen. Select to indicate the nursing action that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the client's care at this time. 1. Palpate the mass to determine size. 2. Keep the client NPO. 3. Administer pain medication as prescribed. 4. Encourage the client's partner to be at the bedside. 5. Monitor vital signs every 15 minutes. 6. Auscultate the mass for a bruit. 7. Administer metformin 500 mg.

1. Contraindicated, 2. Indicated, 3. Indicated, 4. Nonessential, 5. Indicated, 6. Indicated, 7. Contraindicated The client has a history of high cholesterol (due to the history of atorvastatin). In addition, the client has type 2 diabetes mellitus (due to the history of metformin). These are both significant risk factors for aneurysms. The client's symptoms are indicative of an enlarging abdominal aortic aneurysm. The nurse should not palpate the aneurysm as this can increase the risk of rupture; however, the nurse can auscultate for a bruit. The client's vital signs indicate impending rupture and the client will most likely require surgical repair. The nurse would not administer metformin as the client should remain NPO in the event that surgery is required.

The nurse is caring for a 48-year-old male client who presents to the emergency department with reports of chest pain. The client has a history of hypertension and anxiety. He does not smoke and reports that he has not taken any medication lately. The client reports his pain as an 8 on a scale of 0-10. He describes the pain as substernal pressure that woke him up from sleeping. His spouse is with him and reports that the client went to bed early because he did not feel well. Current assessment includes: heart rate 112 beats/min; BP 110/62 mm Hg; RR 18 breaths/min; oxygen saturation 96%; Temperature 98.9° F. Select the nursing action that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the client's care at this time. 1. Obtain a 12-lead ECG. 2. Administer supplemental oxygen. 3. Complete detailed history. 4. Administer sublingual nitroglycerin as prescribed. 5. Monitor vital signs every 30 minutes until the client is pain free 6. Provide intermittent ECG monitoring.

1. Indicated, 2. Contraindicated, 3. Nonessential, 4. Indicated, 5. Contraindicated, 6. Contraindicated This client is most likely experiencing a myocardial infarction. The nurse would obtain a 12 lead ECG within 10 minutes of arrival and administer nitroglycerin as prescribed. It is contraindicated to administer oxygen unless the client is symptomatic with oxygen saturations less than 90%. Vital signs should be monitored every 5 minutes due to the client condition and administration of nitroglycerin. Every 30 minutes is not often enough. The detailed client history can be completed once the client's immediate needs are addressed. Continuous ECG monitoring is required.

The nurse is assessing a client with septic shock. What assessment data indicates a progression of shock? Select all that apply. A. BP change from 86/50 to 100/64 B. HR change from 98 to 76 C. Cool and clammy skin D. Petechiae along the gum line E. Urine output 45 ml/hr

A, C, D As sepsis progresses, cardiac output is higher as are heart rate and blood pressure. The nurse would interpret the increasing blood pressure as an indication of worsening condition versus improvement. As sepsis progresses, circulation is compromised and presents as cool, clammy skin, with pallor and cyanosis. DIC can occur with sepsis progression causing petechiae and ecchymoses, occurring anywhere on the body. The decrease in heart rate is not associated with progression of shock (the heart rate, like the BP would increase). The urine output is within normal limits and would not indicate progression of shock.

Which risk factors are known to contribute to atrial fibrillation? (Select all that apply.) A. Advancing age B. Palpitations C. High Blood Pressure D. Excessive alcohol use E. Use of beta blockers

A, C, D Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and African Americans. Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.

Which assessment data cause the nurse to suspect that a client who had a myocardial infarction (MI) is developing cardiogenic shock? (Select all that apply.) A. Cool, diaphoretic skin B. Crackles in the lung fields C. Anxiety and restlessness D. Respiratory rate of 12 breaths/min E. Temperature of 100.4° F (38.0° C) F. Bradycardia

A, B, C The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/min is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.

The nurse caring for a client with heart failure who is taking digoxin. What assessment data requires that nurse notify the health care provider? (Select all that apply.) A. Anorexia B. Blurred vision C. Fatigue D. Heart rate 110/beats/min E. Serum digoxin level of 1.5 ng/mL (1.92 nmol/L)

A, B, C The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur. Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your healthcare provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the healthcare provider if elevated."

A, B, C, D, E Ivabradine is an HCN channel blocker that slows the heart rate. Side effects include: bradycardia, hypertension, atrial fibrillation, and luminous phenomena (visual brightness) The nurse will teach the client that visual changes are expected initially. The nurse will advise to take this medication with meals and teach the client how to check radial pulse and to report low heart rate or irregularity to the health care provider. The nurse will also teach clients that visual changes are associated with light and clients should use caution when driving or using machines in situations where light intensity may change abruptly.

A client in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output

A, B, D, E, H Compensatory mechanisms attempt to maintain perfusion and gas exchange to vital organs. Thus these mechanisms shunt blood away from less vital organs and try to prevent further volume losses. The increasing pallor occurs because blood is shunted away from skin and mucous membranes to the heart, brain, liver, and lungs. Increasing thirst and decreasing urine output help to increase blood volume by stimulating the patient to drink and by preventing fluid loss through the urine. Increasing heart rate and respiratory rate work to maintain gas exchange to those selected organs that continue to be perfused. Increasing confusion indicates the compensatory mechanisms are failing and that the brain is not being adequately perfused. Decreasing systolic blood pressure also is an indication of worsening shock. Decreasing blood pH is not a compensatory action; it is an indication of inadequate gas exchange.

The nurse is caring for a client with heart rate of 143 beats/min. Which assessment data will the nurse anticipate? (Select all that apply.) A. Chest discomfort B. Hypotension C. Flushing of the skin D. Increased energy E. Palpitations

A, B, E Tachycardia is a heart rate greater than 100 beats/min; the patient with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope ("blackout") from hypotension. Chest discomfort and palpitations may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue. In this situation, the patient will have pale, cool skin and not flushing of the skin. Also, reduced cardiac output and possible development of heart failure will cause fatigue and not increased energy.

The nurse is caring for a client with heart failure. What assessment data will the nurse anticipate? (Select all that apply.) A. Fatigue B. Sleeping on back without a pillow C. Chest discomfort or pain D. Tachycardia E. Expectorating thick, yellow sputum

A, C, D When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15-25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased.

A, C, D, E A normal troponin value is anticipated with unstable angina. A troponin value of 0.6ng/mL is elevated and would be indicative of a myocardial infarction. All other assessment data can accompany unstable angina.

The nurse is admitting a client with an ulcer on the right foot. Which statement made by the client indicates venous insufficiency? Select all that apply. A. "My ankles swell up all the time." B. "My leg hurts after I walk about a block." C. "My feet are always really cold." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."

A, D, E Symptoms of venous insufficiency include ankle and leg swelling, ankle discoloration, and full veins with dependent positioning of the legs. Pain with ambulation would signal claudication and cold extremities would indicate poor arterial perfusion.

The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply. A. Denial is a common reaction to chest pain. B. A myocardial infarction can occur in minutes. C. Exercise at least 20 minutes 3 to 4 times per week. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.

A, D, E, F Denial is a common reaction to chest pain that often causes a delay in seeking treatment. Age is a significant risk factor in the development of CAD, with risk increasing with age. Women are more likely to experience atypical symptoms of chest pain such as indigestion. Atherosclerosis is the primary factor in development of CAD. A myocardial infarction evolves over hours, not minutes. Exercise for 20 minutes 3 to 4 times a week is not often enough or long enough.

The nurse is teaching a client with a new pacemaker. What teaching will the nurse include? (Select all that apply.) A. Do not lean over electrical or gasoline motors. B. Take your pulse for 20 seconds each day and record the rate. C. You may bathe, taking only showers. D. Be sure that you remember the rate at which your pacemaker is set. E. Avoid the use of microwave ovens. F. Avoid sudden, jerky movements for 8 weeks.

A, D, F Clients with a new pacemaker should be taught to take their pulse daily for 1 full minute each day. It is important to be aware of the rate the pacemaker is set to know which rate changes that are important to report to your health care provider. Clients with pacemakers can use microwave ovens and may bathe normally, in either the shower or bath. Sudden, jerky movements should be avoided for 8 weeks to allow the pacemaker to settle in place. Leaning over electrical or gasoline motors should be avoided and it is important to make sure electrical devices are properly grounded.

The nurse is teaching a client with a new permanent pacemaker. Which client statement indicates a need for further teaching? A. "I no longer need my heart pills." B. "I need to take my pulse every day." C. "I will be able to shower again soon." D. "I might trigger airport security metal detectors."

A. "I no longer need my heart pills." All prescribed medications, including heart medications, are still needed after the pacemaker is implanted. Once the wound from the surgery heals, the patient will be able to shower. The patient's pulse will have to be taken and recorded for 1 full minute at the same time each day. The metal in the pacemaker will trigger the alarm in metal detector devices. A card can be shown to authorities to indicate that the patient has a pacemaker.

The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use? A. "The nitroglycerin should tingle when I put it in my mouth." B. "I will keep nitroglycerin in the glove compartment of my car" C. "Since the pills are small, they won't be hard to swallow." D. "The nitroglycerin should relieve the pain immediately."

A. "The nitroglycerin should tingle when I put it in my mouth." Nitroglycerin should tingle when placed under the tongue. If it does not, it is likely old and should be replaced. Nitroglycerin should be kept with the client at all times, not stored in the car. Nitroglycerin is not swallowed; it dissolves under the tongue. Nitroglycerin should begin to work in 5 minutes, not immediately.

The nurse is teaching a client about the risk for bradydysrhythmias. What teaching will the nurse include? A. "Use a stool softener." B. "Stop smoking and avoid caffeine." C. "Avoid potassium-containing foods." D. "Take nitroglycerin for a slow heartbeat."

A. "Use a stool softener." The nurse will advise the client to use a stool softener. Patients at risk for bradydysrhythmias would avoid bearing down or straining during a bowel movement. The Valsalva maneuver associated with bearing down can cause bradycardia. Patients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the patient is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people would stop smoking, patients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.

The nurse is teaching a client with peripheral arterial disease. What teaching will the nurse include? A. "Walk to the point of leg pain, then rest, resuming when pain stops." B. "Inspect your legs daily for brownish discoloration around the ankles." C. "Apply a heating pad to the legs if they feel cold." D. "Elevate your legs above heart level to prevent swelling."

A. "Walk to the point of leg pain, then rest, resuming when pain stops." The teaching point the nurse include for a client with PAD is walk to the point of leg pain, rest, and then resume when pain stops. Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther. Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous disease. Application of heat must be avoided in clients with PAD due to a lack of sensation and possible burns to the legs.

The home health nurse visits a client with heart failure who has gained 5 lb (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? A. Auscultate the client's posterior breath sounds. B. Notify the health care provider about the client's weight gain. C. Remind the client about dietary sodium restrictions. D. Assess the client for peripheral edema.

A. Auscultate the client's posterior breath sounds. The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed. Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately? A. Blood pressure (BP) 192/102 mm Hg B. Report of constipation C. Anxiety D. Heart rate 52 beats/min

A. Blood pressure (BP) 192/102 mm Hg The problem that must be addressed immediately in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture. The nurse must consider the client's usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.

Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? A. Carotid artery bruit B. HDL 60 mg/dL C. Palpable peripheral pulses D. BP 120/58 mm/Hg

A. Carotid Artery Bruit A bruit is considered an abnormal finding that is associated with atherosclerotic disease. A bruit is a turbulent, swishing sound that occurs when blood is passing through a narrowed artery. All other values are related to atherosclerotic disease- however, they are normal values. Abnormal values or findings would be anticipated in a client with severe atherosclerotic disease.

The nurse is caring for a client with heart failure in a cardiac clinic. What assessment data indicates that the client has demonstrated a positive outcome related to the addition of metoprolol to the medication regimen? A. Client states, "I can sleep on one pillow." B. Current ejection fraction is 25%. C. Client reports feeling like her heart beats very fast at times. D. Records indicate five episodes of pulmonary edema last year.

A. Client states, "I can sleep on one pillow." A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol. An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning? A. Digoxin therapy daily. B. Daily metoprolol. C. Furosemide twice daily. D. Currently taking an antacid for upset stomach.

A. Digoxin therapy daily. Confusion, blurry vision, and upset stomach are symptoms of Digoxin toxicity, which is common in older adults and requires immediate treatment. The other answers are important assessment data but do not indicate immediate connection to the client's presentation.

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? A. Do not smoke or chew tobacco. B. Avoid alcoholic beverages. C. Reduce abdominal fat. D. Implement stress-reduction techniques.

A. Do not smoke or chew tobacco. The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure. Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.

A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.

D. Assess the client and check lead placement. ALWAYS check the client first. Cardiac monitors are a tool for assessment, but they do not replace hands on nursing assessment.

The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate? A. Heart rate 118 B. 2+ pedal pulses C. Bilateral fine crackles in lung bases D. BP change from 100/60 to 100/40

A. Heart rate 118 With the initial stage of shock, an increase is heart rate is often the first indicator. Because stroke volume is decreased the pedal pulses are often difficult to palpate and easily blocked. A normal pedal pulse (2+) would not be anticipate. The nurse would not anticipate bilateral fine crackles in the lungs with hypovolemic shock. The nurse would anticipate a narrow pulse pressure change (versus a widened pulse pressure). With vasoconstriction, diastolic pressure increases, but systolic pressure remains the same. This creates a narrow pulse pressure.

The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment data indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 ml of bloody drainage in chest tube over 4 hours

A. Heart rate of 50 beats/min A heart rate of 50 beats per minute is a risk for decreased perfusion. All other choices are not risks for decreased perfusion or normal parameters.

Which nursing action may be delegated to assistive personnel (AP) working on the medical unit? A. Obtain daily weights for several clients with class IV heart failure. B. Check for peripheral edema in a client with endocarditis. C. Monitor the pain level for a client with acute pericarditis. D. Determine the usual alcohol intake for a client with cardiomyopathy.

A. Obtain daily weights for several clients with class IV heart failure. The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A. Place the client in high-Fowler position with the legs down. B. Reassure the client that distress can be relieved with proper intervention. C. Ask a family member to remain with the client. D. Monitor pulse oximetry and cardiac rate and rhythm.

A. Place the client in high-Fowler position with the legs down. The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler position with the legs down. High-Fowler position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

The nurse is assigned to all of these clients. Which client would the nurse assess first? A. The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. B. The client admitted with hypertensive crisis who has a nitroprusside drip and blood pressure of 149/80 mm Hg. C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid. D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot.

A. The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. The client who would be assessed first is the client who had a percutaneous vascular intervention of the right femoral artery 30 minutes ago. This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure. The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment and can be assessed after the client who had a percutaneous vascular intervention.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which nursing assessment data, obtained the day after admission, is the best indicator that the treatment has been effective? A. The client's weight decreases by 2.5 kg. B. The client has diuresis of 400 mL in 24 hours. C. The client's blood pressure is 122/84 mm Hg. D. The client has an apical pulse of 82 beats/min.

A. The client's weight decreases by 2.5 kg. The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 lb (2.5 kg) in 1 day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding alone, it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding alone, it is not significant to determine whether hypervolemia is relieved.

To assess if a client has had a myocardial infarction (MI), which lab value will the nurse assess? A. Troponin B. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol C. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase D. Homocysteine and C-reactive protein

A. Troponin Positive findings for troponin are the most specific cardiac marker used to determine whether an MI has occurred. Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.

The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 mm Hg C. +3 pedal pulses D. Absent bowel sounds

A. Urine output of 20 mL over 2 hours The nurse caring for a client who had an AAA repair would be most alarmed with the client's urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria. Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output. +3 pedal pulses is a normal physical assessment finding.

A 54-year-old female is admitted to the hospital with an acute exacerbation of heart failure. The client has a history of heart failure and takes furosemide daily. In addition, the clients have a current smoking history, diabetes mellitus type 2, and osteoarthritis. Select to indicate which nursing action listed in the far left column is appropriate for the potential heart failure complication. Note that not all nursing actions will be used. Potential Complications: A. Decreased Oxygen Saturation B. Retention of Water and Sodium C. Decreased Contractility D. Arrhythmia E. Anxiety and Increased Preload Nursing Intervention: 1 Administer morphine sulfate as prescribed. 2 Consult with a specialist to manage pain. 3 Administer oxygen via nasal cannula maintain oxygen saturation greater than 90%. 4 Administer furosemide as prescribed. 5 Administer digoxin as prescribed. 6. Apply a cardiac monitor 7 Prepare to administer a blood transfusion.

A3, B4, C5, D6, E1

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply.) A. Urine output B. Respiratory rate C. Heart rate D. Heart rhythm E. QT interval

C, D, E Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed. Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.

The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? A. Sinus Tachycardia B. Sinus Bradycardia C. Normal Sinus Rhythm D. Sinus arrhythmia

C. Normal Sinus Rhythm The nurse will document this rhythm interpretation as normal sinus rhythm. The heart rate does not reflect tachycardia or bradycardia and the rhythm is not irregular. All other assessment parameters are within normal sinus rhythm interpretation.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? A. Obtain a request from the primary health care provider for a dietary consult. B. Administer a clonidine patch for hypertension. C. Develop a plan for discharge, and assess home care needs. D. Assess leg ulcers for signs of infection.

B. Administer a clonidine patch for hypertension. The action the nurse delegates to the LPN/LVN caring for a client with dark-colored toe ulcers and a BP of 190/100 mm Hg is to administer a clonidine patch for hypertension. Administering medication is within the scope of practice for the LPN/LVN. The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." Which nursing response is appropriate? A. "You must find someplace to walk." B. "Where might you be able to walk?" C. "You are right. Focus more on your diet." D. "Walk around the edge of your apartment complex."

B. "Where might you be able to walk?" In this situation, the best response by the nurse is to ask the client where he or she might be able to walk. This calls for cooperation and participation from the client. Increased activity is imperative for this client. Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.

The nurse is teaching a client's family regarding the diagnosis of septic shock. Which teaching will the nurse include? Select all that apply. A."The blood cultures will tell us for sure if your loved one has septic shock." B."The client's change in behavior and lethargy may be associated with septic shock." C. "Antibiotics, as prescribed, will be started within the hour to treat the sepsis." D."An insulin drip has been started to keep the client's glucose as low as possible." E. "Septic shock is easily treated with multiple antibiotics."

B, C A recent change in behavior or altered level of consciousness are often indicators of sepsis and septic shock. Part of the sepsis bundle of care is the administration of antibiotics within one hour of recognizing sepsis. The blood cultures may or may not confirm he diagnosis of septic shock. Bacteremia may not be present. Insulin therapy is used to maintain blood glucose levels between 140 mg/dL (7.7 mmol/L) and 180 mg/dL (10 mmol/L). Keeping the blood glucose level below 110 mg/dL (6.1 mmol/L) is associated with increased mortality. Septic shock is not easily treated.

Which characteristics place women at high risk for myocardial infarction (MI)? (Select all that apply.) A. Breast cancer B. Abdominal obesity C. Family history D. Increasing age E. Premenopausal

B, C, D Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. Also, a large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI. Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) A. Sharp, inspiratory chest pain B. Dyspnea C. Extreme fatigue D. Dizziness E. Anorexia

B, C, D Many women who experience an MI present with dyspnea, light-headedness and dizziness, and fatigue. Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.

The nurse is assessing a 54-year-old male client for risk of atherosclerosis. What assessment data is associated with an increase in risk? (Select all that apply.) A. Takes acetylsalicylic acid daily. B. BMI is 32. C. History of type 2 diabetes mellitus. D. LDL of 160 mg/dL. E. The client's father has lung cancer. F. Current smoking history.

B, C, D, F Risk factors that contribute to atherosclerosis include: an increase in LDL (160 mg/dL is high), obesity (as indicated by a BMI is 32), smoking, and type 2 diabetes. ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. While atherosclerosis can be genetic, the fact that the client's father has lung cancer does not increase his risk for atherosclerosis.

The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.) A. Allow the client to eat a meal. B. Ensure electrodes are in place for continued monitoring. C. Assess the chest for burns. D. Document results of procedure. E. Remove crash cart from the room. F. Provide continued sedation G. Administer oxygen

B, C, D, G The nurse would not allow the client to eat a meal immediately following a cardioversion. The nurse will assess level of consciousness and overall client status and start with sips of liquid once the client is fully awake. The nurse will continue to carefully monitor the client, ensuring that electrodes are in place and assessing for chest burns from the electrodes used during the cardioversion. The nurse will administer oxygen until the client is fully awake. The nurse will not provide continued sedation. The nurse will document the procedure and the crash cart should remain in the room until the client is stable as lethal arrhythmias can occur during and after cardioversion.

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

B, C, E, F For a client with left sided heart failure the nurse will anticipate assessment findings of crackles in both lungs, tachypnea, tachycardia, and a third heart sound, usually an S3 gallop. Peripheral edema and ascites are associated with right sided heart failure.

The nurse is teaching the client dietary methods to reduce LDL levels. What teaching will the nurse include? (Select all that apply.) A. Aim for 10% of calories from saturated fat B. Limit trans-fat intake. C. Emphasize the intake of whole grains. D. Avoid cooking with all oil. E. Nuts are a good snack food. F. Try to purchase skinless chicken to cook with.

B, C, E, F The American Heart Association publishes dietary recommendations to decrease LDL levels. These recommendations include: emphasizing the intake of whole grains, vegetables, and fruits; consuming poultry without the skin; consuming low-fat dairy products and nuts; cooking with nontropical oils (e.g. Canola); limiting trans-fat intake and aiming for a dietary pattern that includes 5% to 6% of calories from saturated fat.

The nurse is teaching a course on hemodynamic (HD) monitoring. Which teaching will the nurse include? (Select all that apply.) A. Invasive hemodynamic monitoring provides maximum data with minimal risk. B. Hemodynamic monitoring directly measures pressures in the heart and great vessels. C. Pressure tubing is required for intra-arterial blood pressure monitoring. D. Catheter placement in central veins is a less invasive form of hemodynamic monitoring. E. Ventricular arrhythmias can occur during insertion of a pulmonary artery catheter. F. When right atrial pressure is low, it can indicate hypovolemia. G. Normal pulmonary artery occlusion pressure ranges from 5 to 12 mm Hg H. Noninvasive hemodynamic monitoring cannot assess stroke volume and cardiac output. I. A hemodynamic transducer converts mechanical energy into electrical energy

B, C, E, F, G, I Invasive hemodynamic monitoring does provide maximum data; however, it involves significant risk. HD monitoring does directly measure pressures in the heart and great vessels. Pressure tubing is required for intra-arterial blood pressure monitoring because the arterial vascular system is a high-pressure system. Catheter placement in the central veins is a more (not less) invasive form of HD monitoring. Ventricular arrhythmias can occur during and following the insertion of a pulmonary artery catheter. Low right atrial pressure does indicate hypovolemia. Normal pulmonary artery occlusion pressure ranges from 5 to 12 mm Hg. Noninvasive HD monitoring, including finger cuff systems can assess stroke volume cardiac output, and blood pressure. A transducer is used to convert mechanical energy into electrical energy that is displayed as waveforms or numbers on a monitor.

The nurse is assessing a client with right-sided heart failure. What assessment findings will the nurse anticipate? (Select all that apply.) A. Oliguria B. Ascites C. Pulmonary congestion D. Peripheral edema E. Shortness of breath F. Third heart sound

B, D Right-sided heart failure is associated with increased systemic venous pressure and congestion; producing signs such as peripheral edema, ascites, liver enlargement, and neck vein distension. Left-sided heart failure is associated with pulmonary congestion and can produce shortness of breath, weakness, fatigue, oliguria, and a third heart sound (S3 gallop).

A 32-year-old female client is being worked up because of her subjective report of extreme fatigue that has been present for the past 3 months. The nurse is performing the intake assessment. Select the assessment findings that indicate to the nurse that the client's fatigue may be related to a hematologic problem? (Select All That Apply) A. The client reports a 20 lb (9.1kg) weight gain in the past 3 months. B. The conjunctivae are pale. C. The client is a registered nurse who works in the emergency department. D. The client's vital signs include a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and blood pressure of 94/56. E. The client's identical twin sister died of leukemia 2 yr ago. F. The client's most recent health problem was cystitis. G. The client's hobby is quilting. H. The client takes NSAIDs for joint and muscle aches. I. The client is allergic to penicillin. J. The client has a smooth tongue.

B, D, E, H, J The hematologic problem of anemia is associated with pale conjunctivae and low blood viscosity. When blood viscosity of the blood is associated with a low blood pressure. When anemia is present, hypoxemia is present and it leads to compensatory responses of an increased heart rate and respiratory rate. Identical twins share a genetic predisposition to some hematologic problems, including leukemia. Taking NSAIDs of any type regularly increases the risk for bleeding. Aspirin has an even greater effect because the disruption of platelet activity lasts much longer per dose. A smooth tongue is associated with both pernicious anemia and iron-deficiency anemia. The client's weight gain, occupation, hobby, recent bacterial cystitis, and penicillin allergy are not relevant to or associated with anemia or any other possible hematologic problems.

The nurse is assessing a client with arterial insufficiency. What assessment data would cause the nurse to suspect an acute arterial occlusion of the right lower extremity? (Select all that apply.) A. Tachycardia B. Mottling of right foot and lower leg C. Bounding right pedal pulses D. Numbness and tingling of right foot E. Hypertension F. Cold right foot

B, D, F Signs/symptoms of acute arterial occlusion of the right lower extremity include cold right foot, numbness and tingling of the right foot, and mottling and tingling of the right foot. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.

A 45 year old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? (Select all that apply.) A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight

B, D, F Tobacco use, diet, and weight are all considered modifiable risk factors and should be included in the plan of care.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which client statement indicates the need for further teaching? A. "I won't put the salt shaker on the table anymore." B. "I need to avoid eating hamburgers." C. "I need to avoid lunchmeats but may cook my own turkey." D. "I must cut out bacon and canned foods."

B. "I need to avoid eating hamburgers." Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

B. "I need to take potassium supplements with this medication." Spironolactone is a potassium sparing diuretic. This drug can cause hyperkalemia and as such the client would not take potassium supplements with this drug. The statement, "I need to take potassium supplements with this medication" requires additional nursing education. It is appropriate to take the medication daily at the same time, to avoid table salt on food, and the medication does cause increased urination as it is a diuretic.

The client in the cardiac care unit has had a large myocardial infarction. What assessment data indicates to the nurse the onset of left ventricular failure? A. Expectoration of yellow sputum B. Crackles in the lung fields C. Pedal edema D. Urine output of 1500 mL on the preceding day

B. Crackles in the lung fields Signs and symptoms of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields. A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.

A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? A. Shortness of breath and hemoptysis B. Sudden, severe low back pain and bruising along the flank C. Gradually increasing substernal chest pain and diaphoresis D. Rapid development of patchy blue mottling on feet and toes

B. Sudden, severe low back pain and bruising along the flank A sudden onset of low back pain with flank bruising is a classic sign of aneurysm rupture. This is a medical emergency requiring immediate nursing intervention.

The nurse is caring for a client who is being treated for hypertensive crisis. Which prescribed medication would the nurse question? A. Enalapril B. Dopamine C. Labetalol D. Sodium Nitroprusside

B. Dopamine The nurse would question the prescription for dopamine. Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure, and would not be used in hypertensive crisis. Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies. Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies. Labetalol, an intravenous calcium channel blocker, is used in hypertensive crisis when oral therapy is not feasible.

A new nurse is caring for four clients. Which client is at risk for secondary hypertension? A. The client who is physically inactive. B. The client with kidney disease. C. The client with depression. D. The client who eats a high-sodium diet.

B. The client with kidney disease. The client who is most at risk for secondary hypertension is the client with kidney disease. Kidney disease is one of the most common causes of secondary hypertension. Some psychiatric conditions can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High-sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which data is essential for the nurse to assess prior to administration? A. Troponin B. Heart rate C. ST segment D. Myoglobin

B. Heart rate The monitoring of the patient's heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand. ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.

The nurse is preparing to administer digoxin as prescribed to a client with heart failure and notes: Temperature: 99.8° F (37.7° C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action will the nurse take? A. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. B. Hold the digoxin, and obtain a prescription for a potassium supplement. C. Give the digoxin; document assessment findings in the medical record. D. Give the digoxin; reassess the heart rate in 30 minutes.

B. Hold the digoxin, and obtain a prescription for a potassium supplement. The nurse needs to hold the digoxin and gets a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? A. Incisional pain with decreased urine output B. Muffled heart sounds with the presence of JVD C. Sternal wound drainage with nausea D. Increased blood pressure and decreased heart rate

B. Muffled heart sounds with the presence of JVD Symptoms are part of Beck's Triad, which are indicative of tamponade. Incisional pain is expected. While sternal wound drainage is a problem, it is not an indicator of cardiac tamponade. With tamponade, blood pressure will decrease and the heart rate will increase.

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What condition will the nursing suspect? A. Pulmonary embolus B. Renal infarction C. Transient ischemic attack D. Splenic infarction

B. Renal infarction The classic clinical signs of renal infarction, associated with embolization from infective endocarditis, are flank pain, hematuria, and pyuria.

Which intervention provides safety during cardioversion? A. Setting the defibrillator at 220 joules B. Setting the defibrillator to the synchronized mode C. Applying oxygen D. Obtaining informed consent

B. Setting the defibrillator to the synchronized mode Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation. Cardioversion is usually performed starting at a lower rate of 120 to 200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.

Which assessment by a new nurse requires the charge nurse to intervene? A. Assessing pedal pulses by Doppler B. Simultaneously palpating bilateral carotids C. Measuring blood pressure in both arms D. Measuring capillary refill in the fingertips

B. Simultaneously palpating bilateral carotids The vascular assessment by the new nurse that requires intervention by the charge nurse is simultaneously palpating bilateral carotids. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint. Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. Many clients with vascular disease have poor blood flow. Pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is often assessed in both arms.

While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous, and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.

B. Stop suctioning the patient. Removing the noxious stimuli causing the vagal response would be the first action. If this does not resolve the bradycardia, second action would be to administer atropine and call provider. Continuing to suction is not appropriate as this is the cause of the vagal episode.

The nurse is caring for a client receiving intravenous heparin for treatment of DVT that begins to begins to vomit blood. What action should the nurse be prepared to take? A. Administer Vitamin K B. Stop the infusion of heparin C. Administer an antiemetic D. Insert a nasogastric tube

B. Stop the infusion of heparin The nurse should be prepared to stop the infusion of heparin if the client is vomiting blood. The nurse would not administer Vitamin K as that is the antidote for warfarin not heparin. The nurse would not administer an antiemetic as the vomiting is from bleeding. The nurse will not insert a nasogastric tube yet as stopping the heparin may stop the bleeding and insertion of the NG tube with elevated PTT could cause additional bleeding.

Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care? A. Begin chest compressions B. Check carotid pulse C. Notify the Rapid Response Team D. Get the crash cart/AED E. Provide rescue breaths

C, D, B, A, E When the nurse enters the room to find an unresponsive person the order of care is: Call for help (Notify the Rapid Response Team) Secure the crash cart/AED Check the carotid pulse for 5- 10 seconds Begin chest compressions Provide rescue breaths

The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug.

C, D, E Hydrochlorothiazide is a common thiazide diuretic used in the treatment of HTN. This medication can cause excretion of potassium. As such clients should be instructed to increase their dietary intake of potassium. Diuretics should not be taken before bedtime as an increase in urination is expected. Taking at night will prevent the client from sleeping well due to nocturia. Clients with diabetes mellitus must use caution as this drug can alter glucose production.

The nurse in the cardiology clinic is reviewing teaching provided at the client's last appointment regarding hypertension management. Which actions by the client indicate that teaching has been effective? (Select all that apply.) A. Reports walking the neighborhood once weekly. B. Reports eating fast food frequently to cut down on food costs. C. Weight loss of 3 lb (1.4 kg) since last seen in the clinic. D. Reports eating a low-sodium diet. E. Reports drinking one less cup of coffee daily.

C, D, E Teaching about hypertension has been effective when the nurse notes that the client has been on a low-sodium, diet has lost 3 lb (1.4 kg) since the last clinic visit, and has cut down on caffeine. Clients with hypertension need to consume low-sodium foods and would avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure. Although eating out may be cost-saving, fast food is often higher in saturated fat. The goal is to exercise three times and not once weekly.

The nurse is teaching a client the precautions to take while on warfarin therapy. Which client statement demonstrates that teaching has been effective? A. "I can use an electric razor or a regular razor." B. "When taking warfarin, I may notice some blood in my urine." C. "Eating foods like green beans won't interfere with my warfarin therapy." D. "If I notice I am bleeding a lot, I should stop taking warfarin right away."

C. "Eating foods like green beans won't interfere with my warfarin therapy." Teaching about the precautions of warfarin has been effective when the client says "that eating foods like green beans won't interfere with my Coumadin therapy." Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin. Warfarin "thins" the blood, so the risk for cutting oneself and bleeding is very high with the use of a regular razor. The client needs to use an electric razor. Clients must apply pressure to bleeding wounds and must seek medical assistance immediately. While they may need to discontinue warfarin therapy, the priority is to apply pressure to the bleeding area and seek medical care. Blood in the urine of a client taking warfarin therapy is not a side effect. The client must notify the primary health care provider immediately if this occurs.

A client who is 9 days post coronary artery bypass graft presents to a follow up appointment. Which client statement requires nursing action? A. "My chest hurts when I sneeze or cough." B. "If I get tired when I walk, then I stop and rest for a bit." C. "I have a bandage on my sternum to collect the drainage." D. "I haven't had my normal appetite since the surgery."

C. "I have a bandage on my sternum to collect the drainage." Sternal wound infections can develop between 5 days and several weeks following CABG surgery. The client should not be experiencing any drainage from sternum at this time, and the need for a bandage to collect the drainage is indicative of sternal infection. This requires immediate notification of the healthcare provider. It is expected that the client will have chest discomfort when sneezing or coughing because of the sternotomy incision. Resting after walking or walking until tired is also an appropriate method to build stamina following surgery. It is not uncommon to have a decreased appetite for 5 -6 weeks following CABG surgery.

A client who recently had a heart valve replacement is preparing for discharge. What statement by the client indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

C. "I need to take a full course of antibiotics prior to my colonoscopy." Antibiotics are only required prior to dental procedures. Good oral hygiene is the best prevention for endocarditis. The statement in option A is correct and shows the patient understands the need for oral hygiene. The patient with a mechanical valve will be on warfarin thus, foods high in Vitamin K should be avoided. This statement in option B is correct and shows the patient understands foods that are LOW in Vitamin K. This statement in option D is also correct and shows that the patient understands the importance of regular BP assessment as well as when to call the provider based on the assessment.

The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider" C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

C. "I'm glad I don't need to change my diet. Salads are my favorite food." Clients taking warfarin need to avoid foods high in Vitamin K including green leafy vegetables; INR needs to be measured frequently; black stools are a sign of bleeding and should be reported; herbal medications interfere with functioning of coumadin.

A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate? A. "You will need both drugs long term to provide long-term anticoagulation." B. "Warfarin is easier on your stomach so you can take it long term." C. "It takes several days for warfarin to begin working, so both drugs are required for a short time." D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."

C. "It takes several days for warfarin to begin working, so both drugs are required for a short time." Warfarin works in the liver to inhibit synthesis of the four different Vitamin K clotting factors and it takes 3-4 days for the drug to provide therapeutic anticoagulation. As such, many clients are started on heparin therapy as well as warfarin. Both drugs work differently, and the heparin provides rapid anticoagulation that can be discontinued once the warfarin has reaching a therapeutic level as demonstrated by the client's INR.

The nurse is teaching a client with atrial fibrillation about a new prescription for warfarin. What teaching will the nurse include? A. "Avoid caffeinated beverages." B. "You would take aspirin or ibuprofen for headache." C. "Report bruising to your health care provider." D. "It is important to consume a diet high in green leafy vegetables."

C. "Report bruising to your health care provider." Bruising could be indicative of excessive dosing of warfarin. Warfarin is an anticoagulant and causes decreased ability for blood to clot. Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; these vegetables would be eaten in moderate amounts. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time and the international normalized ratio, causing predisposition to bleeding. These agents would be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin.

A client with angina has received education about acute coronary syndrome. Which client statement indicates understanding? A. "Because this is temporary, I don't need medications for my heart." B. "I need to tell my wife I've had a heart attack." C. "This is a warning sign and I need to change my lifestyle to prevent a heart attack." D. "Angina is a temporary blood flow problem that will resolve."

C. "This is a warning sign and I need to change my lifestyle to prevent a heart attack." The statement by the client that angina is a warning sign and needing to alter lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of progression in unstable angina and/or MI. Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A. A 79 year old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min. B. A 55 year old admitted with pulmonary edema who received furosemide and whose current O2 saturation is 94%. C. A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. D. A 68 year old with pericarditis who is reporting sharp chest pain with inspiration.

C. A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. The nurse would first assess the 46 year old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical signs and symptoms of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia. The 55 year old is stable and can be assessed after the client with aortic stenosis. The 68 year old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79 year old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with pericarditis who has a paradoxical pulse and distended jugular veins. B. Client with heart failure who is receiving dobutamine. C. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. D. Client with rheumatic fever who has a new systolic murmur.

C. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What lab values will the nurse anticipate? A. pH 7.51 B. PaO2 106 mmHg C. PaCO2 49 mmHg D. Lactate 0.4 mmol/L

C. PaCO2 49 mmHg The client with hypovolemic shock is most likely experiencing anerobic cellular metabolism. As such, the nurse will anticipate decreased pH, decreased PaO2, increased PaCO2, and increased lactate levels.

The nurse receives a report that a client with a pacemaker has experienced loss of capture. What assessment data would the nurse anticipate? A. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. B. The patient demonstrates hiccups. C. Pacemaker spikes are noted, but no P wave or QRS complex follows. D. The pacemaker spike falls on the T wave.

C. Pacemaker spikes are noted, but no P wave or QRS complex follows. Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode. Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 beats/min with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly. Demand pacing would cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.

A client with peripheral arterial disease (PAD) has a percutaneous vascular intervention. What is the priority nursing assessment? A. Dye allergy B. Gag reflex C. Pedal pulses D. Ankle-brachial index

C. Pedal pulses After a client with PAD has had a percutaneous vascular intervention, it is essential for the nurse to assess for pedal pulses. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring distal pulses to ensure adequate perfusion. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).Ankle-brachial index is a diagnostic study used to detect the presence of PAD. This is not necessary after percutaneous vascular intervention. It is imperative to assess for dye allergy before performing the procedure. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy).

The nurse is caring for a client with heart failure who is on oxygen at 2L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4L. C. Place the client in a high Fowler's position. D. Draw arterial blood for arterial blood gas analysis.

C. Place the client in a high Fowler's position. The first action of the nurse is to place the client in high Fowler's position. This position allows for maximal lung expansion. The nurse can also place pillows under each arm to maximize chest expansion. Repositioning the client with heart failure can improve overall gas exchange. If dyspnea continues the nurse may contact respiratory therapy for a breathing treatment, assess arterial blood gases (as prescribed) or increase oxygen if warranted by ABG results.

The nurse is caring for a client with heart failure in the coronary care unit. The client is exhibiting signs of air hunger and anxiety. Which nursing intervention will the nurse perform first for this client? A. Monitor and document heart rate, rhythm, and pulses. B. Encourage alternate rest and activity periods. C. Position the client to alleviate dyspnea. D. Determine the client's physical limitations.

C. Position the client to alleviate dyspnea. The nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action. Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

The nurse is caring for a client 36 hours after coronary artery bypass grafting. Which assessment causes the nurse to terminate an activity and return the client to bed? A. Incisional discomfort B. HR 72 beats/min and regular C. Respiratory rate 28 breaths/min D. Urinary frequency

C. Respiratory rate 28 breaths/min The activity should be terminated when the nurse assesses the client's respiration rate of 28 breaths/min. This indicates activity intolerance. Pulse 72 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.

The nurse is assessing a client with a cardiac infection. Which nursing assessment data causes the nurse to suspect infective endocarditis instead of pericarditis or rheumatic carditis? A. Thickening of the endocardium B. Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Friction rub auscultated at the left lower sternal border

C. Splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

The nurse is assessing a client with chest pain to evaluate whether the client is experiencing angina or myocardial infarction (MI). Which assessment is indicative of an MI? A. Chest pain brought on by exertion or stress. B. Substernal chest discomfort relieved by nitroglycerin or rest. C. Substernal chest pressure relieved only by opioids D. Substernal chest discomfort occurring at rest.

C. Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI. Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. The nurse monitors the client's pulse and blood pressure frequently. B. The client ambulates around the nursing unit with a walker. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when the client becomes tachycardia.

C. The nurse obtains a bedside commode before administering furosemide. The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation.

The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day. B. "I will restrict my intake of daily dietary lean protein. C. "I am only going to drink one cup of coffee to start my day.". D. "I will drink a glass of low fat milk with my breakfast."

D. "I will drink a glass of low fat milk with my breakfast." The client's statement, "I will drink a glass of low-fat milk with my breakfast" indicated correct understanding of the DASH approach which includes low-fat dairy products. Caffeine (in coffee) should be avoided and sodium should be reduced to an optimal goal of 1500 mg daily. The DASH guidelines do not restrict the intake of lean protein.

A client with hypertension is started on verapamil. What teaching will the nurse provide for this client? A. "Consume foods high in potassium." B. "Monitor for muscle cramping." C. "Monitor for irregular pulse." D. "Avoid grapefruit juice."

D. "Avoid grapefruit juice." The nurse teaches the client who is taking verapamil to avoid grapefruit juice. Grapefruit juice must be avoided with calcium channel blockers, such as verapamil, because it can enhance the action of the drug. Foods high in potassium would be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. Bradycardia, not irregular pulse, is a typical side effect of verapamil. Muscle cramping may occur with statins, not with calcium channel blockers.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I have a headache. May I have some acetaminophen?" B. "I have had hoarseness for a few weeks." C. "I feel my heart beating in my abdominal area." D. "I just started to feel a pain in my belly and low back."

D. "I just started to feel a pain in my belly and low back." The nurse suspects dissection of an AAA when the client says that "I just started to feel a tearing pain in my belly." Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA. The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which client statement indicates understanding of the teaching? A. "I should expect occasional chest pain." B. "I will try walking for 1 hour each day." C. "I will report to the provider weight loss of 2 to 3 lb (0.9 to 1.4 kg) in a day." D. "I will call the provider if I have a cough lasting 3 or more days."

D. "I will call the provider if I have a cough lasting 3 or more days." The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs. The client would call the provider for weight gain of 3 lb (1.4 kg) in a week or 1-2 lb (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 m) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

The nurse is caring for a client with intermittent claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management? A. "I need to reduce the number of cigarettes that I smoke each day." B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."

D. "I'll start to exercise gradually, stopping when I have pain." Gradual exercise can improve collateral circulation and decrease pain associated with intermittent claudication. Teach the client to walk until they have pain, then to stop and rest, only to resume walking again. This promotes collateral development. Complete abstinence from smoking is essential to prevent vasoconstriction. While maintaining warmth is good to promote vasodilation, use of a heating pad is not safe due to the decreased sensation that can occur. Elevation of the extremities may be beneficial to reduce swelling; however, they should not be elevated above the heart level.

The nurse is caring a college athlete who collapsed during soccer practice. The client has been diagnosed with hypertrophic cardiomyopathy and states, "This can't be. I am in great shape. I eat right and exercise." Which nursing response is appropriate? A. "How does this make you feel?" B. "This can be caused by taking performance-enhancing drugs." C. "It could be worse if you weren't in good shape." D. "This may be caused by a genetic trait."

D. "This may be caused by a genetic trait." The appropriate nursing response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait. Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

The cardiac care unit charge nurse is assigning clients to the oncoming shift. Which patient is appropriate to assign to a float RN from the medical-surgical unit? A. A 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min. B. An 88-year-old client admitted with elevated troponin level who is hypotensive with a heart rate of 96 beats/min. C. A 71-year-old client admitted for heart failure who is shortness of breath and has a heart rate of 120 to 130 beats/min. D. A 64-year-old client admitted for weakness with sinus bradycardia and heart rate 58 beats/min.

D. A 64-year-old client admitted for weakness with sinus bradycardia and heart rate 58 beats/min. The 64-year-old client has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the patient develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This patient can be managed by a nurse with less cardiac dysrhythmia training. The 71-year-old client is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old client is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old client is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse.

Which client who has just arrived in the emergency department does the nurse assess as emergent and in need of immediate medical evaluation? A. A 64 year old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C). B. A 60 year old with venous insufficiency who has new-onset right calf pain and tenderness. C. A 69 year old with a 40-pack-year cigarette history who is reporting foot numbness. D. A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic.

D. A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic. The client who just arrived in the ED and needs immediate medical evaluation is the 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic. This client's history and clinical signs and symptoms suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery. The 64 year old is most stable and can be seen last. The 60 year old and the 69 year old would both be seen soon, but the 70-year-old client must be seen first.

Which assessment data indicates proper function of the sinoatrial (SA) node? A. The QRS complex is present B. The ST segment is elevated. C. The PR interval is 0.24 second. D. A P wave precedes every QRS complex.

D. A P wave precedes every QRS complex. A P wave is generated by the SA node and represents atrial depolarization and needs to be followed by a QRS complex. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead. The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Normal PR level is up to 0.20 seconds. Elevation of the ST segment indicates myocardial injury.

The nurse is caring for a client with hypovolemic shock that is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action? A. Insert a large bore IV catheter. B. Administer supplemental oxygen. C. Elevate the client's feet, keeping the head flat. D. Apply direct pressure to the area of overt bleeding.

D. Apply direct pressure to the area of overt bleeding. The priority nursing action is to apply direct pressure to the area of overt bleeding. The nurse will first apply pressure then elevate the client's feet, administer supplemental oxygen if oxygen saturations are below 92% and insert a large bore IV catheter.

The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8° F (37° C). All of these medications are available on the medication record. What action will the nurse take? A. Administer clonidine. B. Administer atropine. C. Administer digoxin. D. Continue to monitor.

D. Continue to monitor. The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs. Atropine is used in emergency treatment of symptomatic bradycardia. This patient has a normal sinus rhythm. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse anticipate administering? A. Magnesium sulfate B. Atropine C. Dobutamine D. Heparin

D. Heparin The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin, warfarin, and novel oral anticoagulants, when nonvalvular, such as dabigatran, rivaroxaban, apixaban, or edoxaban) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.

The nurse is caring for client who is experiencing occasional premature ventricular contractions. What is assessment data is most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking

D. History of smoking The client's potassium, magnesium, and heart rate are within normal limits. Nicotine can be a cause of premature ventricular contractions (PVSs) and should be discussed with this provider and the client.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? A. Administers oxygen therapy. B. Provides pain relief medication. C. Remains calm and stays with the client. D. Obtains the client's description of the chest discomfort.

D. Obtains the client's description of the chest discomfort. A description of the chest discomfort must be obtained first, before further action can be taken. Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first. Remaining calm and staying with the client are important but are not matters of highest priority.

A client is receiving unfractionated heparin (UFH) by infusion. What laboratory data will the nurse report to the primary health care provider (PCP)? A. Hemoglobin 12.2 g/dL (122 mmol/L) B. White blood cells 11,000/mm3 (11 × 109/L) C. Partial thromboplastin time (PTT) 60 seconds D. Platelets 32,000/mm3 (32 × 109/L)

D. Platelets 32,000/mm3 (32 × 109/L) When caring for a client receiving UFH, the nurse notifies the PCP of a platelet level of 32,000/mm3 (32 × 109/L). UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm3 (100 to 120 × 109/L).A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.

A client admitted after using cocaine develops ventricular fibrillation. After determining unresponsiveness, which action will the nurse take next? A. Place an oral airway and ventilate. B. Start cardiopulmonary resuscitation (CPR). C. Establish IV access. D. Prepare for defibrillation.

D. Prepare for defibrillation. Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols. After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.

The nurse is caring for a client with peripheral arterial disease (PAD). Which symptom will the nurse anticipate? A. Decreased pain when legs are elevated B. Unilateral swelling of affected leg C. Pulse oximetry reading of 90% D. Reproducible leg pain with exercise

D. Reproducible leg pain with exercise The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.

Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99° F (37.2° C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.

D. Serum lactate and serum potassium levels are declining. Serum lactate levels and serum potassium levels both rise when shock progresses and more tissues are metabolizing under anaerobic conditions. A decline in both values indicates that the client is responding to the current interventions for hypovolemic shock. Oxygen saturation staying the same suggests that the shock is not progressing at this time but does not indicate the interventions are correcting shock. The increase in body temperature is not great enough to indicate improvement or worsening of shock. The fact that the client can correctly state the month and the year by itself does not indicate improvement because information is not provided about his or her earlier cognition or level of consciousness.

A client with heart failure is prescribed furosemide. Which assessment data concerns the nurse with this new prescription? A. Serum sodium level of 135 mEq/L (135 mmol/L) B. Serum magnesium level of 1.9 mEq/L (0.95 mmol/L) C. Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) D. Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

D. Serum potassium level of 2.8 mEq/L (2.8 mmol/L) The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.

A client's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? A. Sinus rhythm with premature ventricular contractions B. Normal sinus rhythm C. Sinus bradycardia D. Sinus tachycardia

D. Sinus tachycardia These are the characteristics of sinus tachycardia. A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.

After receiving change-of-shift report in the coronary care unit, which client will the nurse assess first? A. The client who had a percutaneous coronary angioplasty who has a dose of heparin scheduled. B. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction. C. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min. D. The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea.

D. The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea. The nurse needs to first assess the client with acute coronary syndrome with dyspnea and weight gain. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention. A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate.

A client begins therapy with lisinopril. What does the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The potential for bradycardia C. Liver function tests D. The risk for hypotension

D. The risk for hypotension At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

A 68-year-old male client is admitted to the hospital following two transient ischemic attacks (TIAs). This afternoon he had a cerebral angiogram to determine if he has any blood vessel strictures or blockages. The night nurse reviews the day nurse's notes for the client. Nurses' Notes 3/16/20 1800 Client is alert and oriented, but remains drowsy from sedation for the angiogram earlier this afternoon. VSS. Small amount of bright red blood on femoral insertion site dressing. Client reported that he took his own ibuprofen this morning to help with arthritic pain. Drinking adequate amounts of fluids but ate little dinner. The night nurse would check the client's ___________________ because he is at high risk for ___________________. The nurse would also teach the client to avoid taking ___________________ because these drugs can cause hemorrhage and ___________________. (Line 1 Options: Vital signs, Needle insertion site, Level of consciousness, Oxygen saturation, Distal pulses) (Line 2 Options: Unconsciousness, Bleeding, Respiratory failure, Dysrhythmias, Stroke) (Line 3 Options: Antibiotics, NSAIDs, Antidepressants, Antihypertensives, Diuretics) (Line 4 Options: Liver damage, Allergic rea

Needle Insertion Site, Bleeding, NSAIDS, Liver Damage

Supraventricular Tachycardia (SVT)

P and T waves are hidden behind each other (merged into one wave)

A 74-year-old male was evaluated in the emergency department due to pain with ambulation. The client states, "I can only walk so far and then my leg hurts so bad I can't continue."; The client also reports that his right foot feels like it is "burning." Choose the most likely options for the information missing from the statements by selecting from the list of options provided. Note that not all options will be used. Due to the client's reports he is most likely at risk for ___________________. To prevent complications, the client should ___________________ when sitting down and ___________________ ambulation. The client is at risk of ulcers ___________________. (Options: Peripheral arterial disease, Peripheral venous disease, Wear slippers, Avoid crossing legs, Slowly increase, Decrease, Between toes, On the ankle)

Peripheral Arterial Disease, Avoid Crossing Legs, Slowly Increase, Between Toes The client is most likely at risk for peripheral arterial disease as his reports are consistent with intermittent claudication. To prevent complications, the client should avoid crossing legs and slowly increase ambulation as this may promote collateral circulation in the extremity. Arterial ulcers typically form on the end or between the toes.

A 65-year old male client with Class III heart failure is admitted from home to the hospital with increasing shortness of breath. According to his wife, he needs assistance with ADLs because he "can't do anything without being short of air". Due to the client's heart failure, he is currently most likely at risk for ___________________ and ___________________. (Options: Pulmonary edema, Pressure injury, Aspiration, Falling, Decreased perfusion, Urinary incontinence, Bleeding, Diabetes mellitus) During his hospital stay, he is also most likely at risk for complications associated with decreased perfusion, especially ___________________ and ___________________. (Options: Increased stroke volume, Reduced afterload, Increased preload, Reduced preload, Increased afterload, Increased contractility)

Pulmonary Edema, Decreased Perfusion, Increased Afterload, Increased Preload