Cardiac - Prep-U/Test Bank

What is the nurses first action when planning to teach the parents of an infant with a CHD? A. Assess the parents anxiety level and readiness to learn B. Gather literature for the parents C. Secure a quiet place for teaching D. Discuss the plan with the nursing team

A. Assess the parents anxiety level and readiness to learn Rationale: Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing level of anxiety is often needed before new information can be processed.

The nurse is addressing exercise and physical activity during discharge education with a client diagnosed with heart failure. What should the nurse teach this client about exercise? A. "Do not exercise unsupervised." B. "Eventually aim to work up to 30 minutes of exercise each day." C. "Keep exercising but slow down if you get dizzy or short of breath." D. "Start your exercise program with high-impact activities."

B. "Eventually aim to work up to 30 minutes of exercise each day." Rationale: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms, such as dizziness or shortness of breath, should prompt the client to stop exercising, not simply to slow the pace. Low-impact activities should be prioritized.

The nurse's comprehensive assessment of a client who has heart failure includes evaluation of the client's hepatojugular reflux. What action should the nurse perform during this assessment? A. Elevate the client's head to 90 degrees. B. Press the right upper abdomen. C. Press above the client's symphysis pubis. D. Lay the client flat in bed.

B. Press the right upper abdomen. Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux.

A nurse is working with a client who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the client? A. The client will remain on bed rest for 48 to 72 hours after the procedure. B. The client will be given vitamin K infusions to prevent bleeding following PCI. C. A sheath will be placed over the insertion site after the procedure is finished. D. The procedure will likely be repeated in 6 to 8 weeks to ensure success.

C. A sheath will be placed over the insertion site after the procedure is finished. Rationale: A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Clients resume activity a few hours after PCI and repeated treatments may or may not be necessary. Anticoagulants, not vitamin K, are given during PCI.

Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of which complication? A. Pulmonary edema B. Pericardiocentesis C. Cardiac tamponade D. Pericarditis

C. Cardiac tamponade Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiologic process.

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting? A. Monitor and record blood pressure daily. B. Monitor and record radial pulses daily. C. Monitor weight daily. D. Monitor bowel movements.

C. Monitor weight daily. Rationale: To assess fluid balance at home, the client should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.

The ED nurse is caring for a client with a suspected MI. What drug should the nurse anticipate administering to this client? A. Oxycodone B. Warfarin C. Morphine D. Acetaminophen

C. Morphine Rationale: The client with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta-blocker, and other medications as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.

The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A. Coronary artery bypass graft (CABG) B. Percutaneous transluminal coronary angioplasty (PTCA) C. Atherectomy D. Cardiopulmonary bypass

D. Cardiopulmonary bypass Rationale: Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.

When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? A. A diastolic blood pressure that is lower during exhalation B. A diastolic blood pressure that is higher during inhalation C. A systolic blood pressure that is higher during exhalation D. A systolic blood pressure that is lower during inhalation

D. A systolic blood pressure that is lower during inhalation Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.

The nurse has entered a client's room and found the client unresponsive and not breathing. What is the nurse's next appropriate action? A. Palpate the client's carotid pulse. B. Illuminate the client's call light. C. Begin performing chest compressions. D. Activate the Emergency Response System (ERS).

D. Activate the Emergency Response System (ERS). Rationale: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.

The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client's risk for heart failure? A. The client takes furosemide 20 mg/day. B. The client's potassium level is 4.7 mEq/L. C. The client is white. D. The client's age is greater than 65.

D. The client's age is greater than 65. Rationale: Heart failure is the most common reason for hospitalization of people older than 65 years of age and is the second-most common reason for visits to a physician's office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for heart failure. The fact that the client takes furosemide 20 mg/day does not indicate an increased risk for heart failure, although this drug is often used in the treatment of heart failure. The client being white indicates a decreased risk for heart failure compared with Black and Hispanic clients.

The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be: A. drug therapy and smoking cessation. B. diet and drug therapy. C. diet therapy only. D. diet therapy and smoking cessation.

D. diet therapy and smoking cessation. Rationale: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostic findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

For what reason might a newborn infant with a cardiac defect, such as a coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? A. to decrease inflammation B. to control pain C. to decrease respirations D. to improve oxygenation

D. to improve oxygenation Rationale: Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent. This will improve oxygenation.

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure? A. An S3 heart sound B. Pleural friction rub C. Faint breath sounds D. A heart murmur

A. An S3 heart sound Rationale: An S3 heart sound is a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. Heart failure does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of heart failure.

A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi? A. Atrial fibrillation B. Infective endocarditis C. Recurrent pneumonia D. Recent surgery

A. Atrial fibrillation Rationale: Intracardiac thrombi are especially common in clients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.

The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis? A. Pulmonary edema B. Distended neck veins C. Dry cough D. Orthopnea

B. Distended neck veins Rationale: Right-sided heart failure may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers are not characteristic signs of right-sided heart failure.

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects? A. Nervousness or paresthesia B. Throbbing headache or dizziness C. Drowsiness or blurred vision D. Tinnitus or diplopia

B. Throbbing headache or dizziness Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.

The nurse discovers a heart murmur in an infant 1 hour after birth. She is aware that feta shunts are closed in the neonate at what point? A. When the umbilical cord is cut B. Within several days of birth C. Within a month after birth D. By the end of the first year of life

B. Within several days of birth Rationale: In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several day to complete.

The nurse is caring for an older adult client who has just returned from the operating room (OR) after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery, and the client has a history of coronary artery disease, increasing the risk for left-sided heart failure. Which signs and symptoms indicating this condition would the nurse look for? A. Jugular vein distention B. Right upper quadrant pain C. Bibasilar fine crackles D. Dependent edema

C. Bibasilar fine crackles Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

The triage nurse in the emergency department is performing a rapid assessment of a client with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, which action would the nurse take first? A. Check for a carotid pulse. B. Apply supplemental oxygen. C. Give two full breaths. D. Gently shake and shout, "Are you OK?"

D. Gently shake and shout, "Are you OK?" Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.

The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm? A. Pulseless electrical activity (PEA) B. Ventricular fibrillation C. Ventricular tachycardia D. Asystole

D. Asystole Rationale: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.

A client presents to the clinic reporting intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause? A. Decreased cardiac output B. Decreased cardiac contractility C. Infarction of the myocardium D. Coronary arteriosclerosis

D. Coronary arteriosclerosis Rationale: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should monitor what assessment information? A. Skin turgor B. Potassium level C. White blood cell count D. Peripheral pulses

B. Potassium level Rationale: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.

The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the client. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A. P-wave inversion B. T-wave inversion C. Qwave changes with no change in ST or T wave D. P-wave enlargement

B. T-wave inversion Rationale: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. Which medication would the nurse anticipate administering to this client? A. A beta-adrenergic blocker B. An antiplatelet aggregator C. A calcium channel blocker D. A nonsteroidal anti-inflammatory drug (NSAID)

A. A beta-adrenergic blocker Rationale: Several medications are routinely prescribed for systolic heart failure, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.

The nurse providing care for a client post PTCA knows to monitor the client closely. For what complications should the nurse monitor the client? Select all that apply. A. Abrupt closure of the coronary artery B. Venous insufficiency C. Bleeding at the insertion site D. Retroperitoneal bleeding E. Arterial occlusion

A. Abrupt closure of the coronary artery C. Bleeding at the insertion site D. Retroperitoneal bleeding E. Arterial occlusion Rationale: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute kidney injury. Venous insufficiency is not a postprocedure complication of a PTCA.

A cardiac client's resistance to left ventricular filling has caused blood to back up into the client's circulatory system. Which health problem is likely to result? A. Acute pulmonary edema B. Right-sided heart failure C. Right ventricular hypertrophy D. Left-sided heart failure

A. Acute pulmonary edema Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The client quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided heart failure, left-sided heart failure, and right ventricular hypertrophy do not directly occur.

Before giving a dose of digoxin (Lanoxin), the nurse checked an infant's apical heart rate and it was 114 bpm. What should the nurse do next? A. Administer the dose as ordered. B. Hold the medication until the next dose. C. Wait and recheck the apical heart rate in 30 minutes. D. Notify the physician about the infant's heart rate.

A. Administer the dose as ordered. Rationale: The infants heart rate is above the lower limit for which the medication is held (100 BPM), the dose can be given.

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? Select all that apply. A. Improve functional status B. Prevent endocarditis. C. Extend survival. D. Limit physical activity. E. Relieve client symptoms.

A. Improve functional status C. Extend survival. E. Relieve client symptoms. Rationale: The overall goals of management of heart failure are to relieve the client's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of heart failure and preventing it is not a major goal of care.

A client presents to the ED reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A. Begin ECG monitoring. B. Obtain information about family history of heart disease. C. Auscultate lung fields. D. Determine if the client smokes.

A. Begin ECG monitoring. Rationale: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a client reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the client smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.

A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment? A. Blood pressure B. Level of consciousness (LOC) C. Nausea D. Oxygen saturation

A. Blood pressure Rationale: Clients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in clients with heart failure, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply. A. Confusion B. Shortness of breath C. Numbness and tingling in the extremities D. Chest pain E. Bradycardia F. Diuresis

A. Confusion E. Bradycardia Rationale: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.

A nurse educator is conducting an inservice for nursing students about how tobacco use impacts coronary artery disease (CAD)? What are the primary ways that tobacco use impacts CAD? Select all that apply. A. Decreases the supply of oxygen to the myocardium B. Increases platelet adhesion C. Raises the heart rate and blood pressure D. Causes the coronary arteries to dilate E. Increases the blood carbon monoxide level

A. Decreases the supply of oxygen to the myocardium B. Increases platelet adhesion C. Raises the heart rate and blood pressure E. Increases the blood carbon monoxide level Rationale: Nicotinic acid in tobacco triggers the release of catecholamines (hormones that are released due to stress), which raise the heart rate and blood pressure and cause coronary arteries to constrict. This increases the risk of CAD and sudden cardiac death. Tobacco use also increases oxidation of low-density lipoprotein (good) cholesterol, which results in increased platelet adhesion and thrombus formation. Ischemia and reduced contractility can result in the increase in carbon monoxide levels and decreased oxygenation of the myocardium.

The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A. Dyspnea B. Unusual fatigue C. Hypotension D. Syncope E. Peripheral cyanosis

A. Dyspnea B. Unusual fatigue D. Syncope Rationale: Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.

A client with a diagnosis of heart failure is started on a beta-blocker. What is the nurse's priority role during gradual increases in the client's dose? A. Educating the client that symptom relief may not occur for several weeks B. Stressing that symptom relief may take up to 4 months to occur C. Making adjustments to each day's dose based on the blood pressure trends D. Educating the client about the potential changes in LOC that may result from the drug

A. Educating the client that symptom relief may not occur for several weeks Rationale: An important nursing role during titration is educating the client about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.

The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response? A. Explore the factors underlying the client's anxiety. B. Teach the client guided imagery techniques. C. Obtain an order for a PRN benzodiazepine. D. Describe the procedure in greater detail.

A. Explore the factors underlying the client's anxiety. Rationale: An assessment of anxiety levels is required in the client to assist the client in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the client's anxiety before providing interventions such as education or medications.

The nurse is creating a care plan for a client diagnosed with heart failure. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A. Facilitate the presence of friends and family whenever possible. B. Teach the client about the harmful effects of anxiety on cardiac function. C. Provide supplemental oxygen, as needed. D. Provide validation of the client's expressions of anxiety. E. Administer benzodiazepines two to three times daily.

A. Facilitate the presence of friends and family whenever possible. C. Provide supplemental oxygen, as needed. D. Provide validation of the client's expressions of anxiety. Rationale: The nurse should empathically validate the client's sensations of anxiety. The presence of friends and family is frequently beneficial, and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some clients, but alternative methods of relief should be prioritized. As well, medications are given on a PRN basis. Teaching the client about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.

A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client? A. In a high Fowler position B. On the left side-lying position C. In a flat, supine position D. In the Trendelenburg position

A. In a high Fowler position Rationale: Proper positioning can help reduce venous return to the heart. The client is positioned upright. If the client is unable to sit with the lower extremities dependent, the client may be placed in an upright position in bed. The supine and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying position does not promote circulation.

The nurse is caring for a client who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A. Increase in the size of the artery's lumen B. Decrease in arterial blood flow in relation to venous flow C. Increase in the client's resting heart rate D. Increase in the client's level of consciousness (LOC)

A. Increase in the size of the artery's lumen Rationale: PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the client's LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.

The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. Which medical intervention can be performed that may extend the survival of the client? A. Insertion of an implantable cardioverter defibrillator (ICD) B. Insertion of an implantable pacemaker C. Administration of a calcium channel blocker D. Administration of a beta-blocker

A. Insertion of an implantable cardioverter defibrillator (ICD) Rationale: In clients with severe left ventricular dysfunction and the possibility of life-threatening dysrhythmias, placement of an ICD can prevent sudden cardiac death and extend survival. A pacemaker, a calcium channel blocker, and a beta-blocker are not medical interventions that may extend the survival of the client with left ventricular dysfunction.

The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium? A. It may have developed an increased area of infarction during the time without treatment. B. It will probably not have more damage than if the client came in immediately. C. It may be responsive to restoration of the area of dead cells with proper treatment. D. It has been irreparably damaged, so immediate treatment is no longer necessary.

A. It may have developed an increased area of infarction during the time without treatment. Rationale: When the client experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.

The nurse is providing client education prior to a client's discharge home after treatment for heart failure. The nurse gives the client a home care checklist as part of the discharge teaching. What should be included on this checklist? A. Know how to recognize and prevent orthostatic hypotension. B. Weigh yourself weekly at a consistent time of day. C. Measure everything you eat and drink until otherwise instructed. D. Limit physical activity to only those tasks that are absolutely necessary.

A. Know how to recognize and prevent orthostatic hypotension. Rationale: Clients with heart failure should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.

The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? A. Lipids and fibrous tissue B. White blood cells C. Lipoproteins D. High-density cholesterol

A. Lipids and fibrous tissue Rationale: As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.

Cardiopulmonary resuscitation has been initiated on a client who was found unresponsive. When performing chest compressions, the nurse should do which of the following actions? A. Perform at least 100 chest compressions per minute. B. Pause to allow a colleague to provide a breath every 10 compressions. C. Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D. Perform high-quality chest compressions as rapidly as possible.

A. Perform at least 100 chest compressions per minute. Rationale: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitator's goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10 compressions to allow for a breath or for full vital signs monitoring.

A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's lab values, the nurse is not surprised to notice which abnormality? A. Polycythemia B. Infection C. Dehydration D. Anemia

A. Polycythemia Rationale: Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood.

A cardiovascular client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. Which action is the nurse's best action? A. Rapidly assess the client's cardiopulmonary status. B. Arrange for an electrocardiogram (ECG). C. Increase the height of the client's bed. D. Manage the client's anxiety.

A. Rapidly assess the client's cardiopulmonary status. Rationale: Client management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the client, even though each of these actions may be appropriate and necessary.

A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect? A. Reducing the heart's workload by decreasing heart rate and myocardial contraction B. Preventing platelet aggregation and subsequent thrombosis C. Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart D. Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain

A. Reducing the heart's workload by decreasing heart rate and myocardial contraction Rationale: Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are given to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.

A nurse in the critical care unit is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of which sequela? A. Stroke B. Myocardial infarction (MI) C. Hemorrhage D. Peripheral edema

A. Stroke Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.

The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs? A. The client experiences chest pain, palpitations, or dyspnea. B. The client experiences a noticeable increase in heart rate during activity. C. The client's oxygen saturation level drops below 96%. D. The client's respiratory rate exceeds 30 breaths/min.

A. The client experiences chest pain, palpitations, or dyspnea. Rationale: Any activity or exercise that causes dyspnea and chest pain should be stopped in the client with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most clients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.

In which situation is there a risk that a newborn infant will have a CHD? A. Trisomy 21 detected on amniocentesis B. Family history of MI C. Father has T1 diabetes D. Over sibling born with Turner syndrome

A. Trisomy 21 detected on amniocentesis Rationale: The incidence of CHD is approximately 50% in children with trisomy 21 (Down syndrome)

Which CHD results in increased pulmonary blood flow? A. Ventricular septal defect B. Coarctation of the aorta C. Tetralogy of Fallot D. Pulmonary stenosis

A. Ventricular septal defect Rationale: Ventricular septal defect causes a left-to-right shunting of blood, thus increasing pulmonary blood flow. Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal distal aorta. TOF results in a right-to-left shunting of blood, thus decreasing pulmonary blood flow. Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery, decreasing pulmonary blood flow.

What intervention should be included in the plan of care for an infant with the nursing diagnosis of excess fluid volume related to congestive heart failure? A. Weigh the infant every day on the same scale at the same time B. Notify the physician when weight gain exceeds more than 20 g/day C. Put the infant in a car seat to minimize movement D. Administer digoxin (Lanoxin) as ordered by the physician

A. Weigh the infant every day on the same scale at the same time Rationale: Weight changes may indicate fluid retention. An excessive weight gain for an infant is an increase of more than 50 g/day. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid.

A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A. Right-sided heart failure B. Acute pulmonary edema C. Pneumonia D. Cardiogenic shock

B. Acute pulmonary edema Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia

A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional teaching plan has been effective? A. "I will have a ham and cheese sandwich for lunch." B. "I will have a baked potato with broiled chicken for dinner." C. "I will have a tossed salad with cheese and croutons for lunch." D. "I will have chicken noodle soup with crackers and an apple for lunch."

B. "I will have a baked potato with broiled chicken for dinner." Rationale: The client's choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.

In preparation for cardiac surgery, a client was taught about measures to prevent venous thromboembolism. What statement indicates that the client clearly understood this education? A. "I'll try to stay in bed for the first few days to allow myself to heal." B. "I'll make sure that I don't cross my legs when I'm resting in bed." C. "I'll keep pillows under my knees to help my blood circulate better." D. "I'll put on those compression stockings if I get pain in my calves."

B. "I'll make sure that I don't cross my legs when I'm resting in bed." Rationale: To prevent venous thromboembolism, clients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

A nurse is assigned four clients with diagnoses that rule out myocardial infarction (MI) due to chest pain. Which client's test results best demonstrate the specific diagnosis of unstable angina (USA)? A. A 63-year-old client with elevated troponins and no elevation in the ST segment. B. A 72-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponins. C. A 54-year-old client with elevated creatine kinase myocardial band (CK-MB) and ST segment elevations in two contiguous leads on the electrocardiogram (ECG). D. A 48-year-old client with T wave inversions, ST elevation, and abnormal Q waves.

B. A 72-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponins. Rationale: The 72-year-old client with chest pain had clinical manifestations of coronary ischemia, but the ECG showed no evidence of an acute MI. The 72-year-old client had an elevated myoglobin, which is a biomarker but is not a very specific indicator of a cardiac event because an elevation may also occur due to seizures, muscle diseases, trauma, and surgery. The 63-year-old client had test results consistent with a non-ST-elevated myocardial infarction: elevated cardiac biomarkers but no ECG evidence of an acute MI. The 48- and 54-year-old clients had test results consistent with an ST-elevated myocardial infarction: elevated cardiac biomarkers, ECG changes in two contiguous leads, ST elevation, and Q wave abnormalities.

The nurse is creating a plan of care for a client with acute coronary syndrome. What nursing action should be included in the client's care plan? A. Facilitate daily arterial blood gas (ABG) sampling. B. Administer supplementary oxygen, as needed. C. Have client maintain supine positioning when in bed. D. Perform chest physiotherapy, as indicated.

B. Administer supplementary oxygen, as needed. Rationale: Oxygen should be given along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.

What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? A. Recheck the infants blood pressure B. Alert the physician C. Withhold oral feeding D. Increase the oxygen rate

B. Alert the physician Rationale: These are signs of early congestive heart failure and the physician should be notified.

A child had an aortic stenosis defect surgically repaired 6 months ago. Which antibiotic prophylaxis is indicated for an upcoming tonsillectomy? A. No antibiotic prophylaxis is necessary. B. Amoxicillin is taken orally 1 hour before the procedure. C. Oral penicillin is given for 7 to 10 days before the procedure. D. Parenteral antibiotics are administered for 5 to 7 days after the procedure.

B. Amoxicillin is taken orally 1 hour before the procedure. Rationale: The standard prophylactic agent is amoxicillin given orally 1 hour before the procedure. Antibiotic prophylaxis is indicated for the first 5 months after surgical repair. The treatment for infective endocarditic involve parenteral antibiotics for 2-8 weeks.

A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. The complications for which the nurse should monitor the client include which of the following? A. Peripheral edema B. Bleeding at insertion site C. Left ventricular hypertrophy D. Pulmonary edema

B. Bleeding at insertion site Rationale: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include left ventricular hypertrophy because this problem takes an extended time to develop and is not emergent. Bleeding is a more likely and more serious complication than edema.

The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize? A. Monitoring liver function studies B. Blood pressure C. Vitamin D intake D. Monitoring potassium levels

B. Blood pressure Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the client at risk of hypotension. Clients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.

A nurse has taken on the care of a client who had a coronary artery stent placed yesterday. When reviewing the client's daily medication administration record, the nurse should anticipate administering what drug? A. Ibuprofen B. Clopidogrel C. Dipyridamole D. Acetaminophen

B. Clopidogrel Rationale: Because of the risk of thrombus formation within the stent, the client receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.

Which strategy is appropriate when feeding the infant with congestive heart failure? A. Continue the feeding until a sufficient amount of formula is taken B. Limit feeding time to no more than 30 minutes C. Always bottle feed every 4 hours D. Feed larger volumes of concentrated formula less frequently

B. Limit feeding time to no more than 30 minutes Rationale: an infant with CHF may tire easily, so the feeding should not be continued beyond 30 minutes. If inadequate amounts of formula are taken, gavage feedings should be considered.

An adult client is admitted to the ED with chest pain. The client states that there was unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A. Thrombolytics (fibrinolytics), oxygen administration, and nonsteroidal anti-inflammatories B. Morphine sulphate, oxygen, and bed rest C. Oxygen and beta-adrenergic blockers D. Bed rest, albuterol nebulizer treatments, and oxygen

B. Morphine sulphate, oxygen, and bed rest Rationale: The client with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

Before preparing a teaching plan for the parents of an infant with ductus arteriosus, it is important that the nurse understands this condition. Which statement best describes patent ductus arteriosus? A. PDA involve a defect that results in a right-to-left shunting of blood in the heart B. PDA involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close C. PDA is a stenotic lesion that must be surgically corrected at birth D. PDA causes an abnormal opening between the four chambers of the heart

B. PDA involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close Rationale: PDA is failure of the fetal shunt between the aorta and the pulmonary artery to close

The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which CHD? A. Pulmonary stenosis B. Patent doctor arteriosus C. Ventricular septal defect D. Coarctation of the aorta

B. Patent doctor arteriosus Rationale: The classic murmur associated with PDA is a machinery-like one that can be heard throughout both systole and diastole. A systolic ejection murmur that may be accompanied by a palpable thrill is a manifestation of pulmonary stenosis. The characteristic murmur associated with ventricular septal defect is a loud, hard, holosystolic murmur. A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present.

The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of oral diuretics? A. Avoid drinking fluids for 2 hours after taking the diuretic. B. Take the diuretic in the morning to avoid interfering with sleep. C. Avoid taking the medication within 2 hours consuming dairy products. D. Take the diuretic only on days when experiencing shortness of breath.

B. Take the diuretic in the morning to avoid interfering with sleep. Rationale: Oral diuretics should be given early in the morning so that diuresis does not interfere with the client's nighttime rest. Discussing the timing of medication administration is especially important for older adult clients who may have urinary urgency or incontinence. The nurse would not teach the client about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.

The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock? A. The client admitted with acute renal failure B. The client admitted following an MI C. The client admitted with malignant hypertension D. The client admitted following a stroke

B. The client admitted following an MI Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While clients with acute kidney injury are at risk for dysrhythmias and clients experiencing a stroke are at risk for thrombus formation, the client admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.

When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information? A. The client's activities, limitations, and level of consciousness after the attacks B. The client's symptoms and the activities that precipitate attacks C. The client's understanding of the pathology of angina D. The client's coping strategies surrounding the attacks

B. The client's symptoms and the activities that precipitate attacks Rationale: The nurse must gather information about the client's symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The client's coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

An adolescent being seen by the nurse practitioner for a sports physical is identified as having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The initial treatment of secondary hypertension usually involves: A. weight control and diet B. treating the underlying disease C. administration of digoxin D. administration of beta-adrenergic receptor blockers

B. treating the underlying disease Rationale: Identification of the underlying disease should be the first step in treating secondary hypertension

The nurse is writing a care plan for a client who has been diagnosed with angina pectoris. The client describes herself as being "distressed" and "shocked" by the new diagnosis. What nursing diagnosis is most clearly suggested by the client's statement? A. Spiritual distress related to change in health status B. Acute confusion related to prognosis for recovery C. Anxiety related to cardiac symptoms D. Deficient knowledge related to treatment of angina pectoris

C. Anxiety related to cardiac symptoms Rationale: Although further assessment is warranted, it is not unlikely that the client is experiencing anxiety. In clients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to the client's concerns. Similarly, it is not clear that a lack of knowledge or information is the root of the client's anxiety.

The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, which condition is a potential primary cause of the client's heart failure? A. Endocarditis B. Pleural effusion C. Atherosclerosis D. Atrial septal defect

C. Atherosclerosis Rationale: Atherosclerosis of the coronary arteries is the primary cause of heart failure. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of heart failure.

The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments? A. Maximizing cardiac output while minimizing heart rate B. Decreasing energy expenditure of the myocardium C. Balancing myocardial oxygen supply with demand D. Increasing the size of the myocardial muscle

C. Balancing myocardial oxygen supply with demand Rationale: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the client with ACS. Treatment is not aimed directly at minimizing heart rate because some clients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardium's energy expenditure is often beneficial, but this must be balanced with productivity.

The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. Which risk factors should the nurse list that can be controlled or modified? A. Gender, obesity, family history, and smoking B. Inactivity, stress, gender, and smoking C. Cholesterol levels, hypertension, and smoking D. Stress, family history, and obesity

C. Cholesterol levels, hypertension, and smoking Rationale: Four modifiable risk factors—cholesterol abnormalities, tobacco use, hypertension, and diabetes—are established risk factors for CAD and its complications. Inactivity and obesity are also modifiable risk factors associated with CAD. Stress, although not listed as a direct risk factor for CAD, contributes to hypertension, which is itself a risk factor. Gender and family history are risk factors that cannot be controlled.

A client is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk? A. Administration of bronchodilators by nebulizer B. Administration of inhaled corticosteroids by metered dose inhaler (MDI) C. Client's consistent performance of deep-breathing and coughing exercises D. Client's active participation in the cardiac rehabilitation program

C. Client's consistent performance of deep-breathing and coughing exercises Rationale: Clearance of pulmonary secretions is accomplished by frequent repositioning of the client, suctioning, and chest physical therapy, as well as educating and encouraging the client to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions.

The nurse is caring for a client with systolic heart failure whose previous adverse reactions rule out the safe use of angiotensin-converting enzyme (ACE) inhibitors. The nurse should anticipate that the prescriber may choose which combination of drugs? A. Loop diuretic and antiplatelet aggregator B. Loop diuretic and calcium channel blocker C. Combination of hydralazine and isosorbide dinitrate D. Combination of digoxin and normal saline

C. Combination of hydralazine and isosorbide dinitrate Rationale: A combination of hydralazine and isosorbide dinitrate may be an alternative for clients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.

A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? A. Document the client's low urine output and monitor closely for the next several hours. B. Contact the dietitian and suggest the need for increased oral fluid intake. C. Contact the client's health care provider and continue to assess fluid balance and renal function. D. Increase the infusion rate of the client's IV fluid to prompt an increase in renal function.

C. Contact the client's health care provider and continue to assess fluid balance and renal function. Rationale: Nursing management includes accurate measurement of urine output. An output of less than 0.5 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A. Ineffective breathing pattern related to decreased cardiac output B. Anxiety related to fear of death C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D. Impaired skin integrity related to CAD

C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) Rationale: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.

A client with type 2 diabetes and hypertension (HTN) has a routine follow-up appointment after a cardiac stent placement. On assessment the nurse notes the client weighs 250 lb/113.4 kg with a waist circumference of 40 inches/101.6 cm, blood pressure is 162/84 mm Hg, and fasting blood glucose is 220 mg/dl. Based on these findings, which syndrome should the nurse most suspect? A. Adams-Nance syndrome B. Postpericardiotomy syndrome C. Metabolic syndrome D. Alagille syndrome

C. Metabolic syndrome Rationale: A cluster of metabolic abnormalities known as metabolic syndrome is a major risk factor for cardiovascular disease. This diagnosis is made when the client has 3 of the 5 risk factors. These factors include a waist circumference of greater than 35.4 inches/89.9 cm, elevated triglycerides, reduced high-density lipoprotein cholesterol, HTN with a systolic blood pressure above 130 mm Hg, and fasting glucose greater than 100 mg/dL or drug treatment for elevated glucose. Adams-Nance syndrome is an inherited disorder characterized by paroxysmal tachycardia, arterial HTN, syncope, and seizures. Alagille syndrome is a rare genetic disorder that can affect multiple organ systems including the liver, heart, skeleton, eyes, and kidneys. Based on the information presented neither of the above syndromes is likely. Postpericardiotomy syndrome may occur to clients days or weeks after surgery, so a possibility exists, but the signs and symptoms are not presented. Postpericardiotomy is characterized by fever, pericardial/pleural/joint pain, friction rub, and dyspnea.

A nurse is teaching an adolescent about primary hypertension. Which statement made by the adolescent indicates an understanding of primary hypertension? A. Primary hypertension should be treated with diuretics as soon as it is detected B. CHDs are the most common cause of primary hypertension C. Primary hypertension may be treated with weight reduction D. Primary hypertension is not affected by exercise

C. Primary hypertension may be treated with weight reduction Rationale: Primary hypertension in children may be treated with weight reduction and exercise programs

The nurse notes that a client has developed dyspnea; a productive, mucoid cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem? A. Pericarditis B. Cardiomyopathy C. Pulmonary edema D. Right ventricular hypertrophy

C. Pulmonary edema Rationale: As a result of decreased cerebral oxygenation, the client with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the client's hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.

Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A. The symptoms indicate angina and should be treated as such. B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C. The symptoms indicate an acute coronary episode and should be treated as such. D. Treatment should be determined pending the results of an exercise stress test.

C. The symptoms indicate an acute coronary episode and should be treated as such. Rationale: Angina and MI have similar symptoms and are considered the same process but are on different points along a continuum. That the client's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale, cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.

When assessing a child for possible CHDs, where should the nurse measure blood pressure? A. the right arm B. the left arm C. all four extremities D. both arms while the child is crying

C. all four extremities Rationale: When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease.

The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated? A. Teach the client deep breathing and coughing exercises. B. Administer supplemental oxygen at all times. C. Limit the client's activity level. D. Avoid positioning the client supine.

D. Avoid positioning the client supine. Rationale: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of heart failure and, consequently, the nurse should avoid positioning the client supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.

A client in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in the femoral region. What is the nurse's most appropriate action? A. Call for assistance and initiate cardiopulmonary resuscitation. B. Reposition the client's leg in a nondependent position. C. Promptly remove the femoral sheath. D. Call for help and apply pressure to the access site.

D. Call for help and apply pressure to the access site. Rationale: The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.

The nurse working on the coronary care unit is caring for a client with ACS. How can the nurse best meet the client's psychosocial needs? A. Reinforce the fact that treatment will be successful. B. Facilitate a referral to a chaplain or spiritual leader. C. Increase the client's participation in rehabilitation activities. D. Directly address the client's anxieties and fears.

D. Directly address the client's anxieties and fears. Rationale: Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the client's psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some clients, but it may exacerbate it for others.

What is an expected assessment finding in a child with coarctation of the aorta? A. Orthostatic hypotension B. Systolic hypertension in the lower extremities C. Blood pressure higher on the left side of the body D. Disparity in blood pressure between the upper and lower extremities

D. Disparity in blood pressure between the upper and lower extremities Rationale: Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation. The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities.

An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing concern should be identified? A. Altered tissue perfusion risk related to arrhythmia B. Excess fluid volume risk related to medication regimen C. Altered breathing pattern risk related to hypoxia D. Falls risk related to hypotension

D. Falls risk related to hypotension Rationale: The combination of low BP, diuretic use, and ACE inhibitor use constitutes a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The client's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all clients with heart failure, but this is not in evidence for this client at this time.

An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that what vessel is most commonly used as source for a CABG? A. Brachial artery B. Brachial vein C. Femoral artery D. Greater saphenous vein

D. Greater saphenous vein Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.

The nurse is admitting a child to the hospital for a cardiac workup. What is the first step in a cardiac assessment? A. Percussion B. Palpation C. Auscultation D. History and inspection

D. History and inspection Rationale: The assessment should begin with the least threatening intervention of history and inspection. Percussion of the chest is usually deferred. Assessment progression includes inspection, auscultation, and palpation because each step includes more touching.

Which statement made by a parent indicates understanding of restrictions for a child after cardiac surgery? A. My child needs to get extra rest for a few weeks B. My son is really looking forward to riding his bike next week C. I'm so glad we can attend religious services as a family this coming Sunday D. I am going to keep my child out of daycare for 6 weeks

D. I am going to keep my child out of daycare for 6 weeks Rationale: Settings where large groups of people are present should be avoided for 4-6 weeks after discharge, including daycare. The child should resume regular bedtime and sleep schedule after discharge. Activities during which the child could fall are avoided for 4-6 weeks after discharge.

Which statement suggests that a parent understands how to correctly administer digoxin? A. I measure the amount I am supposed to give with a teaspoon B. I put the medicine in the baby's bottle C. When she spits up right after I give the medicine, I give her another dose D. I give the medicine at 8 in the morning and evening every day

D. I give the medicine at 8 in the morning and evening every day Rationale: For max effectiveness, the medication should be given at the same time every day. The medication should be measured with a syringe to ensure the correct dosage. The medication should not be mixed with formula or food as it is difficult to judge whether the child received the proper dose if placed in food or formula. To prevent toxicity, the parent should not repeat dose without contacting the child's physician.

An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply. A. Shortness of breath B. Chest pain C. Anxiety D. Indigestion E. Nausea

D. Indigestion E. Nausea Rationale: Many women experiencing coronary events, including unstable angina, MIs, or sudden cardiac death events, are asymptomatic or present with atypical symptoms. These symptoms include indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among clients of all ages and genders.

The nurse is caring for a client who will have coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse should address which subject? A. Symptoms of hypovolemia B. Symptoms of low blood pressure C. Complications requiring graft removal D. Intubation and mechanical ventilation

D. Intubation and mechanical ventilation Rationale: Most clients remain intubated and on mechanical ventilation for several hours after surgery. It is important that clients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most clients. Teaching would also generally not include rare complications that would require graft removal.

Which postoperative intervention should be questioned for a child after a cardiac catheterization? A. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. B. Check the dressing for bleeding. C. Assess peripheral circulation on the affected extremity. D. Keep the affected leg flexed and elevated.

D. Keep the affected leg flexed and elevated. Rationale: The child should be positioned with the affected leg straight for 4-6 hours after the procedure IV fluids continue until the child is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity.

The nurse is providing care for a client with high cholesterol and triglyceride values. In teaching the client about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? A. High HDL values and high triglyceride values B. Absence of detectable total cholesterol levels C. Elevated blood lipids, fasting glucose less than 100 D. Low LDL values and high HDL values

D. Low LDL values and high HDL values Rationale: The desired goal for cholesterol readings is for a client to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.

Nursing care for the child in congestive heart failure includes: A. Counting the number of saturated diapers B. Putting the infant in the Trendelenburg position C. Removing oxygen while the infant is crying D. Organizing care to provide rest periods

D. Organizing care to provide rest periods Rationale: Nursing care should be planned to allow for periods of undisturbed rest

The hospital nurse is caring for a client who reports that an angina attack is beginning. Which action is the nurse's most appropriate initial action? A. Have the client sit down and put the head between the knees. B. Have the client perform pursed-lip breathing. C. Have the client stand still and bend over at the waist. D. Place the client on bed rest in a semi-Fowler position.

D. Place the client on bed rest in a semi-Fowler position. Rationale: When a client experiences angina, the client is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. There is no need to have the client put the head between the legs because cerebral perfusion is not lacking

Which information should be included in the nurses discharge instructions for a child who underwent a cardiac catheterization earlier in the day? A. Pressure dressing is changed daily for the first week B. The child may soak in the tub beginning tomorrow C. Contact sports can be resumed in 2 days D. The child can return to school on the third day after the procedure

D. The child can return to school on the third day after the procedure Rationale: The day after the catheterization, the pressure dressing is removed and replaced with a band-aid. The catheter insertion site is assessed daily for healing. Any bleeding or sign of infection, such as drainage, must be reported to the cardiologist. Bathing is limited to a shower, sponge bath, or brief tub tab (no soaking) for the first 1-3 days after the procedure. Strenuous exercise is avoided for up to 1 week after the procedure. The child can return to school on the 3rd day after the procedure. It is important to emphasize follow-up with the cardiologist.

A client with hypertension is ambulating in the hospital hallway and reports chest pain. In which order would the nurse assess and treat this client? A. The first set of vital signs are done. B. The nurse assesses the client's angina. C. A 12-lead electrocardiogram (ECG) is performed. D. The client is instructed to stop all activity. E. The client receives the first dose of nitroglycerin. F. The client is transferred to a higher acuity unit.

D. The client is instructed to stop all activity. B. The nurse assesses the client's angina. A. The first set of vital signs are done. C. A 12-lead electrocardiogram (ECG) is performed. E. The client receives the first dose of nitroglycerin. F. The client is transferred to a higher acuity unit. Rationale: The client is first directed to stop all activity and sit, rest, and/or is placed in a semi-Fowler position to reduce the oxygen workload on the heart. The nurse then assesses the client's chest pain/angina to determine whether it is the same as the client typically experiences. Vital signs are performed next and any respiratory distress is noted at this time. Typically oxygen is applied at this time, but because the sequence was not specifically spelled out, it was not included. VSS provides information on the damage to the heart that may or may not be occurring. A 12-lead ECG is performed, which continues to support or eliminate a cardiac event. Nitroglycerin is given sublingually up to 3 doses. It is a vasodilator that opens up blood vessels to improve blood flow and decrease chest pain. If the chest pain continues after interventions and/or a myocardial infarction is diagnosed, the client may be transferred to a higher acuity unit.