Cardiac Test Study Questions

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? "A headache is an indication of an allergy to the medication." "A headache is an expected adverse effect of the medication." "A headache indicates tolerance to the medication." "A headache is likely due to the anxiety about the chest pain."

"A headache is an expected adverse effect of the medication." Rationale: The vasodilation nitroglycerin induces increases blood flow to the head and typically results in a headache.

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A: "Reaching your goal blood pressure will occur within 2 months." B: "Diuretics are the first type of medication to control hypertension." C: "Limit your alcohol consumption to three drinks a day. D: "Plan to lower saturated fats to 10 percent of your daily calorie intake."

"Diuretics are one of the first types of medications that are used to control hypertension." Rationale: The nurse should include in the teaching that diuretic medication is the first type of medication to control hypertension, by decreasing blood volume and lowering blood pressure.

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? "You might feel a slight tingling while the test is being done." "The test will be complete in 30 to 60 minutes." "I will need to apply electrodes to your chest and extremities." "The radioactivity from the dye lasts only a few hours."

"I will need to apply electrodes to your chest and extremities." Rationale: The nurse should inform the client that she will apply small electrodes to the client's chest and extremities before conducting the test. These electrodes transmit electrical current and allow for the recording of the heart's electrical activity.

A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include? "Limit your fluid intake to meal times." "Do not take this medication on an empty stomach." "Increase your daily intake of dietary fiber." "You can expect swelling of the ankles while taking this medication."

"Increase your daily intake of dietary fiber." Rationale: The nurse should instruct the client to increase his daily intake of dietary fiber to reduce the risk of constipation associated with verapamil.

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? "Place the tablet under your tongue, and then take a small sip of water." "The medication can take up to 15 minutes to take effect." "Avoid taking the medication prior to exercising." "Stop taking the medication and notify your provider if you develop a headache."

"Place the tablet under your tongue, and then take a small sip of water." Rationale: A client who takes a sublingual medication should place it under his tongue. A sip of water can help the medication dissolve.

ER nurse is assessing PT with bradydysrhythmia. Which finding should he expect? 1. Confusion 2. Friction Rub 3. HTN 4. Dry skin

1. Confusion- as a result of decreased tissue perfusion

You are caring for a PT who is being treated for HF and has prescriptions for digoxin and furosemide. You plan to monitor for which of the following as an adverse effect of these meds? 1. SOB 2. Lightheadedness 3. Dry cough 4. Metallic taste

2. Lightheadedness - can cause a sudden drop in BP= lightheadedness

You are providing discharge teaching to a PT who has a prescription for the transdermal nitroglycerin patch. Which instruction would you include? 1. Apply new patch to the same site as the previous patch. 2. Place the new patch on an area skin away from skin folds and joints 3. Keep the patch on 24 hr per day 4. Replace the patch at the onset of angina

2. Place the new patch on an area skin away from skin folds and joints - should apply to skin that is prone not to move or wrinkle

When performing a cardiac assessment what is the point of maximal impulse? 1. 2nd intercostal space right to the sternum 2. 2nd intercostal space left to the sternum 3. 5th intercostal space to the left of thermal border 4. Left 5th intercostal space in the midclavicular line

4. Left 5th intercostal space in the midclavicular line -this is best to hear the apex of the heart which is considered maximal impulse

You are reviewing the chart of a PT who is receiving heparin therapy for a DVT. Which intervention should the RN anticipate taking if the PTs aPTT is 96 seconds? 1. Increase heparin infusion rate by 2mL/hr 2. Continue monitor the heparin infusion as prescribed 3. Request a prothrombin time PT 4. Stop the heparin infusion

4. Stop the heparin infusion- pt is above the therapeutic range of 1-5-2 times the control. should discontinue to prevent harm

You are caring for a PT following an abdominal aortic aneurysm resection. Which of the following is priority assessment? 1. Neck vein distention 2. Bowel sounds 3. Peripheral edema 4. Urinary output

4. Urinary output greatest risk is graft occlusion or rupture which will reflect blood flow in the kidneys

You are caring for a PT who has endocarditis. Which finding should you recognize as a complication? 1. Ventricular depolarization 2. Guillain Barre Syndrome 3. Myelodysplastic syndrome 4. Valvular disease

4. Valvular disease- damage will occur as a result of inflammation or infection of the endocardium

A nurse is beginning a morning shift. Which of the following patients should the nurse assess first? A patient on bed rest who complains of swelling in the lower leg A patient complaining that the breakfast tray is late every day A patient diagnosed with pneumonia who has bilateral crackles on an exam A patient admitted with a urinary tract infection who complains of urinary frequency

A patient on bed rest who complains of swelling in the lower leg Rationale: A patient on bed rest is at risk for venous thromboembolic disease, including deep vein thrombosis and pulmonary embolism, which can be fatal. Swelling in the legs is not an expected finding in patients on bed rest. This patient should be the priority initial assessment, as the situation could be life-threatening or life-saving

A nurse is teaching a client who has a new prescription for quinidine. Which of the following statements should the nurse include? A. "Monitor your pulse rate and report changes." B. "Remain upright for 30 minutes after taking this medication." C. "This medication can decrease digoxin levels." D. "This medication can cause urinary incontinence."

A. "Monitor your pulse rate and report changes."

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? Liver Milk Beans Eggs

Beans Rationale: Any food that does not contain animal products does not contain cholesterol. Beans are a good source of protein for a client who follows a low-cholesterol diet.

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave

A. Abnormally prominent U wave

A nurse is providing teaching to a client who has a new prescription for losartan to treat hypertension. The nurse should instruct the client that which of the following findings could indicate an adverse reaction to the drug and needs to be reported? A. Facial edema B. Sleepiness C. Peripheral edema D. Constipation

A. Facial edema

A nurse is caring for a client who is taking amiodarone to treat atrial fibrillation. Which of the following should the nurse instruct the client to avoid while taking this drug? A. Grapefruit juice B. Milk C. Foods high in vitamin K D. NSAIDs

A. Grapefruit juice

A nurse is assessing a client who is taking a loop diuretic and is experiencing a thready, irregular pulse, orthostatic hypotension, and confusion. The nurse should identify that these manifestations indicate which of the following adverse effects? A. Hypokalemia B. Hypoglycemia C. Hypouricemia D. Hyponatremia

A. Hypokalemia

A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results about the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 9.8 g/dL D. Calcium 8.0 mg

A. Potassium 2.8 mEq/L

A nurse is caring for a client who is about to begin captopril therapy. Which of the following adverse effects should the nurse instruct the client to report because it can indicate a need to discontinue drug therapy? (Select all that apply). A. Rash B. Distorted taste C. Swelling of the tongue D. Photosensitivity E. Dry cough

A. Rash B. Distorted taste C. Swelling of the tongue E. Dry cough

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? Apply a new transdermal patch once a week. Apply the transdermal patch in the morning. Apply the transdermal patch in the same location as the previous patch. Apply a new transdermal patch when chest pain is experienced.

Apply the transdermal patch in the morning. Rationale: The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Report changes in the usual pattern of chest pain Avoid situations that contribute to ischemic episodes. Avoid fatty foods and exercise. Take over-the-counter decongestants.

Avoid situations that contribute to ischemic episodes. Rationale: Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants

A nurse is providing teaching about lifestyle changes to a client who has a myocardial infraction and has a new prescription for a beta blocker. which of the following client statements indicates an understanding of the teaching? A. "I should eat foods high in saturated fat" B. "Before taking my medication, I will count my radial pulse rate" C. "I will exercise once per a week for an hour at the health club" D. "I will stop taking my medication when my blood pressure is within normal range"

B. "Before taking my medication, I will count my radial pulse rate"

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. increase cardiac output B. Increased pulmonary congestion C. decreased left atria pressure D. decreased pulmonary artery pressure

B. Increased pulmonary congestion

A nurse is providing teaching to a client who is taking simvastatin. The nurse should instruct the client to report which of the following manifestations as an indication of a serious adverse reaction that could require discontinuing drug therapy? A. Bronchoconstriction B. Muscle pain C. Lip numbness D. Somnolence

B. Muscle pain

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine

B. Pacemaker insertion

A nurse is caring for a client who is taking spironolactone to treat hypertension. The nurse should recognize that which of the following client laboratory values requires immediate intervention? A. Sodium 140 mEq/L B. Potassium 5.2 mEq/L C. Chloride 100 mEq/L D. Magnesium 1.9 mEq/L

B. Potassium 5.2 mEq/L

A nurse is establishing health promotion goal for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? A. The client will list foods that are high in Calcium, which should be avoided B. The client will walk for 30 min 5 days a week. C. The client will increase calorie intake by 200 cal per day D. The client will replace cigarettes with smokeless tobacco products.

B. The client will walk for 30 min 5 days a week. Rationale: CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

You are caring for a client in the first 8 hrs following coronary artery bypass graft (CABG) surgery what findings should you report? 1. Mediastinal drainage 100mL/hr 2. BP 160/80 3.Temp-37.1 4. K 3.8

BP 160/80 -increased vascular pressure can cause bleeding at incision site

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. which of the following findings should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. sunburned appearance with desquamation

C. Dry, pale skin with minimal body hair

A nurse is assessing a client who has pericarditis. which of the following manifestations should the nurse expect? A. bradycardia with S-T segment depression B. relief of chest pain with deep inspiration C. Dyspnea with hiccups D. chest pain that increases when sitting upright

C. Dyspnea with hiccups

A nurse is caring for a client who has a new prescription for propranolol to treat a tachydysrhythmia. The nurse should instruct the client to avoid taking which of the following types of over-the-counter drugs while taking propranolol? A. Antihistamines B. Potassium supplements C. NSAIDs D. Vitamin C

C. NSAIDs

A nurse is monitoring a client who had a myocardial infraction. For which of the following complications should the nurse monitor in the first 24 hr? A. ineffective endocarditis B. pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias

A student nurse is observing a cardioversion procedure and hears the team leader call out,"Stand clear." The student should recognize the purpose of this action is to alert personnel that A. the cardioverter is being charged to the appropriate setting .B. they should initiate CPR due to pulseless electrical activity. C. they cannot be in contact with equipment connected to the client. D. a time‐out is being called to verify correct protocols.

C. they cannot be in contact with equipment connected to the client.

A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." "Exercise is good for you and good for your heart." "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."

Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." Rationale: With this response, the nurse uses the therapeutic communication technique of presenting reality by indicating her perception of the situation for the client.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? Chest pain and dyspnea Bradypnea and bradycardia Hypertension and lack of fever Nonproductive cough and abdominal pain

Chest pain and dyspnea Rationale: As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism

Pentoxifylline (Trental) is a medication used for which of the following conditions? Claudication Thromboemboli Hypertension Elevated triglycerides

Claudication Rationale: Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental

A nurse is caring for a client who is taking carvedilol and has a prescription for an oral antidiabetic drug to manage their new diagnosis of type 2 diabetes mellitus. By taking both drugs concurrently, the nurse should identify that the client is at an increased risk for which of the following conditions? A. Hyperglycemia B. Bradycardia C. Hypotension D. Hypoglycemia

D. Hypoglycemia

A nurse is caring for a client who has a new prescription for verapamil to treat atrial fibrillation. The nurse should instruct the client to avoid drinking grapefruit juice while taking verapamil because it can cause the client to experience which of the following conditions? A. Tachycardia B. Dehydration C. Diarrhea D. Hypotension

D. Hypotension

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories? Within the expected reference range Elevated Stage 1 hypertension Stage 2 hypertension

Elevated Rationale: A blood pressure of 124/79 mm Hg places this client in the elevated, or prehypertension, category. An elevated blood pressure, or prehypertension, is indicated by a systolic pressure between 120 and 129 mm Hg and a diastolic pressure of less than 80 mm Hg.

A nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis? Elevate the legs and arms above the heart when resting Encourage the client to engage in a moderate amount of exercise Encourage extended periods of sitting or standing. Discourage walking in order to limit pain.

Encourage the client to engage in a moderate amount of exercise Rationale: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the client to engage in a moderate amount of exercise serves to improve circulation. Elevating the client's legs and arms above the heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

A nurse is providing teaching for a client who has a new diagnosis of stable angina pectoris. Which of the following information should the nurse include about anginal pain? The pain usually lasts longer than 20 min. Pain can often be relieved by sitting up. The pain persists with rest and organic nitrates. Exertion and anxiety can trigger the pain.

Exertion and anxiety can trigger the pain. Rationale: Exertion and anxiety can trigger the pain of angina, unless it is variant angina, which occurs at rest.

Which class of medication lyses and dissolves thrombi? Fibrinolytic Anticoagulant Platelet inhibitors Factor XA inhibitors

Fibrinolytic Rationale: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.

Understanding atherosclerosis, the nurse identifies which of the following to be both a risk factor for the development of the disorder and an outcome? Hypertension Hyperlipidemia Glucose intolerance Obesity

Hypertension Rationale: Increases in diastolic and systolic blood pressure are associated with an increased incidence of atherosclerosis, often an inherited factor. Elevation of blood pressure results when the vessels cannot relax and impairs the ability of the artery to dilate. Hyperlipidemia, diabetes, and obesity are all risk factors for atherosclerosis but do not result from the disorder.Chapter 23: Management of Patients with Coronary Vascular Disorders - Page 732

A client's elevated cholesterol levels are being managed with atorvastatin daily. What is a side effect the nurse will teach the client that requires monitoring? Hyperuricemia Increased liver function tests Hyperglycemia Mild muscle pain

Increased liver function tests Rationale: Myopathy and increased liver enzymes are significant side effects of the statins. LFTs are monitored at least yearly while a patients are on statin therapy.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse do first? Attach the leads for a 12-lead ECG. Obtain a blood sample. Initiate oxygen therapy. Insert the IV catheter.

Initiate oxygen therapy. Rationale: The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to administer oxygen to help minimize this possibility.

A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil? Isosorbide Phenytoin Metronidazole Prednisone

Isosorbide Rationale: Clients who are on nitrates including isosorbide and nitroglycerin preparations cannot take sildenafil, because of the serious medication interaction. There is the possibility of sudden death due to hypotension.

A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome? History of asthma Large waist size Hypotension Hypoglycemia

Large waist size Rationale: Central obesity due to excessive abdominal fat is a risk factor for metabolic syndrome. Metabolic syndrome increases the risk for the development of diabetes and coronary artery disease.

A patient care partner on the medical surgical floor reports measuring a client's blood pressure at 212/110 mmHg using an automated blood pressure machine. Which of the following should the RN do immediately? Measure the blood pressure using a manual cuff. Notify the client's primary care provider Give the client a prescribed dose of prn clonidine. Direct the patient care partner to ask the client if any symptoms are occurring such as chest pain or headache and recheck the blood pressure

Measure the blood pressure using a manual cuff. Rationale: The nurse should first make an assessment of the client and should verify the reading using a manual cuff. If the reading is accurate, the healthcare provider should be notified. The nurse cannot rely on less skilled or knowledgeable staff members to implement the nursing process

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? Nitroglycerin Aspirin Oxygen Morphine

Morphine Rationale: Morphine is the medication of choice for managing the pain and anxiety of an acute MI. By reducing preload and afterload, it decreases the work of the heart.

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? High-density lipoprotein (HDL) level of 70 mg/dL A diet high in potassium Obstructive sleep apnea (OSA) Taking benazepril

Obstructive sleep apnea (OSA) Rationale: The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? Obtain an EKG. Administer enteric-coated acetaminophen. Administer ibuprofen. Maintain oxygen saturations greater than or equal to 92%.

Obtain an EKG. Rationale: The nurse should obtain an EKG to detect heart rhythm abnormalities within 10 min of the client's reported discomfort.

You are providing teaching to a group of PTs which of the Pts is at risk for developing PAD? 1. PT with hypothyroidism 2. PT with Diabetes Mellitus 3. PT whose daily diet consists of 25% fat 4. Pt who consumes 2 bottles of beer a day

PT with Diabetes Mellitus -at risk for microvascular and progressive peripheral arterial disease

A client who is newly diagnosed with hypertension is going to be starting antihypertensive medicine. What is one of the main things the client and the client's spouse should watch for? Postural hypotension Persistent cough Blurred vision Tremor

Postural hypotension Rationale: A common adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. The client and the client's spouse should be alerted to this possibility and provided with some tips for managing dizziness

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects? Vitamin K Protamine sulfate Acetylcysteine Deferasirox

Protamine sulfate Rationale: Protamine sulfate reverses the effects of heparin by binding with heparin to form a heparin-protamine complex that has no anticoagulant properties.

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? Hemoglobin (Hgb) Prothrombin time (PT) Bleeding time Activated partial thromboplastin time (aPTT)

Prothrombin time (PT) Rationale: This test is used to monitor warfarin therapy. For a client receiving full anticoagulant therapy, the PT should typically be approximately two to three times the normal value, depending on the indication for therapeutic anticoagulation.

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions? Pulmonary Embolism Atelectasis Inefective process Tumor

Pulmonary Embolism Rationale: When a blood clot exists in a pulmonary vessel (embolus), impaired perfusion results. However, ventilation is adequate. With the other choices, ventilation is impaired but perfusion is adequate.

Which finding indicates that hypertension is progressing to target organ damage? Retinal blood vessel damage. Urine output of 60 mL over 2 hours. Blood urea nitrogen concentration of 12 mg/dL. Chest x-ray showing pneumonia

Retinal blood vessel damage. Rationale: Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated. All body systems must be assessed to detect any evidence of vascular damage. An eye examination with an ophthalmoscope is important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The client is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed. A BUN concentration of 12 mg/dL and urine output of 60 mL over 2 hours are normal findings. The presence of pneumonia does not indicate target organ damage.

When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating Sinus arrhythmia Normal sinus rhythm Sinus bradycardia Sinus tachycardia

Sinus arrhythmia Rationale: Sinus arrhythmia occurs when the sinus node creates an impulse at an irregular rhythm. Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the SA node and travels through the normal conduction pathway. Sinus bradycardia occurs when the sinus node regularly creates an impulse at a slower-than-normal rate. Sinus tachycardia occurs when the sinus node regularly creates an impulse at a faster-than-normal rate.

The nurse is caring for a client with peripheral artery disease (PAD). Which finding in this client indicate therapy is effective? The client begins to participate in activities of daily living without pain The client's respiratory status is improved The clients lungs are clear to auscultation The clients pain is relieved by placing the legs in a dependent position

The client begins to participate in activities of daily living without pain Rationale: The client with peripheral artery insufficiency usually has decreased arterial blood flow t the extremities as a result of atherosclerotic narrowing of the arteries. The nurse will know that current therapies are effective when the client's legs are warm and pink with brisk capillary refill and when the clients is able to participate in activities of daily living without ischemic pain.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? The client is 5' 9" tall and weighs 128 lb (58 kg). The client has been pregnant four times, The client usually walks 3 miles a day. The client will be immobile during and shortly after surgery.

The client will be immobile during and shortly after surgery. Rationale: Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate? The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect Administration of two anticoagulants decreases the risk of recurrent venous thrombosis Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants

The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect Rationale: Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin/enoxaparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? Troponin I Lipase B-type natriuretic peptide (BNP) Aspartate aminotransferase (AST)

Troponin I Rationale: The troponins (I and T) are proteins that only exist in cardiac muscle and enter the bloodstream within a few hours of myocardial injury. They are the most specific indicator of myocardial damage

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. Troponin is a lipid whose levels reflect the risk for coronary artery disease. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a protein that helps transport oxygen throughout the body.

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Rationale: Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? Vertigo Uremia Blurred vision Dyspnea

Vertigo Rationale: The nurse should monitor the client for findings such as vertigo, headache, facial flushing, and fainting. These manifestations are consistent with a new diagnosis of essential hypertension.

You are providing teaching to a PT with HF you would instruct him to report what finding? 1. Weight gain of 2lbs in 24hr 2. Increase in 10mmhg in Systolic BP 3. Dyspnea with exertion 4. Dizziness when rising quickly

Weight gain of 2lbs in 24hr - fluid retention r/t worsen HF

A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? a. Atrial rate of 300/min with QRS complex of 80/min b. P waves occurring at 0.16 seconds before each QRS complex c. Ventricular rate of 82/min with an atrial rate of 80/min d. An irregular ventricular rate of 125/min with a wide QRS pattern

a. Atrial rate of 300/min with QRS complex of 80/min

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? analgesic anti-inflammatory antiplatelet aggregate antipyretic

antiplatelet aggregate Rationale: Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart.