Cardiovascular NCLEX- PN Review

The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health?

The ability to take an accurate pulse in either the wrist or neck

An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem?

"Does the pain get worse when you breathe in?"

The nurse is talking with a client with angina about factors that can precipitate an angina attack. Which statement by the client indicates an understanding of the precipitating events?

"I will pay my neighbor to shovel my snow this winter."

The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next?

Give sublingual nitroglycerin per the health care provider's prescriptions.

The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client?

Gives the client a device holder to wear around the waist

A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action?

Have the client stop and lie back down in bed.

The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen usually prescribed to be taken before the administration of the topical nitrate?

Headache is a common side effect of nitrates.

The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA?

Hyperactive bowel sounds in the area

The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?

Hypokalemia

A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations?

I should eat a diet that is low in fat and cholesterol.

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes?

Ingestion of coffee or chocolate

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner?

Instruct the family member to dress the client warmly before going outside.

The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client were performing which of these contraindicated activities?

Isometric exercises of the arms and legs

The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which?

Keep the ankles uncrossed.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu?

Lemonade

The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention?

Limiting movement and abduction of the right arm

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring?

Pulmonary embolism

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse is reviewing the physical examination in the medical record. Which symptom is least likely to be noted by the primary health care provider?

Sharp pain in the leg

The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition?

Shock

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item?

Smoking history

A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client?

Antihypertensives

The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement?

"A daily, half-mile-long, brisk walk generally helps people bounce back more quickly and provides more of a sense of control."

The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement?

"A smoker has twice the risk of having a heart attack as a nonsmoker."

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?

"I need to adhere to my dietary restrictions."

The nurse is giving discharge instructions to the client with varicose veins. The nurse realizes there is a need for further teaching when the client makes which statement?

"I need to sit as much as possible with my legs elevated."

The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?

"I should avoid sitting in one position for long periods of time."

The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?

"I should routinely use polyunsaturated oils in my diet."

The nurse determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement?

"I will avoid walking for exercise."

The nurse is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement?

"I will take this medication every day."

The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement?

"I will walk for one-half hour daily."

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking?

"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement?

"Moving to a warmer climate should help."

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response?

"You are concerned about losing your leg?"

While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic?

"So you're saying that you want to talk to your health care provider?"

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure?

"The best thing about this is that I can use it anywhere, anytime."

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first?

"When was the last time you had your blood pressure checked?"

The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question?

"Where is the pain located?"

The nurse finds a client tensing while lying in bed staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!" Which is the nurse's best response?

"Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?"

The nurse is caring for a client in the cardiac care unit with heart disease. The nurse knows that the direction of blood flows through the heart and lungs in which order? Please arrange the blood flow in the direction of flow. All options must be used.

1 Blood flows to the right atrium from the superior and inferior vena cava. 2 Blood flows from the right atrium to the right ventricle via the tricuspid valve. 3 Blood flows from the right ventricle to the lungs for oxygenation. 4 Blood flows from the lungs to the left atrium. 5 Blood flows from the left atrium via the mitral valve to the left ventricle. 6 Blood flows from the left ventricle to the aorta and then to the systemic circulation.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply.

1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously

In order to assess the dorsalis pedis pulse of a client diagnosed with arterial vascular disease, the nurse palpates which anatomical location? Refer to figure.

D- Top of Foot

The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply.

1.Digoxin 2.Warfarin 5.Electrical cardioversion

A client is diagnosed with disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which laboratory values? Select all that apply.

1.Increased D-dimer 2.Decreased hemoglobin 4.Decreased fibrinogen level

The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply.

1.Monitor the blood pressure at home. 2.Restrict sodium intake as prescribed. 4.Eye examinations with an ophthalmoscope should be routine. 5.Follow-up appointments for blood pressure checks are important.

The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply.

1.Nicotine decreases oxygen to the heart. 2.Hypnosis may be helpful to stop smoking. 3.Avoid exposure to environmental tobacco smoke.

The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply.

1.Obtain annual influenza vaccination. 3.Avoid adding salt to foods or in cooking. 4.Report a weight gain of 3 or more pounds in a week.

A client with left-sided heart failure has been admitted to the hospital. The nurse is reviewing the medical record and notes which signs and symptoms? Select all that apply.

1.Orthopnea 3.Sleep apnea 5.Pink frothy sputum

The nurse is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply.

1.Pink-tinged frothy sputum 2.Increase in respiratory rate 5.Auscultation of crackles throughout the lungs

The nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. What are included in the discharge plan? Select all that apply.

1.Smoking cessation 2.Get a flue vaccination 5.Limit activity in cold weather 6.Check blood pressure and pulse

The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipate? Select all that apply.

1.The client should be placed on a cardiac monitor.4.Rhythm strips should be obtained before, during, and after the procedure. 5.Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.

A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply.

1.Use liquid vegetable oil. 2.Increase intake of fruits. 3.Choose whole grain foods. 4.Remove skin from poultry.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statements by the client indicate a need for further teaching? Select all that apply.

2."I am going to switch to electronic cigarettes." 3."It is best to exercise once a week for an hour."

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply.

2.Be careful not to injure the legs or feet. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet.

A client asks the nurse about metabolic syndrome and what it means. The teaching plan should include which characteristics that define metabolic syndrome? Select all that apply.

2.Blood pressure is elevated with systolic values greater than 130 mm Hg and diastolic values greater than 85 mm Hg. 4.The client has abdominal obesity with a waist greater than 40 inches in males and greater 35 inches in females.

A client with right-sided heart failure has been admitted to the hospital. The nurse is reviewing the medical record and notes which signs and symptoms? Select all that apply.

2.Weight gain 4.Pitting edema

A client has been diagnosed with Prinzmetal's angina. The nurse reviews the medical record and notes which accompanying characteristics? Select all that apply.

3.Prolonged severe pain 5.Happens at the same time each day

The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which positions should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply.

3.Sitting up and leaning forward 5.Head of bed elevated to 45 degrees

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition?

Acute kidney injury

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next?

Administer another nitroglycerin tablet.

A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

Assist the client to get back into bed.

A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first?

Assist the client to sit or lie down.

The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position?

At the midclavicular line at the fifth left intercostal space

The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure.

Atrial fibrillation

The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of taking which measure?

Avoiding exposure to either very hot or very cold weather

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic?

Deep and painful

The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which meal?

Fresh strawberries, steamed vegetables, and baked fish

The nurse is planning a dietary menu for a client with heart failure who is being treated with digoxin and furosemide. Which would be the best dinner choice from the daily menu?

Baked fish, mashed potatoes, and carrot-raisin salad

The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu?

Baked haddock, steamed broccoli, herbed rice, sliced strawberries

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed?

Bathroom privileges and self-care activities

A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?

Bed rest with elevation of the affected extremity

A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?

Bilateral lung crackles

A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin. Before administering the medication to the client, the nurse should first check which parameter?

Blood pressure

The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted?

Blood pressure that increases from 114/82 to 118/86 mm Hg

A client is scheduled for a dipyridamole thallium scan. The nurse should check to make sure that the client has not consumed which substance before the procedure?

Caffeine

About which laboratory values should the nurse be immediately concerned because they could cause cardiac arrest? Select all that apply.

Calcium 7.9 mg/L Potassium 5.9 mEq/L

The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided?

Catsup

A client is wearing a continuous cardiac monitor which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which action first?

Check the client status and lead placement.

A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms?

Chest pain

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse consults with the registered nurse to verify a prescription for which medication that the client was taking before admission?

Chlorpropamide

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally?

Crackles

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted?

Crackles in the lung bases

An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response?

Denial

A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse's response is based on which fact?

Denial is a common occurrence early after MI.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition?

Dependent edema

A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action?

Determine if the pain is cardiac in origin.

A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure?

Digoxin

The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding?

Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease

A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client?

Elevating the head of the bed to at least 45 degrees

The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care?

Encourage the client to increase fluid intake.

A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client?

Evaluating total body fluid

A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time?

Explore specific concerns with the client.

The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which should the nurse do next?

Explore with the client the sources of stress in life.

A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs/symptoms?

Fever and sore throat

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading?

Flat

The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment?

Low stimulus, low stress

A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure?

Lung crackles, peripheral edema, and weight gain

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk?

Marking the location of the pedal pulses on the right leg

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse should make which determination about the client's neurovascular status?

Normal, caused by increased blood flow through the leg

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action?

Place the client in high-Fowler's position.

The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease?

Numbness and tingling in the legs

The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside?

Oxygen tubing and flowmeter

The nurse is using a stethoscope to listen to the client's heart and hears this sound. (Refer to audio.) To assist in identifying the sound, the nurse should take which initial and best action?

Palpate the carotid pulse for a pulsation.

The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem?

Pedal edema that is 3+

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems?

Pericardial friction rub

The nurse is caring for a client who has a malignant lung neoplasm and has developed cardiopulmonary complications. On auscultation, the nurse hears these breath sounds over the left lower sternal border (over the apical area) and interprets the sounds as which? (Refer to audio.)

Pericardial friction rub

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action?

Place the client on a cardiac monitor.

A hypertensive client who has been taking metoprolol has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way?

Precipitate rebound hypertension

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?

Premedicate the client with an analgesic before ambulating.

The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client?

Prinzmetal's angina is generally treated with calcium channel blocking agents.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure?

Prior reaction to contrast media

The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal?

Provide a quiet and low-stimulus environment.

A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted?

Relief of apprehension

The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)?

Respirations and blood pressure

A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe?

Restricting the client's potassium intake

The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action?

Review the intake and output records for the last 2 days.

The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia?

ST-segment depression

A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia?

Semi-Fowler's

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?

Status of airway

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection?

Streptococcal infection

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position?

Supine with head elevation no greater than 30 degrees

When preparing a client for a pericardiocentesis, in which position does the nurse place the client?

Supine with the head of bed elevated at a 45- to 60-degree angle

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use?

Surgical tourniquet

The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client?

Take daily weights and monitor trends.

The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client?

Take in adequate daily fiber to prevent straining during a bowel movement.

The nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?

Tall, peaked T waves

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

Teaches about the effects of cocaine on the heart and offers referral for further help

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings?

The boot has been applied too tightly.

A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home?

The client can verbally describe the daily medications, doses, and times to be administered.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?

The client complains of leg edema, and skin breakdown has started.

The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason?

The client requires prophylactic antibiotics before treatment.

The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse?

The pain has not been relieved by rest and nitroglycerin tablets.

A client who is 36 hours post-myocardial infarction has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made?

The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute.

Acetylsalicylic acid is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin?

To prevent the formation of clots

The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe?

Two pounds per week

For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal?

Using a bedside commode for stools

The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence?

Weigh self every morning before breakfast.

A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect?

Weight gain of 2 to 3 pounds in a few days

A client returns to the nursing unit after an above-knee amputation of the right leg. In which position should the nurse place the client?

With the foot of the bed elevated

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the cardiologist to write a prescription for the client to remain on bed rest. In which position should the bed be positioned?

With the head of bed elevated no more than 30 degrees

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position?

With the head of the bed elevated no more than 15 degrees