Cardiovascular-week 3

which clotting factor would a nurse explain is deficient to the parents of a child newly diagnosed with hemophilia A?

Factor VIII

which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia?

'i have abnormal hemoglobin'

which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? select all that apply

1. diuretics 2. low salt diet 3. daily weight checks 4. fluid restriction 5. intake and output 6. oxygen administration

when both parents have sickle cell trait, what is the chance that a child will have sickle cell disease

25%

which client seen at a health fair will be most at risk for hypertension?

62 year old african american man

which laboratory value would the nurse use to determine whether a client is receiving a therapeutic dose of intravenous heparin?

Activated partial thromboplastin time (APTT) is 70 seconds

which statement indicates that more teaching is needed after the nurse has completed teaching about sclerotherapy for a client with varicose veins?

I should return to the clinic immediately if there is any swelling at the procedure site

which test result would the nurse use to determine whether the daily dose is therapeutic when a client with a venous thrombosis is receiving warfarin?

INR

which part of the Ecg represents depolarization of the ventricles?

QRS interval

which part of the electrocardiogram represents depolarization of the ventricles?

QRS interval

how would the nurse describe cardiogenic shock when a family member of a client tasks for more information about the condition

a failure of the circulatory pump

which behavior would the nurse expect a client to exhibit during the initial stage of grieving after learning that a tumor is malignant and has metastasized to several organs and that the illness is termini e

asking for a second opinion

which action would the nurse take when a client who just returned from a cardiac catheterization reports that the pressure bandage on the right groin is tight

assess the circulatory status of the extremity

which action will the nurse take first when a client with peripheral arterial disease returns to the nursing unit after a femoral angiogram?

assess the clients affected leg

which action would the nurse take when caring for all went on the first postoperative day after a femoral popliteal bypass graft?

assist the client with ambulation

which action by an unlicensed health care worker who is assisting with post procedure care requires that the nurse intervene when caring for a client who has had cardiac catheterization using the femoral approach?

assisting the client to stand and void

which response would the nurse give when a client with syncope from a vagal response asks why it is important to avoid bearing down during a bowel movement

bearing down stimulates a nerve response that decreases your heart rate and blood pressure

which definitive test confirms a diagnosis of multiple myeloma?

bone marrow biopsy

which lymph nodes would the nurse expect to be affected first when a client is diagnosed with hodgkin disease?

cervical

which suggestion will the nurse make to minimize orthostatic hypotension when teaching a client who has a new prescription for antihypertensive medication?

change position slowly when going from lying to standing

which instruction will the home health nurse give when teaching a client with arterial insufficiency of both lower extremities

check pulses in the legs regularly

which explanation would the nurse include when teaching a client with heart failure about the reason for a low sodium diet?

decreased fluid retention

which action by the nurse will be most effective when teaching a client about exercises to prevent venous stasis

demonstrate specific exercises

which information would the nurse include in teaching a client who is advised to wear compression stockings for varicose veins?

don the stockings before getting out of bed in the morning

which response by the nurse is best when a client with palpitations who is admitted to telemetry for observation asks for a cup of coffee?

educate the client about the effect of caffeine on the hearts conduction system

which topic would be the most important to include in teaching when an obese client receives a diagnosis of high blood pressure?

effect of weight loss in hypertension

which finding will the nurse expect when analyzing the cardiac rhythm for a client with first degree AV block?

every P wave is conducted to the ventricles

which clinical manifestation would the nurse include when teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider? select all that apply

extreme fatigue coughing at night difficulty breathing

which factor would the nurse identify as the cause of the pain experienced by a client who is experiencing acute coronary syndrome?

heart muscle ischemia

which information is important for the nurse to consider when caring for a client after a thyroidectomy for cancer of the thyroid

hoarseness and airway obstruction may result from laryngeal nerve damage

which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm

hypovolemic

which complication would the nurse consider in a client who just had a total hip replacement and is experiencing restlessness and changes in mentation?

hypovolemic shock

which type of shock is associated with a ruptured abdominal aneurysm?

hypovolemic shock

which factor is the likely cause of the laboratory result when arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH

lactic acid production

which finding will the nurse expect during the assessment when a client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital?

left upper quadrant tenderness

which information can be obtained from monitoring the pulmonary artery pressure?

left ventricular functioning

which clinical manifestation would the nurse expect to find when a client is admitted with right ventricular failure?

peripheral edema

which distinguishing sign unique to a fat embolus will a nurse motor for in a client with a distal femoral shaft fracture who is at risk for developing a fat embolus?

petechiae

which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure?

sodium

which food would the nurse teach a client who has a prescription for warfarin to limit? select all that apply

spinach broccoli

which object would the nurse teach the client with newly implanted pacemaker to avoid?

strong magnet

which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed?

using a heating pad to warm the extremities

information about which vitamin would be included when teaching a client with atrial fibrillation about a new prescription for warfarin?

vitamin K

which additional assessment finding will the nurse expect when the blood pressure for a clean with possible ruptured spleen after a motor vehicle accident is 100/60

weakened peripheral pulses

which action would the nurse perform when a client is in ventricular fibrillation? select all that apply

1. initiating CPR 2. assessing the EKG 3. using a defibrillator 4. obtaining electrolytes 5. administering epinephrine

which action would the nurse implement when an older adult is brought to the emergency department after being found in the street without a coat during a snowstorm? select all that apply

1. obtain a rectal temperature 2. assess the filters for areas of frostbite 3. determine clients level of consciousness 4. ask for client identification

which action would the nurse take when performing external cardiac compression?

interlock the fingers with the hell of 1 hand on the sternum and the heel fo the other on top of it

which complication will the nurse anticipate when caring for a client in late hypovolemic shock

metabolic acidosis

which assessment finding will the nurse expect when caring for a client with peripheral arterial disease? select all that apply

1. absence of hair on the toes 2. reports of pain associated with exercising

which assessment finding would the nurse expect when a client is diagnosed with left sided congestive heart failure? select all that apply

1. dyspnea 2. crackles 3. frequent cough

which symptom would the nurse include when teaching a group of female clients about clinical manifestations of coronary artery disease that are more common in women? select all that apply

1. dyspnea 2. indigestion 3. unusual fatigue

which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? select all that apply

1. fatigue 2. orthopnea 3. pitting edema 4. dry hacking cough 5. 4 pound weight gain

which finding in a client seen at the outpatient clinic supports a diagnosis of an arterial ulcer? select all that apply

1. lack of hair 2. thickened toenails 3. diminished pedal pulse

which assessment finding will the nurse expect when caring for a client with right ventricular failure?

bilateral lower leg edema

which item would the client with palpitations from premature heartbeats be taught to avoid?

energy drinks

which blood types can potentially be used for transfusion when a client has type A negative blood?

type A or O negative

which condition unrelated to cardiac disease is the major cause of right ventricular failure?

COPD

which information would be used to determine the cause of premature atrial contractions (PACs) observed on a clients EKG? select all that apply

1. stress level 2. tobacco use 3. caffeine intake 4. electrolyte levels 5. home medications

which topic will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? select all that apply

1. symptoms of infection 2. use of pain medications 3. purpose of anticoagulant medications

how far would the nurse depress the lower sternum when performing cardiac compression on an adult client?

2 to 2.4 inches

which symptom will the nurse expect in a client with varicose veins who is scheduled for sclerotherapy?

feeling of heaviness in both legs

which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? select all that apply

providing oxygen assessing vital signs obtaining a 12 lead EKG drawing blood for cardiac enzymes auscultating heart sounds administering nitroglycerin

which over the counter medication would the nurse teach a client taking antihypertensive medication to avoid?

pseudoephedrine

which response would the nurse give when a client with varicose veins asks the nurse "what can i do to help myself"

put on compression hose before getting out of bed in the morning

which action would a nurse take to prevent a parallax error and to ensure accuracy when assessing a clients blood pressure?

read the manometer at eye level

which description would the nurse expect the client to use to characterize the pain when admitted to the coronary care unit with a diagnosis of ST segment elevation myocardial infarction?

severe, intense chest pain

which action by the nurse is priority when a client who is receiving a transfusion of packed red blood cells after cardiac surgery experiences chest discomfort, chills, and anxiety?

stop the transfusion and administer normal saline

which response would the nurse give to a client with type 1 diabetes who asks what causes several brown spots on the skin?

those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot

which response by the nurse uses the technique of paraphrasing when after receiving chemotherapy for non-hodgkin lymphoma, a client states "i get so sick to my stomach. the medication is useless"

you don't think the medication is helping you

which clinical manifestation would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? select all that apply

1. tachycardia 2. restlessness 3. decreased urinary output

which response would the nurse make when a client who has begun an exercise program, after experiencing acute coronary syndrome, asks the nurse how to tell whether the exercise is helping?

you will be able to walk progressively longer distances before tiring

which term describes the inheritance pattern of hemophilia A?

x linked recessive trait

which diet choice by a client who has heart failure indicates that the nurses teaching about diet has been effective? select all that apply

1. lean steak 2. fruit salad 3. broiled chicken 4. roasted potatoes

which dietary choice would the nurse teach for the client with peripheral arterial disease? select all that apply

1. limit salt intake 2. eat whole grain breads 3. use liquid vegetable oil 4. avoid processed meats

which clinical finding would the nurse expect to identify when caring for a client with a left leg venous thrombosis? select all that apply

1. pain in the left calf 2. redness in the affected area 3. swelling of the lower left leg 4. localized warmth in the lower left leg

which clinical finding would the nurse expect when assessing a client who has cariogenic shock? select all that apply

1. pallor 2. agitation 3. tachycardia 4. narrow pulse pressure

which finding would the nurse expect when assessing a client with peripheral arterial disease? select all that apply

1. pallor of feet 2. users on the toes 3. delayed capillary refill

which finding would indicate a need to refer a client to a health care provider when the nurse is screening clients for hypertension?

diastolic blood pressure reading greater than 89

which assessment finding is consistent with a client diagnosis of right sided heart failure? select all that apply

distended abdomen dependent edema decreased appetite

which finding would the nurse expect when caring for a client with right sided heart failure?

distended neck veins

which action would the nurse take to prevent venous thrombus formation after abdominal surgery?

encourage the client to ambulate multiple times daily

how frequently will the nurse plan to assess the blood pressure when a client is admitted to the post anesthesia care unit after surgery?

every 10 to 15 minutes

after the nurse has completed a discharge teaching for a client who has had a myocardial infarction, which client statement indicates that more teaching is needed

i will avoid physical activity

which physiological alteration would be expected with a higher than normal red blood cell count

increased blood viscosity

which group of clients would the nurse anticipate to have the highest incidence of non hodgkin lymphomas?

older adults

which clinical finding is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

syncope

which assessment finding after an open reduction and internal fixation (ORIF) of a fractured hip would cause the nurse to suspect and monitor for signs and symptoms of a fat embolism?

tachycardia and petechiae over the chest

which information would the nurse include when teaching a client with varicose veins about ligation and stripping surgery?

the dilated saphenous veins are removed

which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? select all that apply

weight, inactivity, cholesterol, tobacco use, homocysteine

which clinical manifestation would the nurse expect to find when assessing a client with varicose veins? select all that apply

1. presence of ankle edema 2. increased leg fatigue 3. report of leg fullness and pruritus

which physiological factor helps maintain blood pressure in the client with hypovolemia? select all that apply

1. release of aldosterone 2. activation of angiotensin II 3. sympathetic nervous system activation

which action would the nurse take before developing the teaching plan for a client who has had a myocardial infarction?

identify the learning needs of the client

which response would the nurse give when a client is admitted with chest pain and a family member asks about the purpose of the prescribed 12 lead ECG?

indicated whether a heart attack is occurring

which term will a nurse use to document when a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance?

intermittent claudication

which information would the nurse include when explaining the purpose of a thallium scan to the client who has a history of chest pain?

it assess myocardial ischemia and perfusion

which explanation would the nurse give regarding purpose of early ambulation to a client who had surgery the previous day?

keep blood from pooling in the legs to prevent clots

which confirmatory test would the nurse anticipate for a client with a tentative diagnosis of Hodgkin disease?

lymph node biopsy

which nursing action is most important preoperatively for a client with an abdominal aortic aneurysm

maintaining a low blood pressure

which action will the nurse include when developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site?

maintaining the supine position for a minimum of 4 hours

which initial change in acid base balance will the nurse expect when a client is in the progressive stage of shock

metabolic acidosis

which is involved in the postprocedure nursing care of a child after left side cardiac catheterization?

motoring the insertion site for bleeding

which finding would the nurse expect when assessing a client who has right ventricular failure?

neck vein distention

which fluid therapy will the nurse prepare to infuse when a client with hypovolemic shock has a hematocrit value of 25%?

packed red blood cells

which clinical manifestation would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease?

pain when exercising and thickening of the toenails

which term would the nurse use to document reports of a cent with heart failure waking suddenly and feeling short of breath during the night?

paroxysmal nocturnal dyspnea

which physiological responses occurs first when a client experiences sudden hypovolemia caused by hemorrhage?

peripheral vasoconstriction

which action would the nurse take when planning room placement for a client with squamous cell carcinoma of the tongue that is to be treated with interstitially implanted radon seeds?

place the client in a private room

which position would the nurse place the feet and legs in when caring for a client with peripheral arterial insufficiency

place them slightly lower than the head and chest

which clinical finding can the nurse expect to identify when assessing client with varicose veins? select all that apply

reports of leg fatigue tortuous veins in the legs pain in lower extremities when standing

which clinical manifestation is more likely to occur in women with coronary artery disease compared with men? select all that apply

severe fatigue sense of unease shortness of breath

which position would a nurse place a client in after libation, dissection, and removal of varicose veins

supine with the legs elevated at a 15 degree angle

which response would a nurse give when a client with a prosthetic heart valve asks why it is important to take antibiotics before a dental procedure?

the antibiotic is taken to prevent infection around your artificial dental procedure

which information regarding palliative care as opposed to hospice care would the nurse provide during a home visit to a client with heart failure who asks about this option?

the focus of palliative care is to enhance you and our family quality of life despite your heart failure

which answer would the nurse provide when a client who has had a myocardial infarction asks why a thallium scan has been prescribed?

to establish viability of heart muscle

for which clinical manifestation will the nurse monitor for when caring for a client admitted with heart failure? select all that apply

unusual fatigue dependent edema nocturnal dyspnea

which action would the nurse take when a client with chronic venous insufficiency has ankle edema?

elevate the legs

which cause of high urinary output would a nurse suspect when clients urinary output is 3 times the fluid intake after a cardiac catheterization

an expected effect of the dye used with procedure

how would the nurse describe heart failure to a client?

an inability of the heart to pump blood in proportion to metabolic needs

which clinical manifestation would the nurse expect to find in a client with hypokalemia? select all that apply

anorexia leg cramps

which potential cause of dysrhythmia would the nurse consider when assessing a client who has sinus tachycardia? select all that apply

anxiety, caffeine, exercise, anemia

which behavior by a client who has had an ST segment elevation myocardial infarction indicates that the nurses action to improve client autonomy have been successful?

active participation in providing self care

which action would the nurse take when a client develops epistaxis?

apply direct lateral pressure to the nose

which response would the nurse make when the spouse of a client who has been newly diagnosed with angina tell the nurse, "i guess i'm going to have to cook 2 meals, one for my spouse and one or myself"?

a heart healthy diet includes foods that most people would enjoy eating

which response would the nurse make when postoperatively a client asks "could i have a pillow under my knees? my legs feel stretched?"

a pillow under the knees can result in clot formation because it slows blood flow

which action would the nurse take first after finding a hospitalized client who is unconscious and unresponsive?

initiate a code

which action would help prevent venous thrombosis in a client during the periopertive period? select all that apply

1. administer subcutaneous heparin injections 2. assist the client to don anti embolism stockings 3. apply pneumatic compression devices to the legs

which clinical manifestation will the nurse expect when caring for a client with pulmonary edema? select all that apply

1. crackles 2. coughing 3. orthopnea

which change that occurs with aging increases the risk for hypothermia in older adults? select all that apply

1. decreased amount of body fat 2. diminished energy reserves 3. chronic medical conditions

a client with heart failure weighed 175 lb yesterday and todays weight is 181 lb. how many milliliters of fluid has the client retained?

2700mL

which explanation would the nurse give to a client with a diagnosis of myocardial infarction who asks the nurse, "what is causing the pain i am having"?

inadequate oxygenation of the myocardium

where will the nurse place the V1 lead when obtaining a 12 lead ecg?

fourth intercostal space, right sternal border

which priority action would the nurse instruct a woman who recently under went a hysterectomy to take after she calls the clinic and states that she has tenderness, redness, and swelling in her right calf?

go to the emergency department immediately

which statement by the wife of a client receiving hemodialysis who undergoes surgery to create and arteriovenous fistula indicates that further teaching is required?

i have to take his blood pressure every day in the arm with the fistula

which physiological response explains why elevation in body temperature occurs in clients who experience acute coronary syndrome?

inflammatory response

which activity would the nurse expect to cause the most distress when assessing a client with heart failure for activity tolerance?

climbing a flight of stairs to the bedroom

which action will the nurse take to create negative pressure in the system after emptying the drainage collection chamber for a postoperative clients portable closed suction wound drainage device?

compressing the device while closing the air plug

which finding will the nurse expect when caring for a client who is in hypovolemic shock?

cool skin temperature

which action would the nurse take when calculating a clients heart rate on an electrocardiogram strip?

count the QRS complexes

which treatment option will the nurse anticipate the need to teach the client about when caring for a client with symptomatic bradycardia caused by heart block?

demand pacemaker

which explanation will the nurse give when a client who is admitted for coronary artery bypass great (CABG) surgery asks about the purpose of pacemaker wires inserted during surgery

prevention of slow heart rate after surgery

which suggestion would be given by the nurse when a client asks how to avoid leg swelling when taking long plane flights?

walk around at least every hour

which response would the nurse give to a client whose total cholesterol level is found to be 210 at a screening session at a health fair and asks the nurse what to do in light of this result?

your cholesterol is elevated slightly. a diet low in saturated fats should be followed

which statement by an unlicensed assistive personnel (UAP) who is assisting the nurse in caring for a group of clients indicates a correct understanding of the UAPs role?

'i will take clients vital signs after their procedures are over'

in what order does normal cardiac conduction occur through the heart?

1. Sinoatrial node 2. atrioventricular node 3. bundle of his 4. bundle branches 5. purkinje fibers

which electrical activity of the cardiac conduction system is reflected in the P wave?

atrial depolarization

which suggestion would the nurse make for a client with heart failure?

avoid emotionally stressful situations

which diagnostic test result will the nurse expect when caring for a client with multiple myeloma?

bence jones protein in the urine

which type of lung sounds would the nurse expect to hear when caring for a client with heart failure

crackles

which instruction would the nurse include in the teaching plan when a client is at high risk for heart disease

increase the quantity of complex carbs

which action by a client who requires an above the knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

participates in learning perioperative care

which laboratory result is important to communicate quickly to the health care provider?

potassium 3.0

which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery

prevent clot formation

which likely cause would a nurse suspect is responsible for a drop in blood pressure after a client sustains multiple internal injuries in a motor vehicle accident and the blood pressure suddenly drops form 134/90 and 80/60?

reduction in the circulating blood volume

which action would the nurse take when a client reports pain and burning at a peripheral intravenous site after the nurse has flushed the saline lock with normal saline?

remove the iv catheter and restart the saline lock in another site

which complication will the nurse monitor for when carrion for a client with an infection caused by group A beta hemolytic streptococci?

rheumatic fever

which diagnostic test will the nurse use to confirm the diagnosis when hypokalemia is suspected?

serum potassium level

which condition would the nurse conclude that the client is experiencing when the monitor shows a PQRST wave for each beat, indicates a rate of 120 beats per minute, and the rhythm is regular?

sinus tachycardia

which information will the nurse include when teaching an unlicensed health care worker about blood pressure measurement? select all that apply

support the clients arm at heart level when taking BP have the client rest for 5 minutes before measuring BP

which information will the nurse include when explaining to a client with atrial tachycardia how the use of the valsalva maneuver may decrease the clients heart rate?

the vagus nerve is stimulated

which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker

third degree heart block

which physiological process causes temperature elevation after a client has had a myocardial infarction?

tissue necrosis and inflammation

which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization?

to visualize the disease process in the coronary arteries