CH 25

deficit

During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse:

wheezes with wet lung sounds

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

Obtain an oxygen saturation level.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?

HF

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition? The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition?

Vague symptoms

The nurse knows that women and the elderly are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause?

Impaired myocardial contractility

The nurse reviews a client's lab results and notes a serum calcium level of 7.9 mg/dL. It is most appropriate for the nurse to monitor the client for what condition?

The sinoatrial node

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?

reduced stroke volume

What does decreased pulse pressure reflect?

contractility

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

automaticity

Which term describes the ability of the heart to initiate an electrical impulse?

Methylprednisolone

While the nurse is preparing a client for a cardiac catheterization, the client states that they have allergies to seafood. Which of the following medications may the nurse give prior to the procedure?

"Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy."

A 52-year-old female patient is going through menopause and asks the nurse about estrogen replacement for its cardioprotective benefits. What is the best response by the nurse?

Contact the health care provider and report the findings.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

"Rehabilitation will help me function as well as I physically can."

A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?

Thready pulse

A nurse is caring for a dying client following myocardial infarction. The client is experiencing apnea with a falling blood pressure of 60 per palpation. Which documentation of pulse quality does the nurse anticipate?

"My family is bringing me a cup of coffee to drink before the test."

A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education?

assessing the peripheral pulses in the affected extremity; checking the insertion site for hematoma formation; evaluating temperature and color in the affected extremity

A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply).

Thin fibrous sac that encases the heart.

A patient recently diagnosed with pericarditis asks the nurse to explain what area of the heart is involved. How does the nurse best describe the pericardium to the client?

Vagal response

A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient?

Myocardial ischemia

A patient's heart rate is observed to be 140 bpm on the monitor. The nurse knows that the patient is at risk for what complication?

Loud and may be associated with a thrill sound similar to (a purring cat).

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When ausculatating a murmur, what does the nurse expect to hear?

Count the heart rate at the apex.

The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit?

left ventricle

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?

Right ventricular pressure must be higher than pulmonary arterial pressure.

It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur:

pulmonary artery wedge pressure

The balloon on the distal tip of a pulmonary artery catheter is inflated and the pressure is measured. What is the term for the measurement obtained?

The client is at risk for renal failure due to the contrast agent that will be given during the procedure.

The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider?

Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys.

The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. What explanation will the nurse offer to explain the urination?

sinoatrial node

The electrical conduction system of the heart has several components, all of which are instrumental in maintaining polarization, depolarization, and repolarization of cardiac tissue. Which of the conductive structures is known as the pacemaker of the heart?

international normalized ratio (INR)

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate?

HF

The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?

Metoprolol

The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer?

"If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous."

The nurse is administering a stool softener to a client who experienced a myocardial infarction. The client says, "I had a heart attack; I don't have a problem with constipation." What explanation will the nurse use to answer the client's question?

Report any incident of bloody urine, stools, or both.

The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin?

A heart rate of more than 20 bpm above the resting rate

The nurse is assessing a patient who reports feeling "light-headed." When obtaining orthostatic vital signs, what does the nurse determine is a significant finding?

Pulse pressure

The nurse is assessing a patient's blood pressure. What does the nurse document as the differences between the systolic and the diastolic pressure?

Phase 4

The nurse is assessing a patient's electrocardiogram. What phase does the nurse determine is the resting phase before the next depolarization?

S3

The nurse is assessing heart sounds in a patient with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this?

"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."

The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response?

Assess the client

The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?

Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex.

The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. What nursing intervention is a priority after the procedure?

Chordae tendineae

The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?

Crackles

The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?

Friction rub

The nurse is completing a cardiac assessment. Upon auscultation, the nurse hears a grating sound using the diaphragm of the stethoscope. How will the nurse best document this finding?

Positive family history

The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient?

Left 5th intercostal space at the midclavicular line

The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position?

Avoid tub baths, but shower as desired. Avoid heavy lifting for the next 24 hrs

The nurse is providing discharge education for a client going home after cardiac catheterization. What information is a priority to include when providing discharge education?

K+ 3.1 mEq/L

The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the health care provider?

"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?

endocardium

Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue?

"Have you had any episodes of dizziness or fainting?"

You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment?

The client and family understands the discharge instructions.

You are evaluating the expected outcomes on a client who is recovering from a cardiac catheterization. What is an expected outcome that you would evaluate?

Enzymes

You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels?