Chapter 48 cardiovascular system

A nurse is reinforcing to a client who has a new diagnosis of an aneurysm.. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following statements should the nurse give?

"It is due to hypertension."

A nurse is caring for a client who has a DVT and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse make?

"It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued.

A nurse is reinforcing teaching w/ client who has a new prescription for clopidogrel. Which of the following statement should the nurse make? select all that apply

- "Avoid taking herbal supplements while taking this medication." - "Monitor for the presence of black, tarry stools

A nurse is screening a client for hypertension. Which of the following statements by the clients increases their risk for developing hypertension? Select all that apply

- "Buttered popcorn is one of my favorite daily snacks." - "I drink at least 2-3 beers a day."

A nurse is reviewing information with a newly licensed nurse about the use of cardiopulmonary bypass surgery for coronary artery bypass grafting. Which of the following statements should the nurse include ? Select all that apply

- "The client's demand for oxygen is lowered." - "Motion of the heart stops." - "Rewarming of the client takes place."

Edema

- +1 Trace ( 0-1/16 inch) with rapid response refill - +2 Mild ( 0-¼ inch) with 10-15 seconds refill - +3 Moderate ( ¼-½ inch) with 1-2 minutes refill - +4 Severe ( ½ inch) with 2-5 minutes refill

A nurse is assisting with the care of a group of clients. The nurse should recognize which of the following clients is at risk for the development of a dysrhythmia? Select all that apply

- A client who has metabolic alkalosis - A client who has alcohol use disorder - A client who underwent stent placement in a coronary artery

Thrombophlebitis

- Active dorsiflexion of the foot may result in calf pain which is called Homan's sign - People taking coumadin need to avoid green leafy vegetables because they may affect the effectiveness of the coumadin. These people should also avoid the herbal remedy ginkgo because it can increase the action of coumadin

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 RN and expects which interventions to be prescribed? Select all that apply.

- Administering oxygen - Inserting a Foley catheter - Administering furosemide -Administering morphine sulfate intravenously

Effects of Aging on the Heart

- Blood vessels become thicker and less compliant- this is called sclerosis - Peripheral vascular resistance increases, causing a rise in blood pressure - Atherosclerotic changes in the blood vessels increase

A nurse is reviewing the laboratory findings of a client who is being evaluated for a MI. Which of the following laboratory studies are likely to show elevations if the MI occurred within the last 6 hours ?

- CK-MB - Troponin I - Troponin T - Myoglobin

A hospitalized client w/ CAD complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administer nitroglycerin, 0.4 mg, sublingually after 5 minutes the client states, " my chest still hurts." Which appropriate actions would the nurse take? Select all that apply.

- Check the client's pain level - Check the client's BP - Administers a second nitroglycerin, 0.4 mg sublingually

The nurse at the provider's office is reviewing the laboratory test results for the client. The nurse should identify that which of the following indicates the client is at risk for heart disease? Select all that apply

- Cholesterol (total) 245 mg/dL - LDL 140 mg/dL

A nurse is collecting data on a client who has a new diagnosis of a thoracic aortic aneurysm. Which of the following findings should the nurse expect ? Select all that apply

- Cough - SOB - Altered swallowing

Cardiac Rehabilitation

- Exercise training to help the patient learn how to exercise safely, strengthen muscles, and improve stamina. After 12 weeks post MI, goal should be to walk 2 miles in less than 1 hour. - f pt mouth breathes during BM it will decrease the effect of the valsalva's maneuver ( bearing down) on intrathoracic pressure

A nurse is caring for a client following cardioversion. Which of the following should the nurse include in the documentation of this procedure?

- Follow up ECG - Energy settings used - Skin condition under electrodes

A nurse is assisting with the care of a client who has pericarditis. Which of the the following findings should the nurse expect? Select all that apply

- Friction rub - Cough - Chest pain

Lipids

- Get lipid profile every 4-6 years Desired values: - Total Cholesterol: under 200 - HDL: " Good Cholesterol"The higher the number the better because it protects your heart - High-desired : greater than 60 - Low is considered less than 40 in men and less than 50 in women -LDL: " Bad Cholesterol" The lower the number the better for you. - Optimal: Less than 100 - Near to above Optimal: 100-129 - Borderline High: 130-159 - High: 160-189 - Very High: Greater than 190 - Triglycerides: The buildup of in the arteries leading to narrowing. - Normal: less than 150 - Borderline to High: 150-199 - High: 200-499 - Very High: Above 500

Left sided HF

- Left ventricle cannot pump the blood out well enough to meet the body's demands- patient will show Lung symptoms - lungs fill with fluid - pulmonary edema and pleural effusion occur - dyspnea, orthopnea ( more comfortable sitting up to sleep) , - pulmonary crackles, wheezing, pink frothy sputum and cough

A nurse is reinforcing teaching with a client who has heart failure and new prescription of furosemide and digoxin. Which of the following instructions should the nurse include? Select all that apply

- Monitor daily weight - Expect to experience muscle weakness - Decrease sodium intake

A nurse is contributing to the plan of care for a client following a surgical placement of an endovascular stent graft to repair an aneurysm. Which of the following interventions should the nurse recommend for inclusion in the plan of care? Select all that apply

- Monitor pulses distal from procedure site - Monitor for an increase in pain below the graft site - Monitor procedure site for bleeding - Monitor vital signs frequently

Buerger's Disease

- Most often affects men ages 25-40 who smoke - Treatment focuses mainly on modifying risk factors and stopping smoking

Cardiomyopathy

- Often young adults are diagnosed with this because of use of drugs like cocaine

Diagnostic Tests

- Thallium scanning: Radio isotope is used to transport the material to normal cells. In cells of the heart where damage has occurred, the isotope will not be picked up. "Cold" spots or dark spots on a thallium scan indicate inadequate tissue perfusion. - Laboratory tests: CBC ( Complete Blood Count), PT ( Prothrombin Time), INR ( International Normalized Ratio normal is 2 and 3) PTT( Partial Thromboplastin TIme) ESR, Lipids Study every 4-6 years, ABGs, serum Cardiac markers - Cardiac enzymes and troponin. - An increase in cardiac enzymes occurs from damage to the heart muscle from an MI. The enzyme CK and CK-MB start to rise within 2-3 hours after the start of an MI, peak in 24 hours, and normalize within 24-40 hours.

The primary HCP is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions would the nurse anticipate? select all that apply?

- The client would be placed on a cardiac monitor - Rhythm strips would be obtained before, during, and after the procedure - The vital signs, cardiac rhythm, LOC would be monitored for the procedure

Heart Sounds

- The closing of the AV valves creates the characteristic "lubb," first heart sound - The opening and closing of the semilunar valves creates the characteristic "dubb," or second heart sound

A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which S/S? select all that apply.

- Visual disturbances - Nausea and vomiting - Serum digoxin level of 2.3 ng/mL

The Conduction System of the Heart

1. Sinoatrial (SA) node—the pacemaker of the heart

The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular fibrillation. The client suddenly loses consciousness. Which action would the nurse take first?

Call for help and initiate CPR

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

Check the client status and lead placement

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take ?

Elevate the clients legs for 10 min , two to three times daily while wearing stockings.

The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns r/t the administration of this medication?

Hypokalemia, Hyperglycemia, sulfa allergy

Rheumatic Heart Disease

Is a result of rheumatic fever- main cause of cardiac valve disease

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 dislodgment of the pacing catheter by implementing which intervention?

Limiting movement and abduction of the right arm

A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?

Monitor for signs of bleeding

The Heart

Myocardium- Bulk of of the heart wall and is thickest layer of the heart. Composed of muscle tissue and is responsible for the heart's contraction

A nurse is collecting data on a client who has mitral insufficiency. Which of the following findings should the nurse expect?

Neck vein distention

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

Normal, caused by increased blood flow through the leg.

The nurse is preparing to ambulate a post-op 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

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

Pulmonary embolism

A nurse is assisting w/ care for a client who is one day post- op following a coronary artery bypass grafting (CABG) surgery. The client declines to perform coughing and deep breathing because they are concerned about causing pain at their incision site. Which action should the nurse take?

Reinforce teaching w/ the client to splint their incision w/ a pillow.

A 24 y/o man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse would check the client's medical history for which finding next?

Smoking Hx

A nurse is assisting w/ the admission of a client who has a suspected MI and a history of angina . Which of the following findings will help the nurse distinguish stable angina from an MI?

Stable angina can be relieved with rest and nitroglycerin

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

Status of airway

A nurse is assisting w/ teaching a class about risk factors for inflammatory heart disease. The nurse should instruct that which of the following conditions is a risk factor for rheumatic disease?

Streptococcal pharyngitis

Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a headache. Which action would the nurse suggest to the client?

Take the medication with food.

A nurse is providing teaching to a client who has atrial fibrillation and has a new prescription for an anticoagulant. Which of the following information should the nurse include in the teaching?

The anticoagulant will decrease the risk of blood clots.

A nurse in an outpatient clinic is assisting w/ collecting data from a client who has type 2 diabetes mellitus and hypertension who has recently received a new prescription for metorpolol. Which of the following client data should the nurse report to the provider?

The client has a HR of 50/min

A nurse is reinforcing teaching w/ a client who has hypertension and received a new prescription for spironolactone. Which of the following statements by the clients indicates an understanding of the teaching?

" I should eat foods that are high in potassium."

The nurse is teaching the client who is scheduled for a coronary angiography. Which of the following statements should the nurse make?

"You will need to keep your affected leg straight following the procedure."

Pulmonary Edema

- Nursing interventions: Sit patient up in bed and put legs in a dependent ( low) position to to ease pulmonary edema and to decrease the venous blood return.

The nurse reinforces discharge instructions to a post-op client who is taking warfarin sodium. Which statement made by the clients reflects the need for further teaching?

" I will take enteric coated aspirin for my headaches because it is coated."

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 .mg/ dL. The client is taking cholestyramine. Which statement made by the client indicated the need for further teaching?

" I'll continue my nicotinic acid from the health food store."

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 would help."

A nurse is reinforcing teaching w/ a client who is scheduled for an echocardiogram. Which of the following statements should the nurse include in the teaching?

" The test allows us to see how your heart valves work."

The nurse is teaching the newly licensed nurse about caring for the client who is to have a CVP line placed. Which of the following statements by the newly licensed nurse indicates understanding?

"A chest x-ray is needed to verify placement after surgery

A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to the client about the medications. Which statement by the client indicates an understanding of the instructions ?

"Ibuprofen taken 30 minutes before the nicotinic acid will decrease the flushing."

Heart Failure

- Class I: Minimal - Class II: Mild - Class III: Moderate - Class IV: Severe

Angina Pectoris

- Pain is usually substernal and radiates down the left arm - These people who have unstable angina should not do strenuous activities. - Often nitroglycerin is prescribed for angina. If after 3 doses of nitroglycerin in a 5 minute intervals time frame, pt should go to ER.

Right sided HF

- Right ventricle cannot pump the blood against the pressure in the pulmonary circulation. - edema will occur in sacral area and extremities liver may be congested and ascites may occur (abdomen swells) - distended neck veins - dyspnea, cough, orthopnea

Hypertension

- Secondary HTN occurs as the result of a comorbidity( another condition causes it like renal disease) - Nursing interventions for HTN include measures to identify the cause of non compliance with patients who have issues complying with medication regimens.

Cardiac Dysrhythmias

- Sinus tachycardia: HR 100-150 Regular rhythm. Usually caused by exercise, activity, fever, shock, anxiety. The cardiac complexes each have a P wave and a QRS and a T. - Atrial fibrillation: Disorganized electrical activity in atria. Heart will "quiver" and not efficiently pump. Caused by meds, cardiac surgery, PE, MVP, caffeine. These people develop clots easily. Coumadin is often prescribed and the INR is monitored to maintain a level between 2-3. Often pacemakers are put in to regulate heart for this condition. - Premature ventricular contractions: PVCs abnormal heartbeats arising from the right or left ventricles. - Ventricular tachycardia: Happens with 3 or more PVCs occur in a row, not preceded by a P wave and and HR is over 100 usually runs 140-240. Can be caused by hypoxemia, drug toxicity, electrolyte imbalance etc. This can cause death

A nurse in the ED is collecting data from a client who is being treated for shock. Which of the the following manifestations should the nurse expect to find? Select all that apply

- Slow capillary refill - Hypotension - Tachypnea

A nurse is collecting data on a client who has pulmonary edema. Which of the following findings should the nurse expect? Select all that apply

- Tachypnea - Persistent cough - Orthopnea

A nurse in the ED is assisting with admitting a client who has a blood pressure of 266/147 and reports severe headache and blurred vision. Which of the following actions should the nurse suggest taking first?

Assist with obtaining IV access.

Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level?

Activated partial thromboplastin time (aPTT) of 55 seconds

A post cardiac surgery client with a BUN level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL 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

To use an external cardiac defibrillator on a Client, which action would be preformed to check the cardiac rhythm?

Applying the adhesive patch electrodes to the skin and moving away from the client

The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication. associated w/ propranolol?

The development of audible expiratory wheezes

A nurse is collecting data from a from a client who has a suspected occlusion of the abdominal aorta. Which of the following manifestations should the nurse expect?

Coolness of inferior graft extremity

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

Crackles

Endocarditis

Dental work often requires prophylaxis with antibiotics. These people may be triggered to have an increase in endocarditis with manipulation of oral tissue and gums.

The nurse is collecting data on a client with a diagnosis of right sided HF. the nurse would expect to note which specific characteristics of this condition?

Dependent edema

A nurse is assisting with the care of a client who is on telemetry. The nurse recognizes the client's hr is 46/min and notifies the provider. Which of the the following prescriptions should the nurse anticipate the provider to prescribe?

Pacemaker insertion

A nurse is collecting data from a client who has chronic peripheral arterial disease. Which of the following the findings should the nurse expect?

Pallor on elevation on the limbs, and rubber when the limbs are dependent

A nurse is reinforcing teaching w/ a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include?

Place both legs in a dependent position while sleeping.

Valves of the Heart

Rheumatic fever is the major cause of cardiac valve disease.

Myocardial Infarction

Women often do not have chest pain and may be misdiagnosed with indigestion.

A nurse in the ED is assisting w/ the care of a client who has a possible dissecting abdominal aortic surgery. Which of the following actions the priority for the nurse to take?

ensure the client has IV access