Critical Care Exam 2 Practice

Which nursing action will best evaluate the effectiveness of the furosemide in managing a client with heart failure and acute pulmonary edema? A. Performing daily weights B. Auscultating breath sounds C. Monitoring intake and output D. Assessing for dependent edema

B. Auscultating breath sounds

Which technique will the nurse teach a client who has a prescription for a sublingual nitroglycerin tablet? A. Place the pill inside the cheek and let it dissolve. B. Place the pill under the tongue and let is dissolve. C. Chew the pill thoroughly and then swallow it. D. Swallow the pill with a full glass of water.

B. Place the pill under the tongue and let is dissolve.

Which client information is important to communicate to the health care provider when the nurse is obtaining a health history for a client scheduled for cardiac catheterization? A. Drinks 2 cups of coffee daily B. Reports allergy to most shellfish C. Recently had dobutamine stress test D. Takes daily low-dose aspirin tablet

B. Reports allergy to most shellfish

Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin? A. Relief of anginal pain B. Improved cardiac output C. Decreased blood pressure D. Ease in respiratory effort

A. Relief of anginal pain

Which nursing action is most important preoperatively for a client with an abdominal aortic aneurysm? A. Administering supplemental oxygen B. Maintaining a low blood pressure C. Keeping the client in a supine position D. Monitoring the femoral and pedal pulses

B. Maintaining a low blood pressure

Which clinical finding would the nurse expect for a client with hypertensive emergency? A. Increased urine output B. Severe pounding headache C. Heart rate 110 beats/minute D. Weak and thready radial pulses

B. Severe pounding headache

Which action would the nurse prioritize after applying pressure to the nose of a client who is being treated for uncontrolled hypertension and develops a nosebleed? A. Add humidity to the client's oxygen. B. Teach the client how to avoid nosebleeds. C. Assess the client's blood pressure. D. Obtain the client's pulse rate.

C. Assess the client's blood pressure.

Which information can be obtained from monitoring the pulmonary artery pressure? A. Stroke volume B. Lung function C. Coronary artery patency D. Left ventricular functioning

D. Left ventricular functioning

Which intervention will relieve the chest pain of a client admitted to the cardiac care unit with a myocardial infarction? A. Nitroglycerin sublingually B. Oxygen per nasal cannula C. Lidocaine hydrochloride 50-mg intravenous (IV) bolus D. Morphine sulfate 2 mg IV

D. Morphine sulfate 2 mg IV Morphine is an opioid analgesic that acts on the central nervous system by a sympathetic mechanism. Morphine decreases systemic vascular resistance, which decreases left ventricular afterload, thus decreasing myocardial oxygen consumption. Nitroglycerin sublingually relieves anginal pain, not myocardial infarction pain. Oxygen administration elevates arterial oxygen tension, potentially improving tissue oxygenation; however, oxygen administration will not relieve the pain. Lidocaine is an antidysrhythmic, not an analgesic.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement first? Select All that Apply 1. Administer morphine sulfate Intramuscularly 2. Administer an aspirin orally 3. Apply oxygen via nasal cannula 4. Place the client in a supine position with the HOB flat 5. Administer nitroglycerin subcutaneously

2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain Morphine, if needed, would be given IV. NTG would be given sublingually. Patient should be placed in semi fowler's position.

Within which period of time would a nurse advise the client to anticipate pain relief will begin when nitroglycerin sublingual tables are prescribed for a client with the diagnosis of angina? A. 1 to 3 minutes B. 4 to 5 seconds C. 30 to 45 seconds D. 10 to 15 minutes

A. 1 to 3 minutes The onset of action of sublingual nitroglycerin tablets is rapid (1-3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.

Which finding in a client with pulmonary edema requires the most rapid action by the nurse? A. Weak, rapid pulse B. Oxygen saturation 82% C. Blood pressure 99/54 mm Hg D. Crackles throughout both lungs

B. Oxygen saturation 82%

Which statement by the client indicates the teaching about the prophylactic use of sublingual nitroglycerin prescribe to a client with a history of a myocardial infarction and atrial tachycardia was effective? A. "I should take the medicine three times a day." B. "I will be sure to take my pulse after I have exercised." C. "It will be important to avoid activities that can cause angina." D. "I should take one tablet before attempting activity that has caused angina."

D. "I should take one tablet before attempting activity that has caused angina."

Which assessment finding would indicate to the nurse that the treatment for a client with cor pulmonale has been effective? A. Weight gain B. Increased heart rate C. Reduction of hemoptysis D. Decreased peripheral edema

D. Decreased peripheral edema

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64 2. The client's calcium level is elevated 3. The client's telemetry shows occasional PVCs 4. The client's blood pressure is 90/62

4. The client's blood pressure is 90/62 The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

Which physiological process causes temperature elevation after a client has had a myocardial infarction? A. Tissue necrosis and inflammation B. Thrombosis followed by thrombolysis C. Sympathetic nervous system stimulation D. Infectious process of myocardial muscle cells

A. Tissue necrosis and inflammation

Which finding for a client who has just returned to the nursing unit after an emergency cardiac catheterization would be most important to report to the primary health care provider? A. Anxiety about the results of the procedure. B. ST-segment elevation on the electrocardiogram. C. Pain at the femoral artery catheter insertion site. D. Premature atrial contractions on the cardiac monitor.

B. ST-segment elevation on the electrocardiogram.

Which information will the nurse provide when a client is discharged with a prescription for sustained-release nitroglycerin? A. Swallow the capsule whole B. Take the medication with milk C. Place capsule under the tongue D. Crush the capsule and mix with soft food

A. Swallow the capsule whole The sustained-release capsule should be swallowed whole on an empty stomach.

Which condition unrelated to cardiac disease is the major cause of right ventricular failure? A. Hypovolemic shock B. Chronic kidney disease C. COPD D. SIRS

C. COPD

Which clinical finding would the nurse expect when completing the admission assessment of a client with a large abdominal aortic aneurysm who is admitted for elective surgery? A. Elevated heart rate B. Visible peristaltic waves C. Radiating abdominal pain D. Pulsating abdominal mass

D. Pulsating abdominal mass

Which client in the emergency department would the nurse assess first? A. Client with chest pressure and ST segment elevation on the electrocardiogram. B. Client who reports a sharp chest pain with deep inspiration for the past week. C. Client who ahs history of heart failure with ascites and bilateral 4+ ankle swelling. D. Client with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/minute.

A. Client with chest pressure and ST segment elevation on electrocardiogram.

The nurse teaches a client with COPD and cor pulmonale about nutrition. Which instruction would the nurse include? A. Eat small meals six times a day to limit oxygen needs. B. Drink large amounts of fluid to help liquefy secretions. C. Lie down after eating to conserve energy needed for digestion. D. Increase the intake of protein to decrease intravascular hydrostatic pressure.

A. Eat small meals six times a day to limit oxygen needs.

Which diuretic would the nurse anticipate administering to a client admitted with acute pulmonary edema? A. Furosemide B. Chlorothiazide C. Spironolactone D. Acetazolamide

A. Furosemide Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium; is available for intravenous administration; and is more effective than chlorothiazide, spironolactone, and acetazolamide.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A. "I will replace my nitroglycerin supply every 6 months." B. "I can take up to five tablets every 3 minutes for relief of my chest pain." C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B. "I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

The nurse prepares a discharge teaching plan for a 44-year-old male patient who has recently been diagnosed with coronary artery disease. Which risk factor should the nurse plan to focus on during the teaching session? A. Type A personality B. Elevated serum lipids C. Family cardiac history D. Hyperhomocysteinemia

B. Elevated serum lipids Dyslipidemia is one of the four major modifiable risk factors for coronary artery disease (CAD). The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

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? A. Weight loss B. Extreme fatigue C. Coughing at night D. Excessive urination E. Difficulty breathing

B. Extreme fatigue C. Coughing at night E. Difficulty breathing

When assigned the care of a client arriving in the emergency department with possible acute coronary syndrome, which prescribed action would the nurse take first? A. Obtain a 12 lead ECG B. Draw blood for troponin and creatinine kinase MB C. Ask the client about level of intensity of the chest pain D. Notify the cardiac catheterization laboratory about the client

C. Ask the client about level of intensity of the chest pain

Which lab result will be important for the nurse to review when a client is admitted to the hospital with a long history of uncontrolled hypertension? A. Blood glucose level B. White blood cell count C. Blood urea nitrogen D. Lactic dehydrogenase

C. Blood urea nitrogen

A client is admitted to the ICU with pulmonary edema. Which clinical finding would the nurse expect when performing the admission assessment? A. Weak, rapid pulse B. Decreased blood pressure C. Radiating anterior chest pain D. Crackles at bases of the lungs

C. Crackles at bases of the lungs

Which statement would the nurse identify as the purpose of the nitroglycerin patch? A. Decreased heart rate lowers cardiac output. B. Increased cardiac output increases oxygen demand. C. Decreased cardiac preload reduces cardiac workload. D. Peripheral venous and arterial constriction increases peripheral resistance.

C. Decreased cardiac preload reduces cardiac workload. Nitroglycerin reduces cardiac workload by decreasing the preload of the heart by its vasodilating effect. It decreases blood pressure, not heart rate.

Which finding would the nurse expect when assessing a client who has right ventricular failure? A. Slowed pulse rate B. Pleural friction rub C. Neck vein distention D. Elevated temperature

C. Neck vein distention

Which prescribed action has the highest priority when a client comes to the emergency department with moderate substernal chest pain that is unrelieved by rest and nitroglycerin? A. Administer morphine sulfate. B. Transfer to the coronary care unit C. Obtain a 12-lead ECG D. Have a blood specimen drawn for troponin studies

C. Obtain a 12-lead ECG

Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization? A. To obtain the pressures in the heart chambers. B. To determine the existence of congenital heart disease. C. To visualize the disease process in the coronary arteries. D. To measure the oxygen content of various heart chambers.

C. To visualize the disease process in the coronary arteries.

Your patient presents to the E.D. with severe pain in the upper chest while lying down, shortness of breath, and hoarseness while talking. The neck veins appear distended. He states that he has never had pain like this before. What problem do you expect your patient to have? A) MI B) Atelectasis C) Blindness D) Thoracic Aneurysm

D. Thoracic Aneurysm These are all classic symptoms of a thoracic aneurysm

Which finding would the nurse expect when assessing a client with left ventricular failure? A. Crushing chest pain B. Dyspnea of exertion C. Jugular vein distention D. Extensive peripheral edema

B. Dyspnea of exertion

Which finding in a client who has been admitted with myocardial infarction is most important to communicate to the health care provider? A. High anxiety level B. Elevated troponin T C. Urine output 15 mL/h D. Heart rate 58 beats/minute

C. Urine output 15 mL/h

Which laboratory test is important for the nurse to monitor when a client is admitted with acute coronary syndrome? A. Troponin B. Myoglobin C. Homocysteine D. Creatine kinase (CK)

A. Troponin

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90 2. The client's groin dressing is dry and intact 3. The client refuses to keep the leg straight 4. The client denies any numbness and tingling

3. The client refuses to keep the leg straight The client bends the legs, it could cause insertion site bleeding. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.

Which rationale is the basis for planning a nursing intervention when during a health fair, the nurse measures an adult's blood pressure as 200/120 mm Hg? A. There is increased risk for a cerebrovascular accident. B. The elevated pressure reflects the "white coat syndrome". C. Walking around the fair probably raised the blood pressure. D. Information should be obtained regarding prescribed medications.

A. There is increased risk for a cerebrovascular accident.

Which laboratory value will be important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)? A. Troponin T (cTnT) B. C-reactive protein (CRP) C. Low-density lipoprotein (LDL) D. B-type natriuretic protein (BNP)

A. Troponin T (cTnT)

Which finding for a client with pulmonary edema who received furosemide is the best indicator that the treatment has been effective? A. Urine output over 1 hour is 200 mL. B. Oxygen saturation per pulse oximetry is 99%. C. Cardiac monitor shows sinus rhythm, rate 98 beaths/minute. D. No jugular vein distention is seen with head elevated to 90 degrees.

B. Oxygen saturation per pulse oximetry is 99%.

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?"? A. Compression of the heart muscle B. Release of myocardial isoenzymes C. Rapid vasodilation of the coronary arteries D. Inadequate oxygenation of the myocardium

D. Inadequate oxygenation of the myocardium

When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first? A. Attach the cardiac monitor B. Auscultate the heart sounds C. Check the intravenous fluid rate D. Assess alertness and orientation

A. Attach the cardiac monitor

Which information would the nurse include in the preprocedure teaching for a client who requires emergency cardiac catheterization? A. Mild sedation is maintained during the procedure. B. The procedure will take approximately 15 minutes to complete. C. Ambulation is encouraged shortly after the procedure. D. Procedure results will be available after about 24 hours.

A. Mild sedation is maintained during the procedure.

Which common side effect of nitroglycerin will a nurse monitor for in a client who is treated for a suspected myocardial infarction with 500 mL of 5% dextrose in water (D5W) with 50 mg of nitroglycerin intravenously (IV)? A. Bradycardia B. Hypotension C. Nausea and vomiting D. Leg cramps

B. Hypotension The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure; orthostatic hypotension can occur. Bradycardia is not an anticipated response. Nausea and vomiting may occur but are not the most common side effects of IV nitroglycerin. Leg cramps are not a side effect of this medication.

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? A. Unstable angina B. Cardiac tamponade C. Sudden cardiac death D. Cardiac dysrhythmias

D. Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

Which instructions will the nurse give a client for whom nitroglycerin tablets are prescribed? A. Limit the number of tablets to four per day. B. Discontinue the medication if a headache develops. C. Increase the number of tablets if dizziness is experienced. D. Ensure that the medication is stored in its original dark container.

D. Ensure that the medication is stored in its original dark container.

Which medication side effect will a nurse assess for when caring for a client with a myocardial infarction receiving intravenous nitroglycerin to relieve pain? A. Nausea B. Delirium C. Bradycardia D. Hypotension

D. Hypotension The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure and resulting in decreased cardiac workload. Nausea is not a common side effect of intravenous nitroglycerin. Nitroglycerin does not cause delirium. Reflex tachycardia may occur with the decrease in blood pressure.

Which mechanism of sodium nitroprusside would a nurse recall is responsible for decreasing blood pressure? A. Decreasing the heart rate B. Increasing cardiac output C. Increasing peripheral resistance D. Relaxing venous and arterial smooth muscle

D. Relaxing venous and arterial smooth muscles

Which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain? A. Unchanged by rest B. Precipitated by light activity C. Described as a knifelike sharpness D. Relieved by sublingual nitroglycerin

D. Relieved by sublingual nitroglycerin Relief by sublingual nitroglycerin is a classic reaction because it causes vasodilation of peripheral veins and arteries, thereby decreasing oxygen demand by decreasing preload. To a lesser extent, sublingual nitroglycerin dilates coronary arteries, which increases oxygen to the myocardium, thereby decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness.

Which prescribed action would the nurse take first when a client who is admitted to the emergency department with a blood pressure of 240/150 mm Hg reports severe headache, blurred vision, and swelling of the ankles? A. Obtain a glucose blood sample. B. Collect urine and blood samples. C. Assess the client's pulse and respirations. D. Determine the amount of ankle edema.

C. Assess the client's pulse and respirations

Which interventions would you implement after an AAA repair? SATA. 1.Keep HOB elevated at 60 degrees 2.Assess peripheral pulses of both lower extremities 3.Change dressings as ordered with aseptic technique 4.Use the bed's knee gatch to allow for knee flexion during bed rest 5.Keep first pressure on the abdominal incision during coughing exercises

1.Assess peripheral pulses of both lower extremities 2.Change dressings as ordered with aseptic technique 3.Keep first pressure on the abdominal incision during coughing exercises You would keep the HOB 30-40 degrees and knees should be kept straight

The healthcare provider is assessing a patient who has a been diagnosed with an abdominal aortic aneurysm (AAA). Which assessment finding is an indication that the aneurysm is expanding? 1.Hoarseness and cough 2.A report of lower back pain 3.Anginal pain 4.Dysphasia

2. A report of lower back pain As aneurysm enlarge they can compress nearby structures and nerves, causing a variety of signs and symptoms. Compression of the esophagus from a a thoracic aortic aneurysm can cause dysphagia, cough, and hoarseness if they laryngeal nerve is compressed. Symptoms of an AAA are the result of compression of abdominal structures, so back and abdominal pain are often reported. Anginal pain may be a symptom of compromised cardiac perfusion secondary to a thoracic aortic aneurysm.

The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select All that Apply 1. Obtain a midstream urine specimen 2. Attach telemetry monitor to the client 3. Start a saline lock in the right arm 4. Draw a baseline metabolic panel (BMP) 5. Request an order for a STAT 12-lead ECG

2. Anytime a nurse suspects cardiac problems, the electrical conductivity of the heart should be assessed. 3. Emergency medications for heart problems are primarily administered intravenously, so starting a saline lock in the right arm is appropriate. 5. A 12-lead ECG evaluates the electrical conductivity of the heart from all planes.

A patient is diagnosed with an abdominal aortic aneurysm (AAA). Which of the patient's vital signs will be a priority for the healthcare provider to monitor? 1.Core temperature 2.Blood pressure 3.Pulse rate 4.Respiratory rate

2. Blood pressure Blood pressure should be monitored most closely in this patient. Avoiding hypertension is important because this could promote enlargement and rupture of the aneurysm. Hypotension could signal that rupture has occurred and blood volume has been lost. Respiratory rate and pulse rate may be elevated in early shock secondary to AAA leakage or rupture.

The client who has had a myocardial infarction is transferred to a step down unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker 2. Physical therapy 3. Cardiac rehabilitation 4. Occupation therapy

3. Cardiac rehabilitation Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercises, diet teaching, and classes on modifying risk factors.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin 2. Obtain a stat 12 Lead ECG 3. Have the client sit down immediately 4. Assess the client's vital signs

3. Have the client sit down immediately Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.

During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the healthcare provider. Which of the following should be the healthcare provider's next action? 1.Ask the patient to perform a Valsalva maneuver 2.Obtain a bladder scan 3.Measure the abdominal circumference 4.Assess femoral pulses

4. Assess femoral pulses Measuring the abdominal circumference may be an appropriate assessment for a patient who has generalized abdominal enlargement, which may be seen in liver dysfunction. A bladder scan would be an appropriate action if the healthcare provider suspects a distended bladder, which may present as a non-pulsating suprapubic enlargement. A pulsating mass may indicate the presence of an abdominal aneurysm. Assessing the pulses distal to the aneurysm will provide information regarding the degree of circulatory compromise. Increasing abdominal girth may be associated with a ruptured aneurysm. Asking the patient to bear down (Valsalva maneuver) is appropriate if a hernia is suspected.

Which finding would the nurse expect when assessing a client with cor pulmonale? A. Weight loss B. Slow heart rate C. Urinary frequency D. Lower extremity edema

D. Lower extremity edema

Which finding in a client seen in the emergency department with chest pain is most important to communicate to the health care provider? A. Severe nausea and vomiting B. Substernal pain level 9 (0 to 10 scale) C. Blood glucose 230 mg/dL (12.78 mmol/L) D. ST segment elevation on electrocardiogram

D. ST segment elevation on electrocardiogram

What would be the treatment option of choice for an AAA that is 6 cm (type A)? A) Blood pressure medication B) Thrombolytic Agent C) Crestor D) Surgery

D. Surgery For Aneurysms larger than 5.5 cm, surgery is the treatment of choice. If smaller, antihypertensive may be prescribed to lower pressure on aortic wall. B and C are not appropriate in this situation

The nurse is conducting health teaching for a client with a new diagnosis of pulmonary hypertension. The nurse knows to include which teaching ​topics? Select all that apply. 1.Call the health care provider for a weight gain of greater than 5 pounds in 1 week. 2.The medications will control all the symptoms of the disease. 3.The importance of smoking cessation 4.Pulmonary hypertension is a curable disease.

1. Call the health care provider for a weight gain of greater than 5 pounds in 1 week. 3. The importance of smoking cessation Smoking cessation is important for a client with pulmonary hypertension because smoking is an irritant to airways and it has vasoconstrictive properties. The client with pulmonary hypertension should be taught to monitor daily weights and for increasing edema because of the risk for excess fluid volume. Medication adherence is very important to teach the client with respect to disease​ management, but there is no guarantee that medications will control all symptoms of the disease. Pulmonary hypertension is a​ chronic, progressive disease. The most effective​ long-term treatment for pulmonary hypertension is heart/lung or lung transplant.

While recovering from an endovascular aortic repair (EVAR) of an abdominal aortic aneurysm (AAA), the patient experiences numbness and tingling in the feet. What is the healthcare provider's priority action? 1.Palpate the pedal pulses 2.Gently massage the legs and feet 3.Assist the patient to ambulate 4.Apply warm compresses to the feet

1.Palpate the pedal pulses The healthcare provider will monitor pulse and check for pallor, pain, paresthesia, and paralysis; assessing temperature of extremities can be remembered by the words "polar" or "poikilothermia" (varying temperature). Numbness and tingling of the feet and loss of pedal pulses may indicate an occlusion of the graft, which requires immediate attention.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis 2. Diaphoresis and cool clammy skin 3. Intermittent claudication and palor 4. Jugular vein distention and dependent edema

2. Diaphoresis and cool clammy skin Diaphoresis is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this in turn, leads to cold, clammy skin

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging leg movements 2. Report this behavior to the charge nurse as soon as possible 3. Praise the UAP for encouraging the client to move legs 4. Take no action concerning the UAP's behavior

3. Praise the UAP for encouraging the client to move legs The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for developing deep vein thrombosis, and moving the legs will prevent this from occurring.

The client diagnosed with a myocardial infarction is six hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight 2. The pressure dressing to the right femoral area is intact 3. The client is complaining of numbness in the right foot 4. The client's right pedal pulse is +3 and bounding

3. The client is complaining of numbness in the right foot Any neurovascular assessment data that is abnormal requires intervention by the nurse; numbness may indicate decreased blood flow to the right foot

The nurse is reviewing medication orders for a client with pulmonary hypertension. Which medication order would the nurse​ question? 1.Nifedipine​ (Procardia) 2.Warfarin​ (Coumadin) 3.Epoprostenol​ (Flolan) 4.Metoprolol​ (Lopressor)

4. Metoprolol​ (Lopressor) Metoprolol is a​ beta-adrenergic blocker, which is not indicated in a client with pulmonary hypertension. Calcium channel blockers are given to reduce pulmonary vascular resistance and improve cardiac output. Warfarin is given to a client with pulmonary hypertension to prevent clotting. Epoprostenol​ (Flolan) is indicated for clients with pulmonary hypertension who do not respond to calcium channel blockers.

The nurse is instructing a community group regarding risk factors for coronary artery disease. Which risk factor cannot be modified? A. Heredity B. Hypertension C. Cigarette smoking D. Diabetes mellitus

A. Heredity

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administering? A. Oxygen, nitroglycerin, aspirin, and morphine B. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine C. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen D. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

A. Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

Which response indicates that sublingual nitroglycerin prescribed for a client with unstable angina is effective? A. Pain subsides as a result of arteriole and venous dilation. B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves as a response to increased collateral circulation.

A. Pain subsides as a result of arteriole and venous dilation. Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain. An increased pulse rate does not indicate effectiveness; it is a side of effect of nitroglycerin. The tingling indicates that the medication is fresh; relief of pain is the only indicator of effectiveness. Nitroglycerin does not promote the formation of new blood vessels.

Which description would the nurse expect the client to use to characterize the pain when admitted to the coronary care unity with a diagnosis of ST segment elevation myocardial infarction? A. Severe, intense chest pain B. Burning sensation of short duration C. Sharp, stabbing chest pain with breathing D. Squeezing chest pain, relieved by nitroglycerin

A. Severe, intense chest pain

A 52-year-old male patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). To determine the effectiveness of this medication, the nurse should assess the patient for the A. presence of chest pain. B. blood in the urine or stool. C. tachycardia with hypotension. D. decreased level of consciousness.

A. presence of chest pain. Alteplase is a fibrinolytic that is administered to patients who have had an STEMI. If the medication is effective, the patient's chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.

Which of the following are signs of a rupturing AAA? Select all that apply: A) Increased BP B) Decreased Hct C) Low Back Pain D) Decreased BP E) Intermittent abdominal pain

B) Decreased Hct C) Low Back Pain D) Decreased BP B,C, and D. The patient is losing blood pressure and dropping hematocrit due to bleeding. Pain is a key sign of a rupturing (or close to rupturing) Aortic Abdominal Aneurysm. Usually, when rupturing, the pain becomes constant rather than intermittent.

Which action would the nurse take first in a client with an abdominal aortic aneurysm who is suddenly pale and reports feeling light-headed and having abdominal pain? A. Assess the respiratory rate for hyperventilation. B. Check the blood pressure for hypotension. C. Administer the prescribed morphine for pain. D. Inspect the abdomen for distention and firmness.

B. Check the blood pressure for hypotension.

When a client with chronic obstructive pulmonary disease (COPD) reports a 5 lb. (2.3 kg) weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication? A. Polycythemia B. Cor pulmonale C. Compensated acidosis D. Left ventricular failure

B. Cor pulmonale

Which form of nitroglycerin would the nurse anticipate giving to a client with midsternal pain who presents to the emergency department with stable vital signs? A. Oral capsule B. Sublingual spray C. Intravenous solution D. Transdermal patch

B. Sublingual spray Nitroglycerin spray provides prompt relief of symptoms. The nurse administers one to two sprays, up to a maximum of three sprays, onto or under the tongue every 5 minutes until pain is relieved. If unrelieved after three sprays, intravenous nitroglycerin are used for prophylactic purposes, not management of acute pain.

Which instructions about the use of nitroglycerin to prevent angina will the nurse provide to a client? A. "At the point when pain first occurs, place two tablets under the tongue." B. "Place one tablet under the tongue before activity, and swallow another if pain occurs." C. "Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs." D. "Place one tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent recurrence."

C. "Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs."

Which instruction would the nurse include when teaching the client about sublingual nitroglycerin? A. "Once the tablet is dissolved, spit out the saliva." B. "Take tablets 3 minutes apart up to a maximum of five tablets." C. "Common side effects include headache and low blood pressure." D. "Once opened, the tablets should be refrigerated to prevent deterioration."

C. "Common side effects include headache and low blood pressure."

Which statement by a client indicates that the nurse's preprocedure teaching about cardiac catheterization has been effective? A. "I will be asleep during most of the procedure." B. "I will be in the catheterization laboratory for about 15 minutes." C. "I will need to be in bed for several hours after the procedure." D. "I will need to deep breathe and cough frequently after the procedure."

C. "I will need to be in bed for several hours after the procedure."

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? A. Chronic stable angina B. Left-sided heart failure C. Coronary artery disease D. Acute myocardial infarction

D. Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

Which client would be at an increased risk for coronary artery disease (CAD)? A. Client with total cholesterol 175 mg/dL and LDL cholesterol 80 mg/dL. B. Client with total cholesterol 190 mg/dL and HDL cholesterol 40 mg/dL. C. Client with total cholesterol 200 mg/dL and HDL cholesterol 45 mg/dL. D. Client with total cholesterol 250 mg/dL and LDL cholesterol 120 mg/dL.

D. Client with total cholesterol 250 mg/dL and LDL cholesterol 120 mg/dL.

Which type of shock would the nurse monitor for in client with ruptured abdominal aortic aneurysm? A. Obstructive B. Neurogenic C. Cardiogenic D. Hypovolemic

D. Hypovolemic

The nurse is talking with a client about treatment options for a new diagnosis of primary pulmonary hypertension. Which statement indicates to the nurse that the client understands the​ treatment? ​1. "I wonder if I can get on a transplant list​ soon." 2. "A transfusion will help with getting more oxygen with this​ disorder." 3. ​"The blood pressure in my lungs will get better if I take​ yoga." 4. "The medications will cure my​ disease."

​1. "I wonder if I can get on a transplant list​ soon." Lung transplant or heart/lung transplant is the most effective​ long-term treatment for primary pulmonary hypertension. Medications such as calcium channel blockers are used to control pulmonary hypertension but will not cure the disease process. Exercise and lifestyle modifications are indicated for a client with systemic hypertension but will not necessarily affect pulmonary hypertension. Clients with pulmonary hypertension are likely to have polycythemia because of the chronic hypoxia present with this disorder. Periodic phlebotomy is indicated to treat polycythemia.