Evolve: Cardiovascular

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor and concludes that these complexes are a sign of:

Cardiac irritability

A client is discharged with a prescription for sustained-release nitroglycerin. What should the nurse teach the client about sustained-release nitroglycerin?

Swallow the capsule whole

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?

Arteriolar constriction occurs.

A client exhibits persistent pyrexia, abdominal pain, and symptoms of neuritis. A diagnosis of polyarteritis nodosa is suspected. Which adaptation should the nurse expect when assessing the client?

Elevation in blood pressure

A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse concludes that the surgeon should be contacted immediately because the hypertension may indicate that the:

Graft is leaking

A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" The best response by the nurse is, "The pacemaker:

Manages an abnormally slow heart rate."

For which expected response should the nurse monitor a client after a cardiac catheterization?

Marked increase in the volume of urine output

A client with a history of severe intermittent claudication has a femoropopliteal bypass graft. An appropriate postoperative intervention on the day after surgery is to:

Assist the client with ambulation

A nurse is assessing a middle-aged female client for the presence of risk factors associated with coronary heart disease. Which risk factor carries a greater risk for women than for men?

Diabetes mellitus

When a client has a myocardial infarction, one of the major manifestations is a decrease in conductive energy provided to the heart. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart?

Strength of contractions

A client is receiving intravenous heparin for treatment for a deep vein thrombosis (DVT). While completing the client's morning assessment, the nurse notes that the intravenous (IV) insertion site is cool to touch and the skin appears blanched. The nurse also notes there is <1 inch edema around the site. Based on the infiltration scale, how should the nurse properly document the infiltration?

One (1)

A client has been experiencing chest discomfort for several months, especially after eating, which the client attributed to a hiatal hernia. The client reports that after eating a meal today, the client coughed severely and then vomited profusely. The client stated that because the vomitus was bright red in color, medical care was sought. The nurse reviews the plan of care and determines that the priority is to:

Draw blood for typing and crossmatching

What clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply.

Edema Dyspnea

A client with Hodgkin disease enters a remission period and remains symptom free for six months when a relapse occurs. The client is diagnosed at stage IV. The therapy option the nurse expects to be implemented at this time is:

Combination chemotherapy

A client receiving hemodialysis has an external shunt for circulatory access. With which life-threatening complication associated with external cannulas should the nurse be most concerned?

Hemorrhage

An 85-year-old client with a history of congestive heart failure on daily weights has a 2-pound weight gain and pitting edema in lower extremities bilaterally, indicative of fluid retention. The most appropriate response is:

Perform a head-to-toe assessment, including vital signs

A client reports a history of bilateral blanching and pain in the fingers on exposure to cold. When rewarmed, the fingers become bright red and "tingly" with a slow return to their usual color. The client smokes one to two packs of cigarettes per day. The nurse determines that the client has Raynaud's disease and not Raynaud's phenomenon because of the:

Bilateral involvement

A client is brought into the emergency department with complaints of chest pain. What are possible causes for the client's chest pain? Select all that apply.

Costochondritis Pneumonia Pleurisy Myocardial infarction

What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)?

Deflate the balloon as soon as the PCWP is measured.

Which significant risk factors for coronary heart disease carry a greater risk for women than for men? Select all that apply.

Diabetes mellitus Low levels of high-density lipoprotein (HDL) cholesterol

A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. What is an appropriate postoperative nursing intervention on the day after surgery?

Assist the client with walking.

An older client exhibits typical clinical indicators of pulmonary edema. List the following clinical indicators of pulmonary edema in the order they typically appear.

Crackles Increased respirations Tachycardia Orthopnea Frothy, blood-tinged sputum

A client had a femoral-popliteal bypass graft. Four hours after surgery the client's blood pressure (BP) increases to 200/110. The nurse concludes that the increase in blood pressure is a specific indicator of what postoperative complication?

Rupture of the graft

Before a femoral arteriogram is started, the nurse plans to teach the client that:

Local anesthesia will be used to lessen pain at the site

Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that the cause of the increase in the client's urinary output is:

An expected effect of the dye used with the procedure

A 78-year-old client comes to the health clinic complaining of fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL. Which is the most appropriate nursing intervention in response to these laboratory results?

Conduct a complete nutritional assessment of the client.

A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse.

Ensure that the client signed a consent for the transfusion. Determine the client's vital signs. Compare the number on the blood product and laboratory record. Don a pair of clean gloves. Run the transfusion slowly.

Halfway through the administration of a unit of blood, a client complains of lumbar pain. After stopping the transfusion and replacing the tubing, the nurse should:

Increase the flow of normal saline

What is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?

Lower extremity color

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, the nurse recalls that the most accurate measurement of the client's left ventricular pressure is the:

Pulmonary capillary wedge pressure

To ensure accuracy when assessing a client's blood pressure, how does the nurse avoid a parallax error?

Read the manometer at eye level.

The nurse is conducting a nutrition class for a group of clients with congestive heart failure (CHF). It would be most important for the nurse to explain the importance of:

Choosing fresh or frozen vegetables instead of canned ones.

A nurse discusses resumption of sexual activity with a client who is recovering from a myocardial infarction. The nurse should instruct the client to:

Select familiar settings for sexual activity

The client is returned to the surgical unit from the postanesthesia care unit (PACU) after a having a splenectomy. In the immediate postoperative period, the nurse specifically should monitor for which potential complications? Select all that apply.

Shock Abdominal distention Pulmonary complications

A client requiring surgery because of mitral valve incompetence is admitted to the hospital and states, "I need a new valve, with an oil change, too!" What is the nurse's most therapeutic response?

"I'm sure you have a great deal to ask about your surgery."

A client who is diagnosed as having a myocardial infarction is admitted to the coronary care unit with prescriptions for bed rest and medication for chest pain. Within an hour after admission, the nurse finds the client walking around the unit. What is the nurse's best initial response?

"You need to rest. You should get back into bed."

A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?

140 to 159 mm Hg

A client has a splenectomy after a motor vehicle collision. What is a postoperative nursing concern specifically related to this type of surgery?

Adequate lung aeration

The nurse is assessing the pulse of a client with an on-demand pacemaker. What should the nurse identify when a client's on-demand pacemaker is functioning effectively?

At least at the demand rate

A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.

Avoid intramuscular injections. Examine the skin for ecchymotic areas.

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? Select all that apply.

Avoid prolonged exposure to the sun. Schedule regular ophthalmic examinations. Contact your health care provider if skin becomes gray-bronze.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

Bradycardia Hypotension Bladder dysfunction

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms most likely are to be associated with this disorder?

Burning pain after exposure to cold

A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order?

Check health care provider's prescription Obtain vital signs and history of transfusions Ascertain that intravenous catheter size is 18 or 20 gauge Change main line solution to normal saline Check client identification before hanging unit of blood

A client, receiving a potassium infusion via a peripheral intravenous (IV) site, complains of burning sensation above the IV site. What should the nurse do first?

Check the IV access for a blood return.

A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding?

Chemical irritation to the tissues

An 83-year-old client is diagnosed with left-sided congestive heart failure. Which assessment findings should the nurse expect to find on this client? Select all that apply.

Dyspnea Crackles Cool extremities

A client complains of foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. The nurse concludes that further teaching is needed when the client states, "I will:

Elevate my foot"

To help reduce a client's risk factors for heart disease, what should the nurse include in the client's teaching plan?

Increase the quantity of complex carbohydrates

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?

Feeling of heaviness in both legs.

Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply.

Gastrointestinal (GI) suction Diuretic therapy Continuous bladder irrigation

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider the most likely reason for this change?

Increased intravascular volume

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? Select all that apply.

Malaise Swollen lymph glands

An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.

Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification.

Within the first 2½ hours after a radical neck dissection, 40 mL of medium red, bloody fluid is collected in the portable wound drainage system. What should the nurse do first?

Obtain the vital signs.

The nurse is caring for a client that experienced a myocardial infarction (MI). The nurse monitors for the most serious complication that occurs within 48 hours after an MI, which is:

Ventricular tachycardia

A client with chronic heart failure is taking a diuretic twice a day. The health care provider prescribes a diet that includes the intake of dietary potassium. What foods that have a higher amount of potassium should the nurse instruct the client to consume? Select all that apply.

Bananas Baked potatoes with skins

A nurse observes a window washer falling 25 feet to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Begin chest compressions.

The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level?

Increased total iron-binding capacity (TIBC)

What group of clients should the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas?

Older adults

When determining whether or not an atrial rhythm is regular, the nurse determines the consistency of the space between the:

P waves.

A client comes to the outpatient clinic with a large leg ulcer. The clinical finding that supports the diagnosis of arterial ulcer is:

Pain at the ulcer site

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? Select all that apply.

Reports of leg fatigue Tortuous veins in the legs Pain in lower extremities when standing

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.

Absence of hair on the toes Reports of pain associated with exercising

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle?

T wave

A client with Hodgkin disease is to receive the cyclic antineoplastic vincristine (Oncovin) as part of a therapy protocol. The client asks how this medication works. The nurse explains in language that the client will understand that vincristine helps destroy the malignant cells by:

Arresting mitosis in metaphase

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. Select all that apply.

Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

Dependent edema Swollen hands and fingers Right upper quadrant discomfort

A client has arrived on the nursing unit scheduled for a cholecystectomy, and there is one registered nurse, a licensed practical nurse, and a certified nursing assistant. Institution policy is that all admissions must have the initial assessment completed by a registered nurse. The registered nurse currently is caring for a client with a transfusion reaction. Which is the best decision?

Have the practical nurse perform the initial assessment and the registered nurse verify all findings after the transfusion client is stable.

What statement is true of ventricular dysrhythmias? Select all that apply.

The QRS complex appears widened and has a bizarre shape. The polarity of the T wave is opposite that of the QRS complex. Most ventricular dysrhythmias have no apparent P wave.

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? Select all that apply.

Stupor Paresthesia in affected body parts

The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse would look for potential causes such as: Select all that apply

Anxiety Caffeine Exercise Anemia