Exam 1 Cardio

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The nurse is caring for a client with peripheral artery disease (PAD) who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediate action from the nurse?

A change in the intensity of a pulse

A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention?

Prepare the client for surgical intervention

A client who has a history of bacterial endocarditis is scheduled to have oral surgery to remove a tooth. What should the nurse instruct the client to do?

Be sure the dentist prescribes a prophylactic antibiotic before the oral surgery.

The nurse is assessing an individual with peripheral artery disease. Which finding indicates complete arterial obstruction in the lower left leg?

Coldness of the left foot and ankle

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do?

Enroll in a supervised exercise training program.

A physician admits a client with a history of I.V. drug abuse to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has

Osler's nodes and splinter hemorrhages.

A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. What is the nurse's primary goal at this time?

Prepare the client for emergency surgery.

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT)

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching?

Risk for infection

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain.

A physician admits a client to the healthcare facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind when formulating interventions?

stabilizing heart rate and blood pressure and easing anxiety

A community health nurse is involved in a teaching program to help prevent rheumatic fever in school-age children. Which is the most important intervention to decrease the incidence of the disease?

teaching clients to seek medical treatment for streptococcal pharyngitis

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which point(s)? Select all that apply.

to report unexpected bleeding or bleeding that lasts a long time to know that clopidogrel works by preventing platelets from sticking together and forming a clot to understand that the client may bruise more easily and may experience bleeding gums.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

✓ Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

A nurse is working in the intermediate care unit. After receiving change of shift report who should the nurse assess first?

a client with aortic stenosis who has a blood pressure of 84/52 mm Hg

Which statement indicates that the parents understand the need for their child to receive long-term antibiotic therapy after an episode of rheumatic fever?

"It will prevent recurring acute rheumatic fever."

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history?

atrial fibrillation and a mild stroke one month ago

The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor?

gangrene

The nurse is assigned to a client in the ICU. During the initial assessment, the nurse notes jugular vein distention and recognizes that the plan of care will follow which disorder?

heart failure

The nurse is assessing a client admitted to the hospital for surgery to repair an abdominal aortic aneurysm. Before surgery, the nurse should assess the client for which factor that puts the client at risk for rupture?

high blood pressure

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

history of aortic valve replacement

A client is receiving cilostazol for peripheral artery disease causing intermittent claudication. Which statement by the client indicates to the nurse that this medication is effective?

i am able to walk further without leg pain

A client has mitral stenosis and will have a valve replacement. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which prescription would pose the greatest health hazard to this client at this time?

medication therapy

A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action?

weight gain of 2.5 kg (5.5 lb) in 24 hours

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider suspects the client is experiencing a dissecting aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm?

cardiac tamponade


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