EXAM #4 - CH. 16, 21, 23, 27, 56
A newly diagnosed client with hypertension is prescribed a thiazide diuretic. What client education should the nurse provide to this client?
"This medication can cause low blood pressure and dizziness, especially when you get up suddenly."
A client with newly diagnosed hypertension has come to the clinic for a follow-up visit. The client asks the nurse why the client has to come in so often. Which response by the nurse would be best?
"To make sure your health is stable"
The surgical nurse is caring for a client whose wound is classified as clean contaminated. Which type of wound is the nurse likely to assess?
A wound with a drainage system
An adult client is admitted to the ED with chest pain. The client states that there was unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?
Morphine sulphate, oxygen, and bed rest
The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experienced a significant increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD may result in which outcome?
Myocardial ischemia
The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection?
Red, warm, tender incision
When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information?
The client's symptoms and the activities that precipitate attacks
A resident of a long-term care facility has reported chest pain to the nurse. What aspect of the resident's pain would be most suggestive of angina as the cause?
The pain occurs immediately following physical exertion.
A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects?
Throbbing headache or dizziness
The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. The nurse should explain that cardiac catheterization is most commonly done for which purpose?
To assess how blocked or open a client's coronary arteries are
The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply.
Transient ischemic attacks (TIAs) Cerebrovascular disease Retinal hemorrhage
The nurse is monitoring blood pressure for a client with unstable readings. How often should the nurse check the client's blood pressure?
Every 5 minutes
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that what vessel is most commonly used as source for a CABG?
Greater saphenous vein
A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis?
Heart failure
A client presents to the clinic reporting intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause?
Coronary arteriosclerosis
The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response?
Explore the factors underlying the client's anxiety.
When assessing a postsurgical client's risk for deep vein thrombosis, the nurse should prioritize what assessment parameter?
Hydration status
The home health nurse is caring for a client who has a diagnosis of hypertension. What assessment question most directly addresses the possibility of worsening hypertension?
"Do you ever see spots in front of your eyes?"
The nurse is caring for a client who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?
A heart rate of 54 bpm
A client is brought into the emergency department (ED) by family members, who tell the nurse the client grabbed their chest and reported substernal chest pain. The care team recognizes the need to monitor the client's cardiac function closely while interventions are performed. Which form of monitoring should the nurse anticipate?
Hardwire continuous electrocardiogram (ECG) monitoring
The nurse is developing a nursing care plan for a client who is being treated for hypertension. Which outcome is mostappropriate for the nurse to include?
Client will reduce Na+ intake to less than 2 g daily.
A 56-year-old client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response?
"A single elevated blood pressure does not confirm hypertension. Diagnosis requires multiple elevated readings."
A client's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect?
Increased urine output
An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply.
Indigestion Nausea
The health care provider has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a client. The results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis?
Inflammation
The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium?
It may have developed an increased area of infarction during the time without treatment.
The nurse is caring for an 88-year-old client who is recovering from an iliac-femoral bypass graft. The client is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the client, it is clear that the client is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. Which complication should the nurse suspect?
Postoperative delirium
A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize?
Rising slowly from a lying or sitting position
The critical care nurse is caring for a client just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication?
Sodium nitroprusside
A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.
Stable blood pressure Sufficient oxygen saturation Adequate respiratory function
A client has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. This client experienced damage to which area of the heart?
Myocardium
The nurse is providing care for a client with a diagnosis of hypertension. The nurse should consequently assess the client for signs and symptoms of which other health problem?
Atherosclerosis
A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response?
"Hypertension greatly increases your risk of stroke and heart disease."
The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client?
"I will provide privacy. The dressing change should not be painful; you may look at the incision and help."
A presurgical client asks, "Why will I go to the postanesthesia care unit (PACU) instead of just going straight up to the postsurgical unit?" Which response by the nurse would be best?
"It allows us to observe you until you're oriented and have stable vital signs and no complications."
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the sinoatrial (SA) node and then proceeds in which sequence?
AV node to bundle of His to Purkinje fibers
The nurse providing care for a client post PTCA knows to monitor the client closely. For what complications should the nurse monitor the client? Select all that apply.
Abrupt closure of the coronary artery Bleeding at the insertion site Retroperitoneal bleeding Arterial occlusion
A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group?
African-Americans
A lipid profile has been ordered for a client who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results?
After a 12-hour fast
A client presents to the ED reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?
Begin ECG monitoring.
A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. The complications for which the nurse should monitor the client include which of the following?
Bleeding at insertion site
The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe?
Cardiopulmonary bypass
A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action?
Contact the client's health care provider and continue to assess fluid balance and renal function.
An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury?
D. IV
A client with hypertension is ambulating in the hospital hallway and reports chest pain. In which order would the nurse assess and treat this client?
D. The client is instructed to stop all activity. B. The nurse assesses the client's angina. A. The first set of vital signs are done. C. A 12-lead electrocardiogram (ECG) is performed. E. The client receives the first dose of nitroglycerin. F. The client is transferred to a higher acuity unit.
The nurse is caring for a client in the emergency department who was admitted for a hypertensive emergency. The nurse knows the goal of intravenous vasodilator therapy for a hypertensive emergency would be which outcome?
Decrease the systolic blood pressure by no more than 25% within the first hour
The nurse is reviewing the medication administration record of a client who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply.
Decreased peripheral resistance Decreased blood volume Decreased strength and rate of myocardial contractions
A nurse educator is conducting an inservice for nursing students about how tobacco use impacts coronary artery disease (CAD)? What are the primary ways that tobacco use impacts CAD? Select all that apply.
Decreases the supply of oxygen to the myocardium Increases platelet adhesion Raises the heart rate and blood pressure Increases the blood carbon monoxide level
The perioperative nurse is preparing to discharge a client home from day surgery performed under general anesthesia. Which instruction should the nurse give the client prior to the client leaving the hospital?
Do not drive yourself home.
The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.
Dyspnea Unusual fatigue Syncope
A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?
Educating participants about the early signs and symptoms of skin cancer
The surgeon's preoperative assessment of a client finds that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication?
Encourage early ambulation.
A client has been diagnosed as being prehypertensive. What should the nurse encourage this client to do to aid in preventing a progression to a hypertensive state?
Exercise on a regular basis.
The nurse is caring for a client who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?
Increase in the size of the artery's lumen
The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an older adult. The nurse should prioritize which of the following actions?
Keeping the client warm
During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI?
Left midclavicular line of the chest at the fifth intercostal space
The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?
Lipids and fibrous tissue
A client with type 2 diabetes and hypertension (HTN) has a routine follow-up appointment after a cardiac stent placement. On assessment the nurse notes the client weighs 250 lb/113.4 kg with a waist circumference of 40 inches/101.6 cm, blood pressure is 162/84 mm Hg, and fasting blood glucose is 220 mg/dl. Based on these findings, which syndrome should the nurse most suspect?
Metabolic syndrome
The ED nurse is caring for a client with a suspected MI. What drug should the nurse anticipate administering to this client?
Morphine
A client in hypertensive urgency is admitted to the hospital. The nurse should be aware of which goal of treatment for a client in hypertensive urgency?
Normalizing BP within 24 to 48 hours
A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?
Perform hand hygiene.
The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response?
Place saline-soaked sterile dressings on the wound.
The nurse is caring for an older adult client in the postanesthesia care unit. The client begins to awaken and responds to their name, but is confused, restless, and agitated. Which principle should guide the nurse's subsequent assessment?
Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss.
The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication?
Pulmonary embolism
The nurse is collaborating with the dietitian and a client with hypertension to plan dietary modifications. Which modifications should be the priority?
Reduced intake of fat and sodium
A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of which condition?
Retinal blood vessel damage
The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the client. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?
T-wave inversion
The nurse is caring for a postoperative client who needs daily dressing changes. The client is 3 days' postoperative and is scheduled for discharge the next day. Until now, the client has refused to learn how to change the dressing. What would indicate to the nurse the client's possible readiness to learn how to change the dressing? Select all that apply.
The client expresses interest in the dressing change. The client is willing to look at the incision during a dressing change. The client assists in opening the packages of dressing material for the nurse.
A client underwent an open bowel resection 2 days ago, and the nurse's most recent assessment of the client's abdominal incision reveals that it is dehiscing. Which factor should the nurse suspect may have caused the dehiscence?
The client has vomited three times in the past 12 hours.
Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
The symptoms indicate an acute coronary episode and should be treated as such.
A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure?
The test is noninvasive, and nothing will be inserted into the client's body.
A client newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the client and advises that the client should avoid tobacco use. What is the primary rationale behind that advice to the client?
Tobacco use increases the client's concurrent risk of heart disease.
The dressing surrounding a client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
Trace the outline of the drainage on the dressing for future comparison.
An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. Which topic should the nurse include in health education?
Use of strategies to prevent falls stemming from orthostatic hypotension
The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?
Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately
The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client:
avoid placing body weight on the healing site.
The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:
diet therapy and smoking cessation.
