HESI Cardiovascular
A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? Arterial spasm Heart muscle ischemia Blocking of the coronary veins Irritation of nerve endings in the cardiac plexus
Heart muscle ischemia Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.
When interpreting an electrocardiogram rhythm strip, the nurse identifies that ventricular contraction is displayed as what? P wave T wave PR interval QRS interval
QRS interval The QRS interval represents time taken for depolarization of both ventricles. The P wave represents repolarization of the atria. The T wave represents repolarization of the ventricles. The PR interval represents the time taken for the impulse to spread through the atria.
What is the most important teaching for a nurse to provide for a client who had sclerotherapy for varicose veins? Limit activity until edema subsides. Remove compression bandages when in bed. Place a pillow under the knees when lying in bed. Walk for several minutes every hour when awake.
Walk for several minutes every hour when awake. Walking activities are encouraged to improve circulation and dilute the sclerosing agent. Limiting activity is contraindicated; inactivity contributes to venous stasis and engorgement of veins. Compression bandages should be left in place for several days to ensure external compression of veins, which enhances venous return. Placing a pillow under the knees when lying in bed is contraindicated because it will impede venous return.
A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, "What can I do to help myself?" How should the nurse respond? "Limit walking to as little as possible." "Reduce fluid intake to 1 L of liquid a day." "Apply moisturizing lotion on your legs several times a day." "Put on compression hose before getting out of bed in the morning."
"Put on compression hose before getting out of bed in the morning." As valves become incompetent, they allow blood to pool in the veins, which increases hydrostatic pressure and leads to further valve destruction. Compression hose provide external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. The legs are less congested after sleeping, and therefore the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming, because muscle contraction encourages venous return to the heart. Prolonged sitting, standing, or crossing the legs should be avoided because they reduce venous return. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin more supple, it will not treat enlarged and tortuous veins.
A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects which diagnostic finding specific for multiple myeloma? Occult blood in the stool Low serum calcium levels Bence Jones protein in the urine Positive bacterial culture of sputum
Bence Jones protein in the urine Bence Jones protein (globulin) results from tumor cell metabolites. It is present in clients with multiple myeloma. Occult blood in the stool is not specific for the diagnosis of multiple myeloma; it is a late complication of multiple myeloma related to coagulation defects. Hypercalcemia, not hypocalcemia, occurs with multiple myeloma because of bone erosion. Multiple myeloma is not caused by a bacterial infection.
After undergoing a cardiac catheterization, the client complains of tingling sensations in the affected leg. What should the nurse do to determine the cause of the tingling? Assess for bleeding at the puncture site. Evaluate the affected leg for signs of inflammation. Compare femoral, popliteal, and pedal pulses in both legs. Obtain the temperature, pulse, respirations, and blood pressure.
Compare femoral, popliteal, and pedal pulses in both legs. Tingling indicates decreased arterial circulation to the extremity; it may be caused by an embolus distal to the arterial insertion site. Checking all pulses will help locate an embolus. Tingling sensations of an extremity are not related to bleeding, but rather to lack of circulation. Signs of inflammation are associated with thrombophlebitis; tingling is associated with arterial obstruction. Obtaining the temperature, pulse, respirations, and blood pressure will be done if there are systemic responses to compromised heart function; tingling in an extremity is a localized response.
A 28-year-old male client is undergoing tests to confirm the diagnosis of Hodgkin lymphoma. The client and his wife are worried that he may have cancer. The wife states, "Don't you think it is unlikely for someone like my husband to have cancer?" The nurse's response is based on what information about Hodgkin lymphoma? More likely to affect women than men Diagnosed during adolescence and young adulthood Typically a disease of older rather than younger adults Common among populations of Asian heritage
Diagnosed during adolescence and young adulthood Hodgkin lymphoma occurs most often between the ages of 15 and 35 years and 50 and 60 years. Hodgkin lymphoma affects younger men and women equally and affects more men than women between the ages of 50 and 60 years. The incidence of Hodgkin lymphoma is not limited to people in older age groups. The prevalence of Hodgkin lymphoma is increased in teenagers and young adults (15 to 35 years of age). Asian populations are less likely to develop Hodgkin lymphoma than other populations.
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? Bradycardia Hypotension Spastic paralysis Bladder dysfunction Increased pulse pressure
-Bradycardia -Hypotension -Bladder dysfunction
A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse? Increased blood volume Hyperactivity of the heart Increased cardiac sufficiency Decreased force of contraction
Decreased force of contraction A direct relationship exists between systolic blood pressure and the force of left ventricular contraction. A decreased pulse pressure is associated with heart failure or hypovolemia. A decreased blood volume is indicated by a decreased pulse pressure. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac sufficiency.
A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities? Restrict fluids. Elevate the legs. Apply elastic bandages. Do range-of-motion exercises.
Elevate the legs. Elevation of extremities promotes venous and lymphatic drainage by gravity. Restricting fluids and applying elastic bandages are dependent functions of the nurse. Doing range-of-motion exercises may have little effect on edema.
A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances? Restrict family visits Withhold analgesic medications Plan for maximum periods of rest Keep the room light on most of the time
Plan for maximum periods of rest Sleep deprivation alone can cause these disturbances because of the interruption in rapid eye movement (REM) sleep. Lack of contact with significant others increases anxiety and feelings of isolation, which can lead to disturbances in rest. Pain limits or interrupts periods of sleep and rest. Analgesics should be administered as prescribed. Constant light increases cerebral arousal and limits sleep.
A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? Obtain vital signs Initiate a cardiac arrest code Administer oxygen using a face mask Encourage the use of an incentive spirometer
Administer oxygen using a face mask The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted. The client is not experiencing a cardiac arrest, and therefore a code should not be initiated. After more definitive medical intervention, deep breathing and coughing or use of an incentive spirometer may be done to prevent or treat atelectasis.
A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? Allows excess tissue fluid to be excreted Helps to control the volume of food intake and thus weight Aids the weakened heart muscle to contract and improves cardiac output Assists in reducing potassium accumulation that occurs when sodium intake is high
Allows excess tissue fluid to be excreted A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.
After multiple bee stings, a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what processes? Respiratory depression and cardiac arrest Bronchial constriction and decreased peripheral resistance Decreased cardiac output and dilation of major blood vessels Constriction of capillaries and decreased peripheral circulation
Bronchial constriction and decreased peripheral resistance Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs. Respiratory depression and cardiac arrest are the problems that result from bronchial constriction and vascular collapse. Dilation of arterioles occurs. Arterioles dilate, capillary permeability increases, and eventually vascular collapse occurs.
A client with heart failure is on a drug regimen of digoxin and furosemide. The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat? Apples Grapes Cantaloupe Cranberries
Cantaloupe Furosemide is potassium depleting; cantaloupe is high in potassium. Apples, grapes, and cranberries are low in potassium.
A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? Hypokalemia Hypocalcemia Hyponatremia Hypomagnesemia
Hypokalemia Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.
A client is at high risk for heart disease. Which instructions should the nurse include in the client's teaching plan? Avoid eating between meals. Limit unsaturated fats in the diet. Decrease the amount of fat-binding fiber. Increase the quantity of complex carbohydrates.
Increase the quantity of complex carbohydrates. The fiber component of complex carbohydrates helps bind and eliminate dietary cholesterol and fosters growth of intestinal microorganisms to break down bile salts and release the cholesterol component for excretion. It is what, not when, the client eats that is important. Saturated fats should be decreased. Fat-binding fiber should be increased.
A client develops ventricular fibrillation in a coronary care unit. Which action is priority? Administer oxygen Initiate defibrillation Initiate cardioversion Administer sodium bicarbonate intravenously
Initiate defibrillation Ventricular fibrillation is a lethal dysrhythmia and, once identified, must be terminated immediately by defibrillation so the sinus node can act again as the heart's pacemaker. Oxygen is administered to correct hypoxia, but if the heart is not pumping, oxygen will not be delivered to the tissues; it does not take priority over defibrillation. Cardioversion is not effective in ventricular fibrillation. Bicarbonate is administered to correct acidosis; it does not take priority over defibrillation.
An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? Spinal stenosis Buerger disease Rheumatoid arthritis Intermittent claudication
Intermittent claudication Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.
A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. What should be the nurse's first action? Stop the transfusion. Obtain the vital signs. Assess the pain further. Monitor the hourly urinary output.
Stop the transfusion. Flank pain is an adaptation associated with a hemolytic transfusion reaction; it is caused by agglutination of red cells in the kidneys and renal vasoconstriction. The infusion must be stopped to prevent further instillation of blood, which is being viewed as foreign by the body. Although obtaining the vital signs, assessing the pain further, and monitoring the hourly urinary output will be done eventually, they are not the priority actions.
When a client has a myocardial infarction, one of the major manifestations is a decrease in the conductive energy provided to the heart. When assessing this client, the nurse is aware that the existing action potential is in direct relationship to what? Heart rate Refractory period Pulmonary pressure Strength of contraction
Strength of contraction A direct relationship exists between the strength of cardiac contractions and the electrical conductions through the myocardium. The heart rate is related to factors such as sinoatrial (SA) node function, partial pressures of oxygen and carbon dioxide, and emotions. The refractory period is when the heart is at rest, not when it is contracting. Pulmonary pressure does not influence action potential; it becomes elevated in the presence of left ventricular failure.
A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction? Alanine aminotransferase (ALT) Serum aspartate aminotransferase (AST) Total lactate dehydrogenase (LDH) Troponin T (cTnT)
Troponin T (cTnT) Troponin T has an extraordinarily high specificity for myocardial cell injury. Cardiac troponins elevate sooner and remain elevated longer than many of the other enzymes that reflect myocardial injury. ALT is found predominantly in the liver; it is found in lesser quantities in the kidneys, heart, and skeletal muscles and is primarily used to diagnose and monitor liver, not heart, disease. AST, also known as serum glutamic-oxaloacetic transaminase (SGOT), is elevated 8 hours after a myocardial infarction. Total LDH levels elevate 24 to 48 hours after a myocardial infarction.
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client? 5% Dextrose and lactated Ringer solution 0.9% normal saline solution Total parenteral nutrition Whole blood products
Whole blood products The client has experienced acute blood loss from the long bone and pelvic fractures and is tachycardic and hypotensive. Therefore the most appropriate parenteral fluid is whole blood.
A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? "Do you have chest pain?" "Are you feeling anxious?" "Do you have any palpitations?" "Are you feeling short of breath?"
"Do you have chest pain?" Females may present with atypical symptoms of myocardial infarction, such as absence of chest pain, overwhelming fatigue, and indigestion. Anxiety, palpitations, and shortness of breath are common clinical manifestations in both males and females who are experiencing a myocardial infarction.
A primary healthcare provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse? "The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." "I wouldn't bother. For this diet all that you need to do is to reduce the amount of salt you use and fry foods in peanut oil." "You're right. Be careful to cook a small portion for each of you to eat to not waste food." "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen."
"The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals. Fried foods are not advocated on a heart-healthy diet; peanut oil is a monounsaturated fatty acid, and these acids should not exceed 15% of the calories of the diet. The responses "You're right. Be careful to cook a small portion for each of you to eat to not waste food" and "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen" can be discouraging and encourage noncompliance.
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? Dependent edema Swollen hands and fingers Collapsed neck veins Right upper quadrant discomfort Oliguria
-Dependent edema -Swollen hands and fingers -Right upper quadrant discomfort With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.
A client's diet is modified to eliminate foods that act as cardiac stimulants. Which foods will the nurse instruct the client to avoid? Iced tea Red meat Club soda Hot cocoa Chocolate pudding
-Iced tea -Hot cocoa -Chocolate pudding Tea contains caffeine, which stimulates catecholamine release and acts as a cardiac stimulant; tea should be avoided. Hot cocoa contains chocolate, which contains caffeine; it stimulates catecholamine release and acts as a cardiac stimulant. Cocoa should be avoided. The chocolate in chocolate pudding has a high caffeine content, which may stimulate catecholamine release and act as a cardiac stimulant; chocolate should be avoided. Red meat does not stimulate the myocardium; however, it should be decreased or eliminated if serum cholesterol levels are elevated. Club soda does not contain caffeine and does not stimulate the myocardium; however, most club sodas contain sodium, which promotes fluid retention and should be avoided by a client with a cardiac condition.
A woman comes to the emergency department reporting signs and symptoms that are determined by the primary healthcare provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? Severe fatigue Sense of unease Choking sensation Chest pain relieved by rest Pain radiating down the left arm
-Severe fatigue -Sense of unease A myocardial infarction in women may be asymptomatic, atypical, or mild. Unique symptoms include overwhelming fatigue, a sense of uneasiness, indigestion, and shoulder tenderness. A sense of unease is a unique characteristic of a myocardial infarction in women. The client knows something is not right but cannot identify what it is. This uneasiness often is disregarded by the client. A choking sensation occurs in both men and women with a myocardial infarction. Chest pain relieved by rest occurs in both men and women with angina; it is caused by coronary artery spasms leading to myocardial ischemia. Angina frequently is a precursor to a myocardial infarction. Pain radiating down the left arm occurs in both men and women. It can radiate also to the neck, lower jaw, left arm, left shoulder, and, less frequently, the right arm and back.
A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider? A loud Korotkoff sound An irregular pulse of 92 beats per minute A diastolic blood pressure that remains greater than 90 mm Hg A throbbing headache over the left eye when arising in the morning
A diastolic blood pressure that remains greater than 90 mm Hg A sustained diastolic pressure exceeding 90 mm Hg reflects pathology and could indicate hypertension. A loud Korotkoff sound is unrelated to hypertension. An irregular pulse of 92 beats per minute reflects the heart rate and rhythm, not the pressure within the arteries. Initially hypertension usually is asymptomatic; although headaches can be associated with hypertension, there are other causes of headaches.
An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. What does the nurse expect the primary healthcare provider to prescribe to confirm the presence of hypokalemia? A complete blood count A serum electrolyte level An arterial blood gas panel An x-ray film of long bones
A serum electrolyte level Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and an x-ray film of long bones have no significance in diagnosing a potassium deficit.
A client is diagnosed with pancytopenia caused by chemotherapy. What should a nurse teach the client about this complication? Begin a program of meticulous mouth care. Avoid traumatic injury and exposure to infection. Increase oral fluid intake to at least 3 L/day. Report unusual muscle cramps or tingling sensations in the extremities.
Avoid traumatic injury and exposure to infection. Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase the susceptibility to infection. Beginning a program of meticulous mouth care is helpful for stomatitis, not pancytopenia; aggressive oral hygiene may precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic byproducts of chemotherapy, this will have no effect on pancytopenia. Unusual muscle cramps or tingling sensations in the extremities are signs of hypocalcemia and do not apply to pancytopenia.
A 78-year-old client comes to the health clinic presenting with fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL (105 mmol/L). Which is the most appropriate nursing intervention in response to these laboratory results? Conduct a complete nutritional assessment of the client Nothing, because these are expected values for this client's age Advise the client to come back to the clinic to have the test repeated in three months Investigate the cause of the anemia while understanding that mild anemia is an expected response to the aging process
Conduct a complete nutritional assessment of the client A nutritional assessment starts the investigation for a cause of the client's anemia and is an independent function of the nurse. These are not expected values; an intervention is indicated. Medical treatment should be initiated first, and then the test should be repeated to determine the client's response to therapy; it is not within the legal function of the nurse to give medical advice. Anemia is not an expected response to the aging process.
The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip? First degree atrioventricular (AV) block Second degree AV block Mobitz I (Wenckebach) Second degree AV block Mobitz II Third degree AV block (complete heart block)
First degree atrioventricular (AV) block Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second-degree AV block type I, also called Mobitz I or Wenckebach heart block, is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s).
A client experiences crushing chest pain and is brought to the emergency department. When assessing the electrocardiogram (ECG) tracing, the nurse concludes that the client is experiencing premature ventricular complexes (PVCs). Which abnormalities of the ECG support this conclusion? Irregular rhythm, abnormally shaped P wave, and normal QRS Irregular rhythm, absence of a P wave, and wide and distorted QRS Regular rhythm, more than 100 beats per minute, normal P wave, and normal QRS Regular rhythm, 100 to 250 beats per minute, absent P wave, and wide and distorted QRS
Irregular rhythm, absence of a P wave, and wide and distorted QRS A PVC is a contraction originating in an ectopic focus in the ventricles; it is characterized by a premature, wide, distorted QRS complex with the P wave and PR interval buried in the distorted QRS complex resulting in an irregular rhythm. Irregular rhythm, abnormally shaped P wave, and normal QRS occur with a premature atrial complex. Regular rhythm, more than 100 beats per minute, normal P wave, and normal QRS occur with sinus tachycardia. Regular rhythm, 100 to 250 beats per minute, absent P wave, and wide and distorted QRS occur with ventricular tachycardia.
A client had a total knee replacement several days ago and has been receiving warfarin sodium therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the healthcare provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. Which is the next action the nurse should take? Assist with meal planning to decrease the intake of foods high in vitamin K Obtain a blood specimen to have a partial thromboplastin time performed Contact the healthcare provider to request the day's dosage of warfarin sodium Maintain the client on bed rest until the healthcare provider reviews the laboratory results
Maintain the client on bed rest until the healthcare provider reviews the laboratory results An INR of 4.6 is higher than the desired therapeutic level of 2 to 3.5. It is prudent to maintain bed rest to prevent injury until the healthcare provider evaluates the client's INR result. Decreasing the intake of food high in vitamin K is contraindicated; vitamin K is the antidote for warfarin sodium. The client should have a consistent, limited intake of food high in vitamin K. A partial thromboplastin time is performed to evaluate a client's response to the administration of heparin. Another dose of warfarin sodium may be contraindicated in light of the client's increased INR result.
A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. Which is the priority nursing intervention for this client? Provide pain medication. Transfer to the coronary care unit. Obtain a single electrocardiogram (ECG). Have a blood specimen drawn for enzyme studies.
Provide pain medication. Providing for comfort reduces anxiety and subsequently decreases catecholamine release, indirectly decreasing myocardial oxygen requirements. The client's condition should be stabilized before transfer; relief of pain facilitates stabilization. Obtaining an electrocardiogram is important, but the client should be placed on continuous monitoring, not just receive a reading; therefore pain relief is the priority. The ECG is significant to examine for progressive myocardial changes. Securing blood for enzyme studies is not an emergency intervention, although a blood sample for cardiac enzymes is important for a definitive diagnosis.
An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action? Offer cool fluids. Suction the airway. Remove the clothing. Prepare for intubation.
Remove the clothing. Clothing retains body heat; clothing must be removed before other cooling methods are employed to reduce body temperature. Offering fluids is contraindicated because the client is unresponsive. There are no data to indicate a need for suctioning. Although intubation may become necessary, it is not the initial action.
It is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. In explaining the pacemaker to the client, what does the nurse say it is necessary for? Simulating a normal heartbeat Shocking the atrioventricular (AV) node to contract Slowing the heart to a more normal rate Synchronizing the action of the heart valves
Simulating a normal heartbeat This type of pacemaker synchronizes impulses to the atria and ventricles to more closely simulate the normal action of the heart; it may be a fixed-rate or, most commonly, a demand-mode pacemaker and may stimulate the atria, the ventricles, or both. The physiologic pacemaker stimulates both the atria and ventricles to contract. It will increase the heartbeat to a more normal rate. It affects the electrical conduction system of the heart, not the anatomic structures.
A client who lives with the parents is diagnosed with stage III Hodgkin disease with a grossly involved spleen and is scheduled for a splenectomy. After the nurse performs preoperative teaching, the client appears anxious. What is the best approach for the nurse to use at this time? Allow the client to regress at this time and rest quietly. State that that the client seems anxious and ask whether the client would like to talk for a while. Consider the reaction an unconscious response and inquire about the client's relationship with the parents. Understand that anxiety prevented the client from comprehending and repeat the information in simpler terms.
State that that the client seems anxious and ask whether the client would like to talk for a while. Stating that the client seems anxious and asking whether the client would like to talk for a while provides an opportunity for the client to explore concerns with the nurse. The data do not indicate regression; the client is anxious, not regressed. If the nurse considers the response an unconscious response relating to the client's relationship with the parents, this is based on an incorrect interpretation of the data. The data do not indicate that the client does not understand; the nurse should attempt to provide for consensual validation before coming to this conclusion.
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? P wave T wave P-R interval QRS complex
T wave The T wave is the period of repolarization of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation. If a premature ventricular contraction strikes on the P wave, it will not cause ventricular fibrillation; the P wave represents atrial contraction. The P-R interval represents the time it takes the impulse to travel from the sinoatrial (SA) node to the ventricular musculature. The QRS complex is the term used to represent the entire phase of ventricular contraction.
