Hypertension/PAD/PVD/Ateriosclerosis/Hyperlipidemia/PE

A nurse is caring for a client who weighs 220 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) _____ mg

90 mg 220 / 2.2 = 110kg 1mg/kg do not exceed 90mg

Selective cholesterol screening is recommended for children older than the age of 2 years with which risk factor? a. Body mass index (BMI) = 95th percentile b. Blood pressure = 50th percentile c. Parent with a blood cholesterol level of 200 mg/dl d. Recently diagnosed cardiovascular disease in a 75-year-old grandparent

: A Obesity is an indication for cholesterol screening in children. A BMI in the 95th percentile or higher is considered obese. Children who are hypertensive meet the criteria for screening, but blood pressure in the 50th percentile is within the normal range. A parent or grandparent with a cholesterol level of 240 mg/dl or higher places the child at risk. Early cardiovascular disease in a first- or second-degree relative is a risk factor. Age 75 years is not considered early

The nurse is teaching an adolescent with hypertension foods recommended on the DASH diet. What foods should the nurse include in the teaching session? (Select all that apply.) a. Green beans b. Energy drinks c. Low-fat yogurt d. Chocolate milk e. Whole grain bread

: A, C, E The DASH diet provides a lower salt diet that has been associated with improvement in BP and is believed to be beneficial for all patients with hypertension. DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is plentiful in vegetables, fruits, whole grains, and low-fat dairy products and low in sugar and salt. Energy drinks are high in sugar, and chocolate milk is high in fat.

A child with heart failure is on Lanoxin (digoxin). The laboratory value a nurse must closely monitor is which? a. Serum sodium b. Serum potassium c. Serum glucose d. Serum chloride

: B A fall in the serum potassium level enhances the effects of digoxin, increasing the risk of digoxin toxicity. Increased serum potassium levels diminish digoxin's effect. Therefore, serum potassium levels (normal range, 3.5-5.5 mmol/L) must be monitored

What medication used to treat heart failure (HF) is a diuretic? a. Captopril (Capten) b. Digoxin (Lanoxin) c. Hydrochlorothiazide (Diuril) d. Carvedilol (Coreg)

: C Hydrochlorothiazide is a diuretic. Captopril is an ACE inhibitor, digoxin is a digital glycoside, and carvedilol is a beta-blocker

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

A A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics

A African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

What cardiovascular defect results in obstruction to blood flow? a. Aortic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

A Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. Tricuspid atresia results in decreased pulmonary blood flow. The atrial septal defect results in increased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."

A Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

The health care provider suggests surgery be performed for ventricular septal defect to prevent what complication? a. Pulmonary hypertension b. Right-to-left shunt of blood c. Pulmonary embolism d. Left ventricular hypertrophy

A Congenital heart defects with a large left-to-right shunt (e.g., in ventricular septal defect, patent ductus arteriosus, or complete AV canal), which cause increased pulmonary blood flow, may result in pulmonary hypertension. If these defects are not repaired early, the high pulmonary flow will cause changes in the pulmonary artery vessels, and the vessels will lose their elasticity. The blood does not shunt right to left, a pulmonary embolism is not a complication of ventricular septal defect, and the left ventricle does not hypertrophy.

Seventy-two hours after cardiac surgery, a young child has a temperature of 38.4° C (101.1° F). What action should the nurse perform? a. Report findings to the practitioner. b. Apply a hypothermia blanket. c. Keep the child warm with blankets. d. Record the temperature on the assessment flow sheet.

A In the first 24 to 48 hours after surgery, the body temperature may increase to 37.8° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or fever continues after this period, it is most likely a sign of an infection, and immediate investigation is indicated. A hypothermia blanket is not indicated for this level of temperature. Blankets should be removed from the child to keep the temperature from increasing. The temperature should be recorded, but the practitioner must be notified for evaluation

A parent of a 7-year-old girl with a repaired ventricular septal defect (VSD) calls the cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has had intermittent fevers around 38° C (100.4° F), and now her muscles and joints ache. Based on this information, how should the nurse advise the mother a. Immediately bring the child to the clinic for evaluation. b. Come to the clinic next week on a scheduled appointment. c. Treat the signs and symptoms with acetaminophen and fluids because it is most likely a viral illness. d. Recognize that the child is trying to manipulate the parent by complaining of vague symptoms.

A These are the insidious symptoms of bacterial endocarditis. Because the child is in a high-risk group for this disorder (VSD repair), immediate evaluation and treatment are indicated to prevent cardiac damage. With appropriate antibiotic therapy, bacterial endocarditis is successfully treated in approximately 80% of the cases. The child's complaints should not be dismissed. The low-grade fever is not a symptom that the child can fabricate

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below google peripheral vascular picture What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium

A This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client's ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

Heart failure (HF) is a problem after the child has had a congenital heart defect repaired. The nurse knows a sign of HF is what? a. Wheezing b. Increased blood pressure c. Increased urine output d. Decreased heart rate

A A clinical manifestation of heart failure is wheezing from pulmonary congestion. The blood pressure decreases, urine output decreases, and heart rate increases

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."

A Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A "drink" is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman's size does not matter.

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?"

A As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the client's disease is worsening. The other questions are useful, but not as important.

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count

A Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal

A client is taking warfarin (Coumadin) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."

A Many foods and drugs interfere with warfarin, St. John's wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.

Nursing care of the child with Kawasaki disease is challenging because of which occurrence? a. The child's irritability b. Predictable disease course c. Complex antibiotic therapy d. The child's ongoing requests for food

A Patient irritability is a hallmark of Kawasaki disease and is the most challenging problem. A quiet environment is necessary to promote rest. The diagnosis is often difficult to make, and the course of the disease can be unpredictable. Intravenous gamma globulin and salicylates are the therapy of choice, not antibiotics. The child often is reluctant to eat. Soft foods and fluids should be offered to prevent dehydration

What structural defects constitute tetralogy of Fallot? a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

A Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertroph

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

A The first step is to assess the reason behind the client's fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like "drugs are safer today" do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

What primary nursing intervention should be implemented to prevent bacterial endocarditis? a. Counsel parents of high-risk children. b. Institute measures to prevent dental procedures. c. Encourage restricted mobility in susceptible children. d. Observe children for complications, such as embolism and heart failure.

A The objective of nursing care is to counsel the parents of high-risk children about the need for both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Restricted mobility in susceptible children is not indicated. Parents are taught to observe for unexplained fever, weight loss, or change in behavior.

A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit .b. Assess the client for dehydration .c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

A There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the client's lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken

The nurse is caring for a child after cardiac surgery. What interventions should the nurse implement with regard to chest tubes placed to a water-seal drainage system? (Select all that apply.) a. Maintain sterility. b. Check for tube patency. c. Do not interrupt the water-seal drainage system. d. Clamp the chest tube when ambulating the child. e. Measure the drainage by emptying the collection chamber every shift.

A, B, C Nursing considerations with regard to chest tubes attached to a water-seal drainage system include 1) do not interrupt water-seal drainage unless the chest tube is clamped 2) check for tube patency (fluctuation in the water-seal chamber) 3) maintain sterility. The chest tube should not be clamped when ambulating the child and the drainage is measured in the collection chamber, not emptied.

An adolescent is being placed on a beta-blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.) a. Medication may cause fatigue. b. Side effects may include impotence. c. Side effects may include bradycardia. d. Take the medication 1 hour before meals. e. Side effects may include peripheral edema.

A, B, C The adolescent should be instructed that the medication may cause fatigue, impotence, and bradycardia. The medications should be taken with meals and side effects do not include peripheral edema.

A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations

A, B, C When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the client's feelings

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings b. Assist with ambulation c. Encourage coughing and deep breathing d. Offer fluids frequently e. Teach leg exercises

A, B, D The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function

The nurse is caring for a child with secondary hypertension. What renal disorders are associated with secondary hypertension? (Select all that apply.) a. Renal tumor b. Hydronephrosis c. Vesicoureteral reflux d. Glomerulonephritis e. Urinary tract infection

A, B, D Renal disorders that can cause secondary hypertension include a renal tumor, hydronephrosis, and glomerulonephritis. Vesicoureteral reflux or urinary tract infections do not cause secondary hypertension.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

A, B, DAssessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

A, C, D, E The Joint Commission's Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted

An adolescent is being placed on an ACE inhibitor. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.) a. Stay well hydrated. b. Increase intake of potassium. c. Avoid rapid position changes. d. Take the medication with meals. e. Side effects may include a cough.

A, C, E The adolescent should be instructed to stay well hydrated and avoid rapid position changes and that side effects may include a cough when on ACE inhibitors. ACE inhibitors do not deplete potassium, and they should be taken 1 hour before meals to increase absorption.

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask b. Ensure the client has a patent airway c. Prepare to assist with suturing the artery d. Start two large-bore IVs with normal saline

B Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures

What statement best identifies the cause of heart failure (HF)? a. Disease related to cardiac defects b. Consequence of an underlying cardiac defect c. Inherited disorder associated with a variety of defects d. Result of diminished workload imposed on an abnormal myocardium

B HF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body's metabolic demands. HF is not a disease but rather a result of the inability of the heart to pump efficiently. HF is not inherited. HF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an important objective to decrease this risk? a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure.

B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents

The nurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks the dose and draws up 4 ml of the drug. The most appropriate nursing action is which? a. Mix the dose with juice to disguise its taste. b. Do not give the dose; suspect a dosage error. c. Check the heart rate; administer digoxin if the rate is greater than 100 beats/min. d. Check the heart rate; administer digoxin if the rate is greater than 80 beats/min.

B Infants rarely receive more than 1 ml (50 mcg, or 0.05 mg) of digoxin in one dose; a higher dose is an immediate warning of a dosage error. To ensure safety, compare the calculation with that of another staff member before giving digoxin.

. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure."

B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

3. A 6-year-old child is scheduled for a cardiac catheterization. What consideration is most important in planning preoperative teaching? a. Preoperative teaching should be directed at his parents because he is too young to understand. b. Preoperative teaching should be adapted to his level of development so that he can understand. c. Preoperative teaching should be done several days before the procedure so he will be prepared. d. Preoperative teaching should provide details about the actual procedures so he will know what to expect.

B Preoperative teaching should always be directed to the child's stage of development. The caregivers also benefit from these explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age group will not understand in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization.

What preparation should the nurse consider when educating a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Let the child hear the sounds of a cardiac monitor, including alarms. c. Explain that an endotracheal tube will not be needed if the surgery goes well. d. Discussion of postoperative discomfort and interventions is not necessary before the procedure.

B The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The family and child should make the decision about a tour of the unit if it is an option. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, endotracheal tube, expected discomfort, and management strategies

The parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. How should the nurse reply to this concern? A)The parents should meet all the child's needs. B)The child needs opportunities to play with peers. C)Constant parental supervision is needed to avoid overexertion. D)The child needs to understand that peers' activities are too strenuous.

B The child needs opportunities for social development. Children are able to regulate and limit their activities based on their energy level. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence

. The nurse is teaching parents about administering digoxin (Lanoxin). What instructions should the nurse tell the parents? a. If the child vomits, give another dose. b. Give the medication at regular intervals. c. If a dose is missed, give a give an extra dose. d. Give the medication mixed with the child's formula.

B The family should be taught to administer digoxin at regular intervals. If a dose is missed, an extra dose should not be given; the same schedule should be maintained. If the child vomits, do not give a second dose. The drug should not be mixed with foods or other fluids because refusal to consume these would result in inaccurate intake of the drug

An infant is diagnosed with transposition of the great vessels. Prostaglandin E1 is given intravenously. The parents ask how long the child will remain on the prostaglandin E1. What is the appropriate response by the nurse? a. Prostaglandin E1 will be given intermittently until corrective surgery is performed. b. Prostaglandin E1 will be given continuously until corrective surgery is performed. c. Prostaglandin E1 will be given continuously throughout the preoperative and postoperative periods until the child is stable. d. Prostaglandin E1 will be given intermittently throughout the preoperative and postoperative periods until the child is stable.

B To provide intracardiac mixing for a child with transposition of the great arteries, intravenous prostaglandin E1 is administered continuously to keep the ductus arteriosus open to temporarily increase blood mixing and provide an oxygen saturation of 75% or to maintain cardiac output until surgery. It is discontinued after surgery.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

B A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system b. Assist in finding one change the client can control c. Determine what stressors the client faces in daily life d. Inquire about delegating some of the client's obligations.

B All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client's feelings of control.

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.

B An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

B Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to the (lower pressure) right side can result in which condition? a. Cyanosis b. Heart failure c. Decreased pulmonary blood flow d. Bounding pulses in upper extremities

B As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and the child is at high risk for heart failure. Cyanosis usually occurs in defects with decreased pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the aorta.

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

B Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

What drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Furosemide (Lasix) b. Captopril (Capoten) c. Chlorothiazide (Diuril) d. Spironolactone (Aldactone)

B Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Chlorothiazide works on the distal tubules. Spironolactone blocks the action of aldosterone and is a potassium-sparing diuretic

A client is receiving an infusion of aLteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the client's neurologic status b. Notify the Rapid Response Team c. Prepare to administer vitamin K d. Turn down the infusion rate.

B Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the client's manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

The nurse is giving discharge instructions to the parent of a 6-year-old child who had a cardiac catheterization 4 hours ago. What statement by the parent indicates a correct understanding of the teaching? a. "My child should not attend school for the next 5 days." b. "I should change the bandage every day for the next 2 days." c. "My child can take a tub bath but should avoid taking a shower for the next 4 days." d. "I should expect the site to be red and swollen for the next 3 days."

B Discharge instructions for a parent of a child who recently had a cardiac catheterization should include changing the bandage every day for the next 2 days. The child should avoid strenuous exercise but can go back to school. The child should avoid a tub bath, but an older child could take a shower the first day after the catheterization. The site should not have swelling or redness; if there is, it should be reported to the health care practitioner.

A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate? a. 60 beats/min b. 90 beats/min c. 100 beats/min d. 120 beats/min

B If a 1-minute apical pulse is less than 90 beats/min for an infant or young child, the digoxin is withheld. Sixty beats/min is the cut-off for holding the digoxin dose in an adult. One hundred to 120 beats/min is an acceptable pulse rate for the administration of digoxin

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.

B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the client's perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

An infant has tetralogy of Fallot. In reviewing the record, what laboratory result should the nurse expect to be documented? a. Leukopenia b. Polycythemia c. Anemia d. Increased platelet level

B Persistent hypoxemia that occurs with tetralogy of Fallot stimulates erythropoiesis, which results in polycythemia, an increased number of RBCs

What sign/symptom is a major clinical manifestation of rheumatic fever (RF)? a. Fever b. Polyarthritis c. Osler nodes d. Janeway spots

B Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation. The affected joints will change every 1 or 2 days. The large joints are primarily affected. Fever is considered a minor manifestation of RF. Osler nodes and Janeway spots are characteristic of bacterial endocarditis.

What blood flow pattern occurs in a ventricular septal defect? a. Mixed blood flow b. Increased pulmonary blood flow c. Decreased pulmonary blood flow d. Obstruction to blood flow from ventricles

B The opening in the septal wall allows for blood to flow from the higher pressure left ventricle into the lower pressure right ventricle. This left-to-right shunt creates increased pulmonary blood flow. The shunt is one way, from high pressure to lower pressure; oxygenated and unoxygenated blood do not mix. The outflow of blood from the ventricles is not affected by the septal defect

. What condition is the leading cause of death after heart transplantation? a. Infection b. Rejection c. Cardiomyopathy d. Heart failure

B The posttransplant course is complex. The leading cause of death after cardiac transplant is rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection. Cardiomyopathy is one of the indications for cardiac transplant. Heart failure is not a leading cause of death.

The nurse notices that a child is increasingly apprehensive and has tachycardia after heart surgery. The chest tube drainage is now 8 ml/kg/hr. What should be the nurse's initial intervention? a. Apply warming blankets. b. Notify the practitioner of these findings. c. Give additional pain medication per protocol. d. Encourage child to cough, turn, and deep breathe.

B The practitioner is notified immediately. Increases of chest tube drainage to more than 3 ml/kg/hr for more than 3 consecutive hours or 5 to 10 ml/kg in any 1 hour may indicate postoperative hemorrhage. Increased chest tube drainage with apprehensiveness and tachycardia may indicate cardiac tamponade—blood or fluid in the pericardial space constricting the heart—which is a life-threatening complication. Warming blankets are not indicated at this time. Additional pain medication can be given before the practitioner drains the fluid, but the notification is the first action. Encouraging the child to cough, turn, and deep breathe should be deferred until after evaluation by the practitioner.

What clinical manifestation is a common sign of digoxin toxicity? a. Seizures b. Vomiting c. Bradypnea d. Tachycardia

B Vomiting is a common sign of digoxin toxicity and is often unrelated to feedings. Seizures are not associated with digoxin toxicity. The child will have a slower (not faster) heart rate but not a slower respiratory rate.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

B Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate.b. Increase the heparin rate.c. No change to the heparin rate.d. Stop heparin; start warfarin (Coumadin).

B ~ For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

A child is recovering from Kawasaki disease (KD). The child should be monitored for which? a. Anemia b. Electrocardiograph (ECG) changes c. Elevated white blood cell count d. Decreased platelets

B' The most serious complication of KD is the development of coronary artery aneurysms and the potential for myocardial infarction in children with aneurysm formation. The nurse should monitor any ECG changes.

hat nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

B, C, D The three E's of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

. An adolescent is being placed on a calcium channel blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.) a. The medication may cause fatigue. b. The medication may increase heart rate. c. The medication may cause constipation. d. The medication may cause cold extremities. e. The medication may cause peripheral edema.

B, C, E Calcium channel blockers may cause an increase in heart rate, constipation, and peripheral edema. Beta-blockers can cause fatigue and cold extremities, but calcium channel blockers do not cause these potential side effects

1. The nurse is caring for a child with Kawasaki disease in the acute phase. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Osler nodes b. Cervical lymphadenopathy c. Strawberry tongue d. Chorea e. Erythematous palms f. Polyarthritis

B, C, E Clinical manifestations of Kawasaki disease in the acute phase include cervical lymphadenopathy, a strawberry tongue, and erythematous palms. Osler nodes are a clinical manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever

client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client's blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

The test that provides the most reliable evidence of recent streptococcal infection is which? a. Throat culture b. Mantoux test c. Antistreptolysin O test d. Elevation of liver enzymes

C Antistreptolysin O (ASLO) titers measure the concentration of antibodies formed in the blood against this product. Normally, the titers begin to rise about 7 days after onset of the infection and reach maximum levels in 4 to 6 weeks. Therefore, a rising titer demonstrated by at least two ASLO tests is the most reliable evidence of recent streptococcal infection

Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infant's status, which finding is indicative of achieving this goal? a. Irritability when awake b. Capillary refill of more than 5 seconds c. Appropriate weight gain for age d. Positioned in high Fowler position to maintain oxygen saturation at 90%

C Appropriate weight gain for an infant is indicative of successful feeding and a reduction in caloric loss secondary to the HF. Irritability is a symptom of HF. The child also uses additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation

A 1-year-old has been admitted for complete repair of a tetralogy of Fallot. What assessment finding should the nurse expect to be documented? a. Weight gain b. Pale skin color c. Increasing cyanosis d. Decrease in hemoglobin and hematocrit

C Elective repair of tetralogy of Fallot is usually performed in the first year of life. Indications for repair include increasing cyanosis and the development of hypercyanotic spells. The child would not have a weight gain, pale skin color, or decrease in hemoglobin and hematocrit

. After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. How should the nurse respond? a. Elevate the affected extremity. b. Notify the practitioner of the observation. c. Record data on the assessment flow record. d. Apply warm compresses to the insertion site.

C The pulse distal to the catheterization site may be weaker for the first few hours after catheterization but should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are not indicated

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings d. Review a 3-day food recall diary

C compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."

C Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

What action by the school nurse is important in the prevention of rheumatic fever (RF)? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts.

C Nurses have a role in prevention, primarily in screening school-age children for sore throats caused by group A streptococci. They can actively participate in throat culture screening or refer children with possible streptococcal sore throats for testing. Routine cholesterol screenings and blood pressure screenings do not facilitate the recognition and treatment of group A hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.

The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. What nursing intervention is most appropriate at this time? a. Administer oxygen. b. Record data on the nurses' notes. c. Report data to the practitioner. d. Place the child in the high Fowler position.

C One of the earliest signs of HF is tachycardia (sleeping heart rate >160 beats/min) as a direct result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible HF. Although oxygen or a semiupright position may be indicated, the first action is to report the data to the practitioner

What child has a cyanotic congenital heart defect? a. An infant with patent ductus arteriosus b. A 1-year-old infant with atrial septal defect c. A 2-month-old infant with tetralogy of Fallot d. A 6-month-old infant with repaired ventricular septal defect

C Tetralogy of Fallot is a cyanotic congenital heart defect. Patent ductus arteriosus, atrial septal defect, and ventricular septal defect are acyanotic congenital heart defects

After returning from cardiac catheterization, the nurse monitors the child's vital signs. The heart rate should be counted for how many seconds? a. 15 b. 30 c. 60 d. 120

C The heart rate is counted for a full minute to determine whether arrhythmias or bradycardia is present. Fifteen to 30 seconds are too short for accurate assessment. Sixty seconds is sufficient to assess heart rate and rhythm

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. "A good abrasive pumice stone will keep my feet soft." b. "I'll always wear shoes if I can buy cheap flip-flops." c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best.

C, D, E Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and won't offer much protection against injur

The nurse is teaching an adolescent with elevated triglycerides foods that should be decreased. What foods should the nurse include in the teaching? (Select all that apply.) a. Avocados b. Canola oil c. White flour d. White rice e. Sugary cereals

C, D, E If triglycerides are elevated, dietary recommendations include decreasing the intake of foods high in simple carbohydrates such as white flour, white rice, white bread, white pasta, sugary cereals, juice, and soda. Avocados and canola oil have beneficial effects on HDL, which is the good cholesterol.

What term is defined as the volume of blood ejected by the heart in 1 minute? a. Afterload b. Cardiac cycle c. Stroke volume d. Cardiac output

D Cardiac output is defined as the volume of blood ejected by the heart in 1 minute. Cardiac output = Heart rate x Stroke volume. Afterload is the resistance against which the ventricles must pump when ejecting blood (ventricular ejection). A cardiac cycle is the sequential contraction and relaxation of both the atria and ventricles. Stroke volume is the amount of blood ejected by the heart in any one contraction.

The parents of a young child with heart failure (HF) tell the nurse that they are nervous about giving digoxin. The nurse's response should be based on which knowledge? a. It is a safe, frequently used drug. b. Parents lack the expertise necessary to administer digoxin. c. It is difficult to either overmedicate or undermedicate with digoxin. d. Parents need to learn specific, important guidelines for administration of digoxin.

D Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects. Parents may lack the expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely

A 12-year-old child with Down syndrome is admitted to the hospital for surgical correction of a heart defect. The boy's mental age is that of a 3-year-old child. The nurse should prepare the child and family for surgery by what method? a. Extend preoperative teaching over several days. b. Explain the surgery to the child and the parents in detail. c. Exclude the child from preoperative teaching; teach only the parents. d. Provide teaching to the parents, keeping the information to the child simple.

D Important factors to consider in planning preparation strategies before cardiac surgery are the child's cognitive developmental level, previous hospital experiences, temperament and coping style, the timing of the preparation, and the involvement of the parents. The teaching should be provided to the parents, keeping the information simple to the child with a mental age of 3 years old.

The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which complication? a. Hypoxemia b. Right-to-left shunt of blood c. Decreased workload on the left side of the heart d. Pulmonary vascular congestion

D In PDA, blood flows from the higher pressure aorta into the lower pressure pulmonary vein, resulting in increased pulmonary blood flow. This creates pulmonary vascular congestion. Hypoxemia usually results from defects with mixed blood flow and decreased pulmonary blood flow. The shunt is from left to right in a PDA. The closure would stop this. There is increased workload on the left side of the heart with a PDA

What nutritional component should be altered in the infant with heart failure (HF)? a. Decrease in fats b. Increase in fluids c. Decrease in protein d. Increase in calories

D Infants with HF have a greater metabolic rate because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in calories is diminished by their fatigue. The diet should include increased protein and increased fat to facilitate the child's intake of sufficient calories. Fluids must be carefully monitored because of the HF.

16. A 3-month-old infant has a hypercyanotic spell. What should be the nurse's first action? a. Assess for neurologic defects. b. Prepare the family for imminent death. c. Begin cardiopulmonary resuscitation. d. Place the child in the knee-chest position.

D The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

D The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

6. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What nursing action is most appropriate to institute initially? a. Notify the physician. b. Place the child in Trendelenburg position. c. Apply a new bandage with more pressure. d. Apply direct pressure above the catheterization site.

D When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified, and a new bandage with more pressure can be applied after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. Trendelenburg positioning would not be a helpful intervention. It would increase the drainage from the lower extremities.

What type of drug reduces hypertension by interfering with the production of angiotensin II? a. Diuretics b. Vasodilators c. Beta-blockers d. Angiotensin-converting enzyme (ACE) inhibitors

D ACE inhibitors act by interfering with the production of angiotensin II, which is a potent vasoconstrictor. Diuretics lower blood pressure by increasing fluid output. Vasodilators act on the vascular smooth muscle. By causing arterial dilation, blood pressure is lowered. Beta-blockers interfere with beta stimulation and depress renin output.

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

A chest radiography examination is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that the radiograph provides which information? a. Shows bones of the chest but not the heart b. Evaluates the vascular anatomy outside of the heart c. Shows a graphic measure of electrical activity of the heart d. Supplies information on heart size and pulmonary blood flow patterns

D Chest radiographs provide information on the size of the heart and pulmonary blood flow patterns. The bones of the chest are visible on chest radiographs, but the heart and blood vessels are also seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the heart. A graphic measure of electrical activity of the heart is provided by electrocardiography

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."

D Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

A 6-month-old infant presents to the clinic with failure to thrive, a history of frequent respiratory infections, and increasing exhaustion during feedings. On physical examination, a systolic murmur is detected, no central cyanosis, and chest radiography reveals cardiomegaly. An echocardiogram is done that shows left-to-right shunting. This assessment data is characteristic of what? a. Tetralogy of Fallot b. Coarctation of the aorta c. Pulmonary stenosis d. Ventricular septal defect

D Heart failure is common with ventricular septal defect that causes failure to thrive, respiratory infections, and an increase in exhaustion during feedings. There is a characteristic murmur. The other defects do not have left-to-right shunting

When caring for the child with Kawasaki disease, what should the nurse know to provide safe and effective care? a. Aspirin is contraindicated. b. The principal area of involvement is the joints. c. The child's fever is usually responsive to antibiotics within 48 hours. d. Therapeutic management includes administration of gamma globulin and salicylates.

D High-dose intravenous gamma globulin and salicylate therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. Aspirin is part of the therapy. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. The fever of Kawasaki disease is unresponsive to antibiotics. It is responsive to anti-inflammatory doses of aspirin and antipyretics.

. The diagnosis of hypertension depends on accurate assessment of blood pressure (BP). What is the appropriate technique to measure a child's BP? a. Assess BP while the child is standing. b. Compare left arm with left leg BP readings. c. Use a narrow cuff to ensure that the readings are correct. d. Measure BP with the child in the sitting position on three separate occasions.

D The diagnosis of hypertension is made after the BP is elevated on three separate occasions. Take the BP in a quiet area with the appropriate size cuff and the child sitting. Although left arm and left leg BP readings may be compared, it is not the procedure to diagnose hypertension. The appropriate size cuff is indicated. The most common cause of inaccurate readings is the use of a cuff that is too small.

Bacterial infective endocarditis (IE) should be treated with which protocol? a. Oral antibiotics for 6 months b. Oral antibiotics (penicillin) for 10 full days c. IV antibiotics, diuretics, and digoxin d. IV antibiotics (penicillin type) for 2 to 8 weeks

D Treatment for IE includes the administration of high-dose antibiotics given intravenously for 2 to 8 weeks to completely eradicate the infecting microorganism

What nursing consideration is important when suctioning a young child who has had heart surgery? a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Expect symptoms of respiratory distress when suctioning. d. Administer supplemental oxygen before and after suctioning.

D When suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated and very carefully to avoid vagal stimulation. The child should be suctioned for no more than 5 seconds at a time. Symptoms of respiratory distress are avoided by using appropriate technique.

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs

D, E The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

b The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.