med surg chap 36

A nurse is auscultating a patient's heart sounds and hears the lub, dub. When the nurse evaluates the "lub" sound, what is the nurse hearing?

Closure of the mitral and tricuspid valves The first heart sound (S1), referred to as lub, occurs when the ventricles contract during systole and when the mitral and tricuspid valves close. The second heart sound (S2), called dub, occurs during ventricular relaxation or diastole and is caused by the closing of the aortic and pulmonic valves. The aortic and pulmonic valves are called the semilunar valves. The cusps or leaflets of the atrioventricular valves are attached by chordate tendineae to the papillary muscles that line the floor of the ventricles. rember tri it before you buy it

Which health promotion technique will the nurse emphasize to patients to decrease coronary artery disease?

Control hypertension Health promotion activities for coronary artery disease include controlling hypertension, reducing (not increasing) low-density lipoproteins, participating in regular moderate exercise (not irregular heavy exercise), and obtaining and maintaining an ideal body weight. Learning to handle stress, rather than ignoring stress, promotes health.

A patient is admitted with right-sided heart failure. Which data will the nurse typically find during data collection?

Dependent edema With right-sided heart failure, the patient has increased central venous pressure, jugular venous distention, abdominal engorgement, and dependent edema. Coughs and crackles occur with left-sided heart failure. Weight gain will occur, not weight loss.

A patient asks the nurse for suggestions to decrease the risk for heart disease. Which modifiable risk factors can the nurse suggest to the patient? Select all that apply.

Diet Exercise Smoking cessation Individuals have the ability to manage diet and weight through healthy choices and exercise. They also have the ability to stop smoking. Individuals cannot change or modify their heredity or age.

Which grade of pulse should the nurse document on the assessment form for a patient who has a weak pulse that is obliterated when pressure is applied?

Grade 1 Grade 1 is given to a pulse that is weak or thready. It is easily obliterated with slight finger pressure but returns when the pressure is relieved. A pulse that is absent or cannot be palpated is graded as 0. Grade 2 refers to a normal pulse that can be palpated easily and is not obliterated with pressure. Grade 3 refers to a bounding pulse.

Which equipment would be most suitable for assessing the presence of conduction defects over a period of 24 hours?

Holter monitor A Holter monitor continuously assesses the electrical activity of the heart over 24 to 48 hours. It is helpful in identifying occasional dysrhythmias. Echocardiography uses ultrasound to create images of the heart to evaluate for valve abnormalities and cardiomyopathy, and no special preparation is needed. Electrocardiogram (ECG) detects abnormalities in conduction, but it cannot be performed for 24 hours because it doesn't allow the patient to move.

A patient has stable angina. During the history taking, which information will the nurse typically expect to hear from the patient?

My chest pain is relieved with nitroglycerin. Usually, stable angina lasts only a few minutes and is relieved by rest or with nitroglycerin. Stable angina (also called chronic angina or exertional angina) occurs most often with exercise or activity and usually subsides with rest. Stable angina occurs intermittently and is often predictable. Unstable angina and variant angina can occur at rest and is unpredictable.

The nurse is preparing to administer digitalis to a patient. Before administering the medication, the nurse would assess which vital sign?

Apical pulse rate Before each dose of digitalis, the apical pulse is counted for 1 full minute. If the heart rate is less than 60 beats per minute, the drug is withheld and the health care provider is notified.

The nurse is reviewing the medical record of a patient who was diagnosed with coronary artery disease (CAD). The nurse expects to find that the patient experiences which symptom?

Chest pain Angina pectoris, or chest pain, is the most common symptom of CAD and is expressed when the demand for oxygen by the myocardial cells exceeds the supply of oxygen delivered.

A nurse is caring for a patient with heart failure. Which finding will cause the nurse to notify the health care provider?

Urine output of 20 ml/h If hourly urine output is being measured, then report an output of less than 30 ml/h to the health care provider as well. In general, the patient is advised to plan rest periods before and after tiring activities. Weight gain of 3 to 5 pounds in 1 week or less will cause the nurse and/or patient to notify the health care provider, not 1 pound in 1 week.

A patient is admitted with an acute myocardial infarction and is reporting pain at a level of 10 out of 10. Respirations are 28, pulse is 90, and blood pressure is 140/90. Which intervention should the nurse implement?

Apply oxygen per nasal cannula. Provide supplemental oxygen as ordered through nasal cannula at 2 to 4 l/min to provide adequate oxygen to the heart muscle. Morphine is usually administered in small amounts (2 to 4 mg) intravenously every few minutes until pain relief is evident. The patient is in pain; a low-fat diet will not be effective against the pain. Lasix is a diuretic, not a pain medication. The head of the bed is usually elevated at least 30 degrees.

The LPN is caring for a patient who is being treated with nitroglycerin ointment. Which is the first step in the process of administering the medication?

Assess the patient's blood pressure and pulse The nurse would assess the patient's blood pressure and pulse before beginning any of the preparations for applying the nitroglycerin ointment to the paper or affixing it to the patient's skin. If the blood pressure and pulse are determined to be within the limits set by the health care provider to administer the medication, the nurse would then apply an even layer of ointment on the paper and apply it on a nonhairy area of the patient's skin. During the process, the nurse must avoid touching the ointment because of the possibility of headache.

The nurse is reviewing the list of present medications a patient is taking. The patient is transferred to the nursing unit from the cardiac care unit following an acute myocardial infarction. Which class of drugs is used for decreasing workload on the heart by decreasing heart rate and cardiac output at rest and during exercise?

Beta-adrenergic blocker Beta-adrenergic blockers are used to decrease workload on the heart exactly by decreasing heart rate and cardiac output. Antiplatelet agents prolong bleeding times and are used to prevent clots that may cause additional myocardial infarctions.

A patient is taking atenolol and the nurse is checking the effectiveness of the drug. Which piece of equipment should the nurse take?

Blood pressure cuff The nurse needs a blood pressure cuff as the blood pressure should decrease. Atenolol is a cardioselective beta-adrenergic blocker used to treat angina and hypertension.

What are contraindications for magnetic resonance imaging (MRI)? Select all that apply.

Cardiac pacemaker Intracranial aneurysm clips

A patient reports having heavy chest pain behind the sternum, which radiates to the arm and jaw, accompanied by diaphoresis. The health care provider has been notified. The nurse realizes which category of drug will likely be prescribed for immediate relief of these symptoms?

Nitroglycerin Nitroglycerin is primarily a vasodilator to be used in the acute phase. Calcium channel blockers act to dilate coronary arteries, decrease O2 consumption, and treat dysrhythmias originating above the ventricles. Beta-adrenergic blockers decrease heart rate, cardiac output, and impulse conduction velocity.

The nurse is obtaining initial vital signs on a newly admitted patient. The patient's apical pulse rate is auscultated to be 96 beats per minute. The nurse describes this rate in which manner?

Normal The normal heart rate is 60 to 100 beats per minute. The rhythm of the heart can be described as regular, irregular, or regularly irregular. The patient's apical pulse rate alone does not provide enough information to determine the regularity of the heart rate. A heart rate greater than 100 beats per minute is considered tachycardia. A heart rate lower than 60 beats per minute is considered bradycardia.

A nurse is assisting with data collection on a patient with pain from pericarditis. Which finding is most typical of a patient with pericarditis?

Pain upon inspiration Chest pain is the hallmark symptom of pericarditis. The pain is most severe on inspiration. It is relieved by sitting up and leaning forward.

While reading a patient's lab reports, the nurse finds an elevated creatine kinase-MB fraction. What does the nurse understand from this finding?

The patient's myocardial tissue cells are damaged Creatine kinase-MB fraction (CK-MB) is an important cardiac marker. An elevated CK-MB result may indicate damage to myocardial function

A patient presents to the emergency department reporting severe, crushing chest pain. The health care provider suspects an acute myocardial infarction. Which laboratory test result will the nurse check to help confirm this diagnosis?

Troponin T Troponin is a protein involved in the contraction of muscles. Two subtypes, troponin T (cTnT) and troponin I (cTnI) are specific to cardiac muscle and are released into the circulation after an acute myocardial infarction. This test is done in the emergency department because the results are available more quickly than the cardiac enzymes.