Medical Surgical Nursing - Cardiovascular Disorders
A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances? early defibrillation in cases of atrial fibrillation cardioversion in cases of atrial fibrillation pacemaker placement early defibrillation in cases of ventricular fibrillation
early defibrillation in cases of ventricular fibrillation
The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance? hyponatremia hypocalcemia hyperkalemia hypermagnesemia
hyperkalemia
A client has been prescribed hydrochlorothiazide to treat heart failure. What adverse effect should the nurse instruct the client to report to the health care provider? urinary retention muscle weakness confusion diaphoresis
muscle weakness
A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. How should the nurse document these findings? heart rate irregular with S3 heart rate irregular with S4 heart rate irregular with aortic regurgitation heart rate irregular with mitral stenosis
heart rate irregular with S3
A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect? left-sided heart failure aortic regurgitation complete heart block pericardial tamponade
pericardial tamponade
A client with a ventricular dysrhythmia is receiving intravenous lidocaine. For which assessment finding should the nurse suspect the client is experiencing toxicity from the medication? nausea and vomiting pupillary changes confusion and restlessness hypertension
confusion and restlessness --> Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine or tocainide — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? blood pressure 110/62 mm Hg, atrial fibrillation with heart rate 82, bilateral basilar crackles confusion, urine output 15 mL over the last 2 hours, orthopnea SpO2 92% on 2 L nasal cannula, respirations 20 breaths/min, 1+ edema of lower extremities weight gain of 1 kg in 3 days, blood pressure 130/80 mm Hg, mild dyspnea with exercise
confusion, urine output 15 mL over the last 2 hours, orthopnea
Metoprolol is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension who has been initially treated with furosemide and ramipril. The nurse should evaluate the client for which expected therapeutic effect? decrease in heart rate. lessening of fatigue. improvement in blood sugar levels. increase in urine output.
decrease in heart rate.
After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first? the client with heart failure who is having some difficulty breathing the anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today the coronary bypass client asking for pain medication for "11 of 10" pain in the donor site the client admitted during the previous shift with new-onset controlled atrial fibrillation, who has a call light on
the client with heart failure who is having some difficulty breathing
A client's electrocardiogram (EKG) tracing shows normal sinus rhythm followed by three premature ventricular contractions (PVCs) and a return to normal sinus rhythm. What is the priority action of the nurse? Assess the client's apical-radial pulse rate. Assess the client's blood pressure. Administer oxygen. Administer amiodarone.
Assess the client's apical-radial pulse rate.
An 86-year-old client with a history of atrial fibrillation takes 5 mg of warfarin daily. Warfarin therapy places the client at risk for which complications? Select all that apply. hypotension hemorrhage hepatitis constipation hematuria
hemorrhage hepatitis hematuria
Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The client is exercising using a stationary bicycle. The nurse should evaluate the client's response to exercise by assessing the presence of which condition? diabetic neuropathy muscle atrophy Raynaud's disease transient ischemic attacks
diabetic neuropathy
A physician admits a client to the healthcare facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind when formulating interventions? decreasing blood pressure and increasing mobility increasing blood pressure and reducing mobility stabilizing heart rate and blood pressure and easing anxiety increasing blood pressure and monitoring fluid intake and output
stabilizing heart rate and blood pressure and easing anxiety
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which prescription from the health care provider should the nurse verify before implementing? Call for urine output less than 30 mL/h for 2 consecutive hours. Administer metoprolol 5 mg IV push. Prepare for a pulmonary artery catheter insertion. Titrate dobutamine to keep systolic blood pressure greater than 100 mm Hg.
Administer metoprolol 5 mg IV push.
The nurse is preparing the client newly diagnosed with peripheral arterial disease for discharge with the medication atorvastatin. What laboratory work should the nurse obtain to establish a baseline before starting the medication? creatinine level and liver function tests white blood cell count and blood sugar hemoglobin and hematocrit levels platelet count and urinalysis
creatinine level and liver function tests
A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client? "You'll continue to take your medications until the morning of the test." "You might be sedated during the procedure and won't remember what's happened." "The test is a noninvasive method of determining the effectiveness of your medication regimen." "During the procedure, the health care provider will insert a special wire used to increase the heart rate and produce the irregular beats that caused your signs and symptoms."
"During the procedure, the health care provider will insert a special wire used to increase the heart rate and produce the irregular beats that caused your signs and symptoms."
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I like to soak my feet in the hot tub every day." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I have my spouse look at the soles of my feet each day."
"I have my spouse look at the soles of my feet each day."
The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. Which comment by the client indicates the client needs further education? "I know I shouldn't drive after taking my furosemide." "I should be careful not to stand up too quickly when taking furosemide." "I should take the furosemide in the morning instead of before bed." "I need to be sure to also take the potassium supplement that the health care provider prescribed along with my furosemide."
"I know I shouldn't drive after taking my furosemide."
A client with unstable angina has been prescribed sublingual nitroglycerin tablets. What statement should the nurse include in client teaching? "As soon as you feel chest pain, take one tablet every 5 minutes until the pain stops." "If the medication doesn't alleviate your chest pain, call your health care provider." "If chest pain persists 5 minutes after you take the first tablet, take 2 more tablets." "If the first dose doesn't work, you can take a second 5 minutes later and, if necessary, a third 5 minutes after that."
"If the first dose doesn't work, you can take a second 5 minutes later and, if necessary, a third 5 minutes after that."
The nurse evaluates the client's understanding of nutritional modifications to manage hypertension. The nurse knows the teaching was successful when the client makes what statement? "A glass of red wine each day will lower my blood pressure." "I should eliminate caffeine from my diet to lower my blood pressure." "If I include less fat in my diet, I'll lower my blood pressure." "Limiting my salt intake to 2 grams per day will lower my blood pressure."
"Limiting my salt intake to 2 grams per day will lower my blood pressure."
Which statement indicates that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? "This device decreases the heart's need for oxygen." "This device increases how hard the heart has to work." "This device decreases the blood flow in the heart." "This device helps stop life-threatening heart rhythms."
"This device decreases the heart's need for oxygen."
A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). To determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? "What time did your chest pain start?" "Did you take any nitroglycerine before coming to the emergency department?" "Do you have any allergies?" "Is this the first time you experienced this type of pain?"
"What time did your chest pain start?"
During a home visit, the nurse assesses a client who is taking hydrochlorothiazide and lisinopril for the treatment of hypertension. Which finding would indicate the nurse should inform the health care provider of a possible need to change medication therapy? Blood pressure is 132/80 mm Hg. Client has a persistent cough. Potassium level is 4.1 mEq/L. Client is experiencing nocturia.
Client has a persistent cough.
A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. What should the nurse should advise the client to do during the 2-hour car ride? Perform arm circles. Do ankle pumps. Elevate the legs. Take an ambulance.
Do ankle pumps.
A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)? Ask what medications the client is taking. Complete a history and health assessment. Identify the time of onset of the stroke. Determine if the client is scheduled for any surgical procedures.
Identify the time of onset of the stroke.
The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? pulse rate oxygen saturation respiratory rate blood pressure
blood pressure
Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet? apple canned tomato juice whole wheat bread hamburger
canned tomato juice
A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider suspects the client is experiencing a dissecting aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm? cardiac tamponade stroke pulmonary edema myocardial infarction
cardiac tamponade
A client has atrial fibrillation. The nurse should monitor the client for which condition? cardiac arrest cerebrovascular accident heart block ventricular fibrillation
cerebrovascular accident
A client is prescribed furosemide to manage heart failure. What laboratory values should the nurse monitor while the client receives this medication? Select all that apply. complete blood count serum potassium prothrombin time (PT) thrombin time international normalized ratio
complete blood count serum potassium
The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? dopamine enalapril furosemide metoprolol
dopamine
A nurse is awaiting the arrival of a client from the emergency department with a diagnosis of anterior wall myocardial infarction. In caring for this client, the nurse would be alert for which signs and symptoms of left-sided heart failure? Select all that apply. jugular vein distention hepatomegaly dyspnea crackles tachycardia skin tenting
dyspnea crackles tachycardia
Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease? decrease anxiety enhance myocardial oxygenation administer sublingual nitroglycerin educate the client about their symptoms
enhance myocardial oxygenation
A young adult has been diagnosed with hypertrophic cardiomyopathy. The nurse should further assess the client for which complication? angina fatigue and shortness of breath abdominal pain hypertension
fatigue and shortness of breath
A nurse is assessing a client with an abdominal aortic aneurysm. Which findings require immediate intervention? Select all that apply. pulsating abdominal mass feet pale without pedal pulses abrupt drop in blood pressure statement of "tearing pain" Audible borborygmi
feet pale without pedal pulses abrupt drop in blood pressure statement of "tearing pain"
The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse? administration of digoxin insertion of an I.V. line immediate defibrillation scheduling a pacemaker insertion
immediate defibrillation
A client is admitted to the emergency department with a history of abdominal aortic aneurysm. The nurse assesses the client for which sign or symptom that suggests the client's abdominal aortic aneurysm is extending? increased abdominal and back pain decreased pulse rate and blood pressure retrosternal back pain radiating to the left arm elevated blood pressure and rapid respirations
increased abdominal and back pain
The plan of care for a client with hypertension taking propranolol hydrochloride should include: instructing the client to discontinue the drug if nausea occurs. monitoring blood pressure every week and adjusting the medication dose accordingly. measuring partial thromboplastin time weekly to evaluate blood clotting status. instructing the client to notify the health care provider of irregular or slowed pulse rate.
instructing the client to notify the health care provider of irregular or slowed pulse rate.
Which activity is least effective in preventing sensory deprivation during a client's stay in the cardiac care unit? watching television visiting with family reading the newspaper keeping the door closed to provide privacy
keeping the door closed to provide privacy
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: showing the location of the obstruction and the collateral circulation. scanning the affected extremity and identifying the areas of volume changes. using ultrasound to estimate the velocity changes in the blood vessels. determining how long the client can walk.
showing the location of the obstruction and the collateral circulation.
The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client who is inquiring about the purpose of the new diet? to improve the gastric acidity of the stomach to reduce the metabolic workload of digestion to address the fluctuation in blood sugar to reduce the amount of fecal elimination
to reduce the metabolic workload of digestion
A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents atrial repolarization. ventricular repolarization. atrial depolarization. ventricular depolarization.
ventricular depolarization.
A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to: weigh daily. take blood pressure daily. keep a daily record of urine output. have a serum potassium level drawn weekly.
weigh daily.
The nurse is preparing to administer 0.1 mg of digoxin intravenously. Digoxin comes in a concentration of 0.5 mg/2 ml. How many milliliters should the nurse administer? Record your answer using one decimal place.
0.4 mL
The nurse is caring for a client prescribed IV heparin for treatment of thromboembolism. The client is prescribed 18 units/kg/hr. The client weighs 145 lb (66 kg). The heparin comes from the pharmacy as 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round to the nearest whole number.
12 --> The recommended dose of 18 units/kg should be obtained by multiplying the weight in kilograms by 18 units. 66 kg × 18 units = 1188 units/hr. Concentration for the medication is 25,000 units/250 mL. Use the formula Desired/Have × Volume: 1188 units/25,000 units × 250 mL = 11.88 mL/hr or 12 mL/hr.
A client with sepsis and hypotension is being treated with dopamine. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine in 250 ml, the infusion pump is running at 23 mL/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using two decimal places.
7.71 --> First, calculate how many micrograms per milliliter of dopamine are in the bag: 400 mg/250 mL = 1.6 mg/mL. Next, convert milligrams to micrograms: 1.6 mg/mL × 1,000 mcg/mg = 1,600 mcg/ml. Lastly, calculate the dose: 1,600 mcg/mL × 23 mL/hour/79.5 kg 79.5 kg/60 minutes/hour = 7.71 mcg/kg/minute
A client is hospitalized following a report of dizziness, shortness of breath, and chest pain. Based on the ECG rhythm, the client is scheduled for a transesophageal echocardiogram (TEE) today. Which nursing intervention would be appropriate at this time? Initiate a heparin drip. Encourage deep breathing exercises. Prepare the client for immediate electrical cardioversion. Administer oxygen via nasal cannula as prescribed.
Administer oxygen via nasal cannula as prescribed.
The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? Assess respiratory status. Draw blood for laboratory studies. Insert a Foley catheter. Weigh the client.
Assess respiratory status.
A client admitted to the telemetry unit with newly diagnosed atrial fibrillation has been started on warfarin. What should the nurse instruct the client to do when taking this medication? Select all that apply. Avoid injury to prevent bruising. Be careful using a razor or fingernail clippers. Report any change in color of urine or stool. Floss the teeth deep into the gums. Not take the medication if the pulse is below 60.
Avoid injury to prevent bruising. Be careful using a razor or fingernail clippers. Report any change in color of urine or stool.
A client prescribed propranolol calls the clinic to report a weight gain of 3 lb (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action? Assess the client's dietary intake for the past 24 hours. Have the client come to the clinic in order to assess the lungs. Review medication administration with the client. Assess the client's knowledge of expected effects of the drug.
Have the client come to the clinic in order to assess the lungs.
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first? Increase the oxygen flow rate from 2 to 4 L/min. Call the health care provider (HCP) immediately. Provide reassurance to the client. Obtain a sample for arterial blood gas analysis.
Increase the oxygen flow rate from 2 to 4 L/min.
A client is admitted with shortness of breath, a brain natriuretic peptide (BNP) level of 615 pg/mL, and pedal edema. Which actions should the nurse take next? Select all that apply. Initiate I.V. diuretic therapy. Give oxygen by mask. Raise the feet on pillows. Schedule an exercise stress test. Increase dietary calcium.
Initiate I.V. diuretic therapy. Give oxygen by mask.
The nurse on the previous night shift documented that the lungs of a client with lung cancer were CTA (clear to auscultation) in all fields. While doing the shift assessment, the day shift nurse noticed decreased breath sounds, especially in the right lower lobe. Which action is the nurse's best choice? Report the findings to the charge nurse for documentation follow up with the previous shift's nurse. Document the findings as the only action, as this is expected in clients with lung cancer. Notify the physician of the change in client status. Call radiology for an X-ray to confirm findings.
Notify the physician of the change in client status.
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? Monitor the laboratory values. Observe neurologic function every 15 minutes. Observe the puncture site for swelling and bleeding. Monitor skin warmth and turgor.
Observe the puncture site for swelling and bleeding.
A client in the intensive care unit has an arterial line that reads 58/30 mm Hg on the monitor. What is the nurse's first action? Flush the catheter. Place the client in the Trendelenburg position. Recalibrate the arterial line. Obtain a manual blood pressure.
Obtain a manual blood pressure.
A nurse hears an irregular heart rate of 110 bpm when listening to a client's chest. After assessing the client and noting the new onset of shortness of breath, which action should the nurse take next? Check the availability of medication to relieve anxiety. Recheck the pulse later in the shift. Obtain a prescription for a stat electrocardiogram. Call the radiology service to obtain a stat chest X-ray.
Obtain a prescription for a stat electrocardiogram.
A client with a history of heart failure has just been admitted with dyspnea and pulmonary edema. What is the appropriate action of the nurse? Select all that apply. Administer carvedilol 3.125 mg. Raise the head of the bed. Administer morphine 2-4mg I.V. push. Administer furosemide 60 mg I.V. push. Administer hi-flow oxygen.
Raise the head of the bed. Administer morphine 2-4mg I.V. push. Administer furosemide 60 mg I.V. push. Administer hi-flow oxygen.
The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch, and pedal pulses are palpable +1. What should the nurse instruct the client to do? Increase the length of time for walking. Include more potassium in the diet. Perform leg circles and ankle pumps. Seek consultation from the health care provider.
Seek consultation from the health care provider.
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. What should the nurse instruct the client to do to achieve this goal? Avoid eating low-fat foods. Elevate the legs above the heart. Stop smoking. Jog daily.
Stop smoking.
Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. What should the nurse instruct the client to do? Climb the steps early in the day. Rest for at least an hour before climbing the stairs. Take a nitroglycerin tablet before climbing the stairs. Lie down after climbing the stairs.
Take a nitroglycerin tablet before climbing the stairs.
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? The client demonstrates ability to tolerate more activity without chest pain. The client exhibits a heart rate within normal limits. The client requests information regarding smoking cessation. The client is able to verbalize the action of all prescribed medications.
The client demonstrates ability to tolerate more activity without chest pain.
A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? The ventricular rate is increasing. The absent pulse is now palpable. The number of premature ventricular contractions is decreasing. The fine ventricular fibrillation changes to coarse ventricular fibrillation.
The number of premature ventricular contractions is decreasing.
A nurse is teaching a client about maintaining a healthy heart. The nurse should include which point in teaching? Smoke in moderation. Use alcohol in moderation. Consume a diet high in saturated fats and low in cholesterol. Exercise one or two times per week.
Use alcohol in moderation.
A client is scheduled for a cardiac catheterization. The nurse should do which preprocedural tasks? Select all that apply. Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure. Insert a urinary drainage catheter.
Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure.
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an antibiotic. anticoagulant. antihypertensive. anticonvulsant.
anticoagulant.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? cholesterol level pupil size and pupillary response bowel sounds echocardiogram
pupil size and pupillary response
A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral arterial disease. The health care provider (HCP) started the client on pentoxifylline once daily. Approximately 1 hour after receiving the initial dose of pentoxifylline, the client reports having chest pain. The nurse should first: advise the client to rest. Inform the HCP. have the client rest in bed. start an intravenous infusion of normal saline.
Inform the HCP.
A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply. Provide oxygen. Administer nitroglycerin. Administer aspirin. Insert a Foley catheter. Administer morphine. Administer acetaminophen
Provide oxygen. Administer nitroglycerin. Administer aspirin. Administer morphine.
A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents atrial repolarization. ventricular repolarization. atrial depolarization. ventricular depolarization.
ventricular repolarization.
A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action? apical heart sounds 2 cm to the left of midclavicular line crackles in lower lung fields during inspiration blood pressure 110/90 mm Hg weight gain of 2.5 kg (5.5 lb) in 24 hours
weight gain of 2.5 kg (5.5 lb) in 24 hours
A nurse administers the first dose of nadolol to a client with a blood pressure of 180/96. During an assessment 4 hours later, which information indicates that the client needs immediate intervention? The client has wheezing throughout the lung fields. The client's heart rate has decreased from 88 to 76 beats/minute. The client's blood pressure (BP) is 142/90 mm Hg. The client has cool fingers and toes bilaterally.
The client has wheezing throughout the lung fields.
A client suddenly develops paroxysmal supraventricular tachycardia (PSVT) at a rate of 180 bpm. Current vital signs: blood pressure 90/45 mm Hg, heart rate 180 bpm, respirations 30 breaths/min, O2 saturation 90% on room air. The client is diaphoretic and reports dizziness. What should the nurse do first? Ask the client about current caffeine use. Administer atropine per agency protocol. Prepare defibrillator for synchronized cardioversion. Start cardiopulmonary resuscitation (CPR).
Prepare defibrillator for synchronized cardioversion.
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? Bleeding time Platelet count Prothrombin time (PT) Partial thromboplastin time (PTT)
Prothrombin time (PT)
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? The client exhibits a heart rate within normal limits. The client requests information regarding smoking cessation. The client is able to verbalize the action of all prescribed medications. The client demonstrates ability to tolerate more activity without chest pain.
The client demonstrates ability to tolerate more activity without chest pain.
A client with stage IV heart failure documents in an advance directive that no ventilatory support should be provided. What should the nurse do when the client begins experiencing severe dyspnea? Coach the client to take slow deep breaths. Administer oxygen, morphine, and a bronchodilator for comfort. Ask the client's family to consent to ventilator placement. Ask the healthcare provider to prescribe bilevel positive airway pressure (BIPAP).
Administer oxygen, morphine, and a bronchodilator for comfort.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). Their blood pressure is 104/68 mm Hg. Their pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? Document the findings and recheck the client in 1 hour. Slow the I.V. fluid to prevent any more swelling at the puncture site. Contact the physician and report the findings. Encourage the client to perform isometric leg exercise to improve circulation in the legs.
Contact the physician and report the findings.
A visiting nurse is teaching a client with heart failure about taking their medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? Ask the client's family to take turns coming to the house at each administration time to assist the client with their medications. Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications. Ask the physician if the client can take fewer pills each day. Come to the client's house each morning to prepare the daily allotment of medications.
Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications.
A nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first? the client admitted with unstable angina pectoris who wants to be discharged the client who suffered an acute myocardial infarction (MI) who is complaining of constipation the client who had a pacemaker inserted yesterday and who is complaining of incisional pain the client who has his call light on
the client who suffered an acute myocardial infarction (MI) who is complaining of constipation
Which client has a need for prophylactic antibiotic therapy prior to dental manipulations? the client who had a TKR (total knee replacement) one year ago the client who had a left THR (total hip replacement) 3 months ago the client who had an in ICD (implantable cardiac defibrillator) 2 weeks ago the client who had an aortic valve replacement 5 years ago
the client who had an aortic valve replacement 5 years ago
The nurse is caring for a client with peripheral artery disease (PAD) who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediate attention from the nurse? a change in the intensity of the pulse from the baseline pain "2 out of 10" at the catheterization site shiny skin and a hairless appearance on the affected leg the presence of an ulcer on the limb of the catheterization site
a change in the intensity of the pulse from the baseline --> A change in the intensity of a pulse maybe indicative of arterial closure and warrants immediate attention; the nurse should notify the health care provider (HCP) immediately. A pain level of 2 out of 10 it is not uncommon from the catheter insertion site especially after the placement of a stent. Shiny and hairless skin is expected in clients with PAD. A client undergoing a catheterization may experience pain at the catheterization site as large bore sheaths are place in the femoral artery. Because people with PAD have poor circulation in their lower extremities, it is possible for them to develop leg ulcers. However it is unlikely that the percutaneous transluminal balloon angioplasty caused this.
A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? magnesium level of 2.5 mg/dl (0.1 mmol/L) calcium level of 7.5 mg/dl (0.4 mmol/L) sodium level of 152 mEq/L (152 mmol/L) potassium level of 3.1 mEq/L (3.1 mmol/L)
potassium level of 3.1 mEq/L (3.1 mmol/L)
