Medsurg - Cardio

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect?

A deep venous thrombosis (DVT) is a blood clot (ie, thrombus) formed in large veins, generally of the lower extremities. DVTs occur commonly as a result of decreased activity or mobility (eg, prolonged travels, bed rest) or as a complication of hospitalization or surgery. Although clients with a DVT may have no symptoms, typical clinical manifestations include unilateral edema, localized pain (eg, calf pain) or tenderness to touch, warmth, erythema, and occasionally low-grade fever (Options 2, 4, and 5). Recognition of a potential DVT is critical because the thrombus can dislodge from the vessel and cause life-threatening pulmonary embolism. (Option 1) Blue, cyanotic toes is an indicator of impaired arterial blood perfusion to the extremity, which may occur with acute arterial occlusion (eg, arterial embolism) or severely reduced blood flow (eg, vasopressor-induced vasoconstriction, atherosclerosis). (Option 3) Dry, shiny, hairless skin are common clinical manifestations of chronic peripheral arterial disease. These characteristic skin alterations occur from long-term impairment of blood flow to the extremity.

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply. 1. "Do not take car rides longer than 4 hours for at least 3-4 weeks." 2. "Drink plenty of fluids every day and limit caffeine and alcohol intake." 3. "Elevate legs on a footstool when sitting and dorsiflex the feet often." 4. "Resume your walking program as soon as possible after getting home." 5. "Sit in a cross-legged position for 5-10 minutes to improve circulation."

A deep venous thrombosis (DVT) is a blood clot (ie, thrombus) formed in large veins, generally of the lower extremities. Risk factors for DVT include venous stasis, blood hypercoagulability, and endothelial damage. Therefore, discharge teaching for a client with resolved DVT emphasizes interventions to promote blood flow and venous return(eg, exercise, smoking cessation) to prevent reoccurrence. Interventions to prevent DVT reoccurrence include: Obtain adequate fluid intake and limit caffeine and alcohol intake to avoid dehydration because dehydration increases the risk for blood hypercoagulability (Option 2). Elevate the legs when sitting and dorsiflex the feet often to reduce edema and promote venous return (Option 3). Resume an exercise program (eg, walking, swimming) and change positions frequently to promote venous return (Option 4). Stop smoking to prevent endothelial damage and vasoconstriction. Avoid restrictive clothing (eg, tight jeans), which interferes with circulation and promotes clotting. Consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels. (Option 1) Clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour). (Option 5) Clients should avoid crossing the legs at the knees or ankles because this compresses the veins and limits venous return.

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first? 1. Atrial fibrillation with a pulse of 76/min in a client prescribed rivaroxaban(8%) 2. Bradycardia in a client with a demand pacemaker set at 70/min(38%) 3. First-degree atrioventricular block in a client prescribed atenolol(24%) 4. Sinus tachycardia in a client with gastroenteritis and dehydration(28%)

A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify the health care provider immediately. (Option 1) Clients with atrial fibrillation are usually prescribed an anticoagulant, such as rivaroxaban (Xarelto), due to increased risk for blood clots that can lead to stroke. This client's ventricular rate is controlled, so there is no urgency. (Option 3) First-degree atrioventricular (AV) block can be associated with beta-adrenergic blocker drugs, such as atenolol (Tenormin), as they delay conduction at the AV node. This is reflected as prolonged PR interval on ECG. Although first-degree AV block should be monitored for progression, it is an expected adverse drug effect. Only second- or third-degree heart block should be the priority. (Option 4) Dehydration can cause hypotension. Tachycardia is a normal compensatory mechanism to increase the cardiac output associated with hypotension.

The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which finding is most important to report to the health care provider (HCP)? 1. Nausea and vomiting(11%) 2. New S3 heart sound(57%) 3. Occasional unifocal premature ventricular contractions (PVCs)(22%) 4. Temperature of 100.4 F (38 C)(8%)

A large anterior wall MI can affect the pumping ability of the left ventricle, putting the client at risk for developing heart failure and cardiogenic shock. The new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension can signal heart failure and should be reported immediately to the HCP. (Option 1) Clients may experience nausea and vomiting during an MI resulting from stimulation of the vomiting center by severe pain or from vasovagal reflexes initiated from the area of the infarction. This finding is not as high a priority as the S3 heart sound. (Option 3) Dysrhythmias are a common complication after an MI. Occasional PVCs are not significant, but the nurse should further assess the client's potassium level and assess the apical-radial pulse for the presence of a pulse deficit. (Option 4) An increase in temperature following a MI is usually due to a systemic inflammatory process caused by myocardial cell death. The elevation may last as long as a week. This finding is not as significant as the S3 heart sound.

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? 1. Bronchial breath sounds at lung periphery(6%) 2. Clear vesicular breath sounds at lung bases(1%) 3. Diffuse bilateral crackles at lung bases(67%) 4. Stridor in upper airways(24%)

Acute-onset dyspnea and cough productive of pink, frothy sputum indicate severe pulmonary edema, likely a complication from myocardial infarction. Pink sputum results from ruptured bronchial veins due to high back pressure. The mix of blood and airway fluids creates the pink tinge. On assessment, crackles can be heard at the lung bases. (Option 1) Bronchial breath sounds are normally heard over the trachea. These are harsh and high-pitched; inspiration and expiration are of similar duration. The presence of these on lung periphery indicates pneumonia (consolidation). (Option 2) Clear vesicular breath sounds (normal breath sounds) are not expected in pulmonary edema. (Option 4) Stridor is consistent with a laryngospasm or edema of the upper airway.

A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Administer oxygen via non-rebreather mask 2. Apply an occlusive dressing over the insertion site 3. Assist the client to high Fowler position 4. Monitor vital signs and respiratory effort 5. Notify the health care provider

Air embolism is a rare but life-threatening complication of central venous catheter (CVC) placement in which air enters the bloodstream. This air displaces blood in the pulmonary vessels, which prevents oxygenation of blood by the lungs. Air embolism may occur after CVC removal, as air can enter the bloodstream via the open, large-bore insertion site. Clients with air embolism can rapidly develop respiratory distress leading to cardiopulmonary collapse. Nurses caring for clients with symptoms of air embolism (eg, hypoxemia, dyspnea, sense of impending doom) after CVC removal or dislodgement should perform these actions: Apply an occlusive dressing to the insertion site to prevent entry of additional air into the bloodstream (Option 2) Administer 100% oxygen via non-rebreather mask to improve oxygenation (Option 1) Position the client in left lateral Trendelenburg position to promote venous air pooling in the heart apex rather than the lung capillary beds Continuously monitor vital signs and client respiratory effort to identify changes in client status (Option 4) Notify the health care provider immediately (Option 5) (Option 3) High Fowler position may worsen respiratory distress caused by air embolism by promoting displacement of venous air emboli into pulmonary circulation.

The nurse has just admitted a client with a history of aortic abdominal aneurysm who is experiencing back pain. The nurse needs to assess for a bruit. Where would the nurse place the stethoscope to auscultate for a bruit?

An aneurysm is an outpouching or dilation of a vessel wall. An abdominal aneurysm occurs on the aorta. A bruit, a swishing or buzzing sound that indicates turbulent blood flow in the aneurysm, is best heard with the bell of the stethoscope. It may be auscultated over the aortic aneurysm in the periumbilical or epigastric area slightly left of the midline.

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? 1. "I'm not worried about the device firing now because I know it won't hurt."(25%) 2. "I will let my daughter fix my hair until my health care provider says I can do it."(56%) 3. "I will look into public transportation because I won't be able to drive again."(9%) 4. "I will notify my travel agent that I can no longer travel by plane."(7%)

An implantable cardioverter defibrillator (ICD) can sense and defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias that may occur after defibrillation. The ICD consists of a lead system placed into the endocardium via the subclavian vein. The pulse generator is implanted subcutaneously over the pectoral muscle. Postoperative care and teaching are similar to those for pacemaker implantation. Clients are instructed to refrain from lifting the affected arm above the shoulder (until approved by the health care provider) to prevent dislodgement of the lead wire on the endocardium (Option 2). (Option 1) Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest. (Option 3) Driving may be approved by the health care provider after healing has occurred. Long-term decisions are based on the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs. (Option 4) Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications while traveling.

A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision of the client's aortic dissection? 1. Administer IV labetalol to maintain blood pressure within prescribed parameters(38%) 2. Initiate and maintain strict bed rest and a low-stimulation environment(22%) 3. Monitor bilateral lower extremity peripheral pulse strength(23%) 4. Prepare the client's consent form for surgical repair of the aorta(15%)

Aortic dissection is a tear in the inner lining of the aorta that allows blood to surge between the layers of the arterial wall, separating and weakening the aortic wall. Perfusion to vital organs may become impaired, and the dissection can rapidly progress to life-threatening cardiac tamponade or aortic rupture. Aortic dissection is characterized by acute onset of excruciating, sharp or "ripping" chest pain that radiates to the back. Emergency surgical repair is usually required. Before surgical repair, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the aorta. Administering IV beta blocker medication (eg, labetalol, metoprolol, propranolol) helps achieve this by lowering the heart rate and blood pressure, which are often elevated with aortic dissection (Option 1). (Option 2) Bed rest and a low-stimulation environment help lower heart rate and blood pressure, but antihypertensive medication is more effective and rapid-acting, making it the highest priority. (Option 3) Assessing peripheral pulses helps monitor for complications of aortic dissection but is not a priority over interventions that reduce the risk of aortic rupture. (Option 4) Informed consent is required before all surgical interventions; however, consent forms can be completed any time prior to surgery and are not a priority over reducing the risk of aortic rupture.

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis? 1. Bounding peripheral pulses(12%) 2. Diastolic murmur(27%) 3. Loud second heart sound(13%) 4. Syncope on exertion(46%)

Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot overcome the worsening obstruction, and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures) and weak, thready peripheral pulses. With exertion, the volume of blood that is pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope. (Option 1) In aortic stenosis, pulses are weak due to obstruction of outflow from the left ventricle. Pulses would be bounding in aortic regurgitation due to more blood being pumped each time (blood accumulation from regurgitation of the previous systole). (Option 2) On auscultation, aortic stenosis produces a loud, ejection systolic murmur over the aortic area as blood is ejected from the left ventricle through the stenosed aortic valve during systole. (Option 3) The second heart sound (S2) is produced by the closure of aortic and pulmonic valves. When these valves are stiff and difficult to close (as with aortic stenosis), S2 is soft or absent.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs)(10%) 2. B-type natriuretic peptide (BNP)(54%) 3. Cardiac enzymes (CK-MB)(28%) 4. Chest x-ray(6%)

BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test.

What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg? Select all that apply. 1. Crackles in lungs 2. Dry mucous membranes 3. Hypotension 4. Jugular venous distension 5. Pedal edema

CVP is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid volume problems. The normal CVP is 2-8 mm Hg. An elevated CVP can indicate right ventricular failure or fluid volume overload. Clinical signs of fluid volume overload include the following: Peripheral edema Increased urine output that is dilute Acute, rapid weight gain Jugular venous distension S3 heart sound in adults Tachypnea, dyspnea, crackles in lungs Bounding peripheral pulses (Options 2 and 3) Dry mucous membranes and hypotension are signs of deficient fluid volume or dehydration.

The client is scheduled to have a cardiac catheterization. Which of the following findings would cause the nurse to question the safety of the test proceeding? Select all that apply. 1. Elevated serum C-reactive protein level 2. History of previous allergic reaction to IV contrast 3. Prolonged PR interval on ECG 4. Received metformin today for type 2 diabetes mellitus 5. Serum creatinine of 2.5 mg/dL (221 µmol/L)

Cardiac catheterization involves injection of IV iodinated contrast to assess for obstructed coronary arteries. Potential complications of IV iodinated contrast include: Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast medium (Option 2). Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore, health care providers may discontinue metformin 24-48 hours before administration of contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option 4). Contrast-induced nephropathy: Iodinated contrast can cause acute kidney injury in clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]). Therefore, clients with renal impairment should not receive iodinated contrast unless absolutely necessary (Option 5). (Option 1) C-reactive protein, produced during acute inflammation, may indicate elevated risk for coronary artery disease. However, it is not an indicator of an acute cardiac event and is not a safety concern for cardiac catherization. (Option 3) First-degree atrioventricular block may precede more serious conditions. However, clients are usually asymptomatic and do not require treatment except for stopping the causative medication (eg, beta blocker, digoxin). This would not prevent the procedure from proceeding.

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency?

Chronic venous insufficiency (CVI) occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and into the surrounding tissues, where tissue enzymes break down red blood cells. The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery (Option 1). Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. (Options 2, 3, and 4) Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with peripheral arterial disease due to hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues.

The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1. Chest tube output of 175 mL in past hour(40%) 2. International Normalized Ratio (INR) of 1.5(14%) 3. Temperature of 100.3 F (37.9 C)(14%) 4. Total urine output of 85 mL over past 3 hours(30%)

Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products. (Option 2) Clients who receive a mechanical valve replacement will be started on anticoagulants. A therapeutic INR is 2.5-3.5. This client just had surgery and so has not received enough anticoagulation to get the INR to a therapeutic level. (Option 3) Although this is an abnormal temperature, it is not as high a priority as the blood loss. The nurse should continue to monitor and administer prescribed postoperative antibiotics. (Option 4) Normal urine output is 30 mL/hr. This urine level is just 5 mL below normal. The nurse should continue to monitor.

A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse include for this client?

Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms Reduce stress and avoid alcohol use (Option 1) Clients should be taught to begin or maintain an exercise program, preferably aerobic exercise, to achieve optimal health. (Option 2) Although MVP may place the client at an increased risk for infective endocarditis, there is no clinical evidence to support the need for prophylactic antibiotics prior to dental procedures. Antibiotic prophylaxis is indicated for clients who have prosthetic valve replacement, repaired valves, or a history of infectious endocarditis. (Option 4) There is no need for a medical alert bracelet. MVP is usually a benign condition.

The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker? 1. Auscultate the client's apical pulse rate(32%) 2. Measure the client's blood pressure(1%) 3. Obtain a 12-lead ECG(56%) 4. Palpate the client's radial pulse rate(9%)

Clients with an implanted permanent pacemaker should be assessed for both electrical capture of heart rhythm and mechanical capture of heart rate. In atrial pacing, pacer spikes precede P waves, whereas in ventricular pacing, pacer spikes precede QRS complexes. Pacing spikes should be immediately followed by their appropriate electrical waveform, indicating electrical capture. Checking for mechanical capture is essential to ensure that the electrical activity of the heart corresponds to a pulsatile rhythm. The best method for checking for a pulsatile rhythm is to assess a central pulse (eg, auscultation of apical, palpation of femoral) (Option 1). This rate should be compared to the electrical rate displayed on the cardiac monitor to assess for pulse deficit. (Option 2) Blood pressure is an important assessment relating to cardiac output and organ perfusion, but it does not determine if the client's pacemaker is capturing the mechanical activity of the heart. (Option 3) A 12-lead ECG does not assess mechanical capture of cardiac activity via the client's pacemaker. (Option 4) Peripheral pulses (eg, radial, pedal, popliteal) are not the best indicators of mechanical action of the heart. Peripheral vasculature may have anatomical changes that impair pulse quality, leading to false perception of a pulse deficit.

The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? Click on the exhibit button for additional information. 1. Captopril PO every 8 hours(13%) 2. Morphine IV PRN for pain(13%) 3. Potassium chloride IVPB once(64%) 4. Regular insulin subcutaneous with meals(7%) Laboratory results Potassium3.3 mEq/L (3.3 mmol/L) Sodium149 mEq/L (149 mmol/L) Glucose157 mg/dL (8.7 mmol/L)

Clients with myocardial infarction (MI) are at risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) both during the MI and following reperfusion therapy (eg, coronary artery stenting). Myocardial ischemia damages cardiac muscle cells, causing electrical irritability (eg, premature ventricular contractions) that can be exacerbated by electrolyte imbalances (eg, hypokalemia). Hypokalemia hyperpolarizes cardiac electrical conduction pathways, increasing the risk for dysrhythmias. Therefore, prompt potassium replacement is the priority in these clients (Option 3). (Option 1) ACE inhibitors (eg, captopril, enalapril, lisinopril) help reduce the risk of future MIs by reducing blood pressure and cardiac workload and inhibiting ventricular remodeling. ACE inhibitors should be administered after MI; however, life-threatening dysrhythmias pose a higher risk to the client. (Option 2) Administering morphine is an appropriate intervention to address the client's back pain, but it is not the priority. (Option 4) Strict glycemic control in the resolution phase of an acute MI is associated with better long-term outcomes (eg, reduced morbidity/mortality), but it does not take priority.

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up? 1. Client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg (6.9 kPa)(13%) 2. Client with heart failure who has a brain natriuretic peptide level of 800 pg/mL (800 ng/L)(15%) 3. Client with infected pressure ulcer who has a white blood cell count of 13,000/mm3 (13.0 x 109/L)(2%) 4. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds(68%)

Clients with pulmonary embolism or deep venous thrombosis are treated with anticoagulation. Unfractionated heparin is one such agent, and its efficacy is measured through partial thromboplastin time (PTT) levels. The goal during anticoagulation therapy is a PTT 1.5-2 times the normal reference range of 25-35 seconds. A PTT of 127 seconds is much too prolonged, and spontaneous bleeding could occur. (Option 1) Clients with chronic obstructive pulmonary disease typically have elevated PaCO2 levels secondary to air trapping. A PaCO2 of 52 mm Hg (6.9 kPa), although elevated from the normal range of 35-45 mm Hg (4.7-6.0 kPa), is not extreme for this client. (Option 2) Clients with heart failure are expected to have elevated brain natriuretic peptide (BNP) levels. The nurse should compare BNP levels with those from the previous day. The client is likely receiving therapy for heart failure and is therefore not a priority. (Option 3) A normal white blood cell (WBC) count is 4,000-11,000/mm3 (4.0-11.0 x 109/L). A WBC count of 13,000/mm3 (13.0 x 109/L) is elevated but would be expected in a client with an infection. Even if this is the client's first WBC result, it is not a priority over the client with elevated PTT.

A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take? 1. Give scheduled dose of metoprolol 50 mg orally(1%) 2. Instruct client to cough forcefully(7%) 3. Place client in reverse Trendelenburg position(23%) 4. Prepare to administer atropine 0.5 mg intravenous (IV) push(67%)

Clients with symptomatic bradycardia should be treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine should be considered. (Option 1) Metoprolol is a beta blocker and would further reduce the heart rate. The nurse should not administer this medication and instead notify the health care provider. (Option 2) A forceful cough may cause a vasovagal reaction and further reduce the heart rate. (Option 3) The Trendelenburg position, not the reverse Trendelenburg position, is used with clients with hypotension.

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP? 1. Blood pressure (BP) of 140/86 mm Hg(12%) 2. Difficulty swallowing(43%) 3. Dry, hacking cough(14%) 4. Low back pain(30%)

Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment. (Option 1) This BP reading is slightly elevated. The nurse would need to assess further to find out if this is a typical BP for this client. Given the client's history of aneurysm, this elevated BP may warrant treatment. (Option 3) The nurse would need to assess the client further as there are multiple causes of cough. (Option 4) Low back pain would be a concern if the client had a history of abdominal aortic aneurysm.

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm? Select all that apply. 1. Assess abdominal incision every 4 hours 2. Check for bleeding at groin puncture sites 3. Measure chest tube drainage 4. Monitor fluid intake and urine output 5. Palpate and monitor peripheral pulses

Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a sutureless aortic graft inside the aortic aneurysm via the femoral artery. It does not require an abdominal incision. The nurse will need to monitor the puncture sites in the groin area for bleeding or hematoma formation (Option 2). Peripheral pulses should be palpated and monitored frequently in the early post-op period and routinely afterward (Option 5). Renal artery occlusion can occur due to graft migration or thrombosis so careful monitoring of urine output and kidney function should be part of nursing care (Option 4). (Option 1) No abdominal incision is required in endovascular repair. (Option 3) Chest tubes are not required in endovascular repair.

The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply. 1. Avoid MRI scans 2. Do not place cell phones directly over the pacemaker 3. Notify airport security when traveling 4. Perform shoulder range-of-motion exercises 5. Refrain from using microwave ovens

Discharge teaching for the client with a permanent pacemaker should include the following: -Report fever or any signs of redness, swelling, or drainage at the incision site. -Carry a pacemaker identification card and wear a medical alert bracelet. -Take the pulse daily and report it to the health care provider (HCP) if below the predetermined rate. -Avoid MRI scans, which can affect or damage a pacemaker (Option 1). -Avoid carrying a cell phone in a pocket directly over the pacemaker and, when talking on a cell phone, hold it to the ear on the opposite side of the pacemaker (Option 2). -Notify airport security of a pacemaker; a handheld screening wand should not be held directly over the device (Option 3). -Avoid standing near antitheft detectors in store entryways; walk through at a normal pace and do not linger near the device. (Option 4) The client should avoid lifting the arm above the shoulder on the side of the pacemaker until approved by the HCP as this can cause dislodgement of the pacemaker lead wires. (Option 5) Microwave ovens are safe to use and do not interfere with pacemakers.

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30)(2%) 2. Partial thromboplastin time of 110 seconds(65%) 3. Platelet count of 80,000/mm3 (80 x 109/L)(23%) 4. Prothrombin time of 11 seconds(8%)

Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. (Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm3 (50 x 109/L). (Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning.

The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority? 1. Ask the UAP to stop compressions and check for a pulse(22%) 2. Establish additional IV access with large-bore IVs(3%) 3. Obtain the defibrillator and apply the pads to the client's chest(43%) 4. Prepare to administer 100% O2 with a bag valve mask(31%)

For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Effective chest compressions are essential for maintaining perfusion to vital organs. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest (Option 3). (Option 1) Interruptions in compressions should be kept to a minimum. Pulse checks are performed every 2 minutes per basic life support (BLS) guidelines or if a rhythm change is noted. (Option 2) Additional large-bore IVs may be needed for emergency medication administration (eg, epinephrine, amiodarone) but can be completed when more help arrives to the client's room. (Option 4) Bag valve mask breaths with 100% oxygen should be initiated after obtaining the defibrillator.

The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)? 1. Pain and pallor in one foot(41%) 2. Pain in both knees(1%) 3. Splinter hemorrhages in the nail beds(21%) 4. Temperature of 102.2 F (39 C)(34%)

In IE, the vegetations over the valves can break off and embolize to various organs, resulting in life-threatening complications. These include the following: Stroke - paralysis on one side Spinal cord ischemia - paralysis of both legs Ischemia to the extremities - pain, pallor, and cold foot or arm Intestinal infarction - abdominal pain Splenic infarction - left upper-quadrant pain The nurse or the client (if at home) should report these manifestations immediately to the HCP. (Options 2 and 4) IE commonly presents with fever, arthralgias (multiple joints pains), weakness, and fatigue. These are expected and do not need to be reported during the initial stages of treatment. IE clients typically require intravenous antibiotics for 4-6 weeks. Fever may persist for several days after treatment is started. If the client is persistently febrile after 1-2 weeks of antibiotics, this must be reported as it may indicate ineffective antibiotic therapy. (Option 3) Splinter hemorrhages can occur with infection of the heart valves (endocarditis). They may be caused by vessel damage from swelling of the blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli). The presence of splinter hemorrhages is not as critical as the macroemboli causing stroke or painful cold leg.

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? Select all that apply. 1. Blood pressure 2. Blood urea nitrogen 3. Liver enzymes 4. Potassium 5. White blood cell count

Loop diuretics (furosemide, torsemide, bumetanide) are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, a medical emergency that can result in other life-threatening complications such as heart arrythmias, as well as muscle cramps and weakness (Option 4). Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. Therefore, these levels should be assessed (Options 1 and 2). (Options 3 and 5) Loop diuretics typically do not cause abnormalities in white blood cell counts or liver function tests, so these do not need to be assessed routinely.

A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? Click the exhibit button for additional information. 1. 0.45% sodium chloride IV(24%) 2. Calcium gluconate(3%) 3. Furosemide(56%) 4. Sodium polystyrene sulfonate(15%)

In heart failure, cardiac output is reduced because the heart is unable to pump blood adequately. This reduction in cardiac output reduces perfusion to the vital organs, including the kidneys. Decreased renal blood flow triggers the kidneys to activate the renin-angiotensin system as a compensatory mechanism, which increases blood volume by increasing water resorption in the kidneys. This compensatory mechanism results in fluid volume excess and dilutional hyponatremia (more free water than sodium). Dilutional hyponatremia can be treated with fluid restriction, loop diuretics, and ACE inhibitors (eg, lisinopril, captopril). Furosemide works to resolve hyponatremia by promoting free water excretion, allowing for hemoconcentration and increased sodium levels (Option 3). (Option 1) 0.45% sodium chloride is a hypotonic solution. Giving hypotonic saline would provide more free water than sodium, thereby worsening fluid overload and hyponatremia. (Option 2) The client's calcium is within normal limits and does not need replacement. (Option 4) Sodium polystyrene sulfonate (Kayexalate, Kionex) is a medication used to treat hyperkalemia that works by exchanging sodium for potassium across the mucous membranes of the bowel and then excreting potassium via stool. Sodium polystyrene sulfonate is not indicated if potassium is within normal limits.

The nurse identifies which risk factors as contributing to the development of peripheral artery disease?

In peripheral artery disease (PAD), the arteries of the extremities become atherosclerotic (progressive thickening and hardening due to chronic vascular damage). PAD reduces tissue perfusion and can cause ischemic pain of the lower extremities with movement or exercise (intermittent claudication). Pain with PAD can also occur at rest and manifests in the lower extremities as burning, aching, or numbness. Factors that cause chronic vascular changes and increase risk for PAD include: Hypertension: Vessel damage from chronically elevated vascular resistance Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option 2) Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option 3) Smoking: Chronic vasoconstriction from nicotine inhalation (Option 1) (Option 4) Elevated estrogen levels (eg, oral contraceptive use, pregnancy, hormone replacement therapy) make blood hypercoagulable. However, elevated estrogen levels are more likely to form thrombi in veins than in arteries due to lower venous pressure and slower blood flow (eg, venous stasis). (Option 5) Unlike chronic venous insufficiency, in which vessels ineffectively return blood from the feet to the central circulation, standing is not a risk factor for PAD, as standing facilitates blood flow by gravity to the lower extremities.

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first? 1. Client post kidney transplant who reports white spots in the oral cavity(37%) 2. Client with a history of mitral valve regurgitation who reports fatigue(25%) 3. Client with erythema and purulent drainage at the site of a spider bite(26%) 4. Client with hypertension who reports a cold and nasal congestion(10%)

Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention. (Option 1) Kidney transplant recipients are on an immunosuppressant regimen to prevent rejection of the transplanted organ, which can leave them susceptible to infections such as candidiasis (thrush) of the oral cavity. (Option 3) The client with a spider bite is displaying signs and symptoms of infection, and further assessment is required to evaluate for conditions such as cellulitis. This client should be called second. (Option 4) Clients with hypertension who develop sinus or nasal congestion have limited options for symptom relief. Decongestants containing a vasoconstrictor (eg, pseudoephedrine) can exacerbate hypertension.

The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding?

Murmurs are produced by turbulent blood flow across diseased or malformed cardiac valves. They can be characterized as musical, blowing, swooshing, or rasping sounds heard between normal heart sounds. The aortic area is located at the second intercostal space, right sternal border. (Option 1) An arterial bruit is a turbulent blood flow sound heard in a peripheral artery. (Option 3) A pericardial friction rub is a high-pitched, scratchy sound during S1 or S2 at the apex of the heart. It is best heard with the client sitting and leaning forward and at the end of expiration. It occurs when inflamed surfaces of the heart rub against each other. (Option 4) An S3 gallop is an extra heart sound that occurs closely after S2. It is a low-pitched sound heard in early diastole that is similar to the sound of a horse's gallop. The mitral area is located at the fifth intercostal space, medial to the mid-clavicular line.

The nurse is preparing to administer medications after assessing a client with a myocardial infarction. Based on the collected data, which of the following prescribed medications are appropriate for the nurse to administer? Click on the exhibit button for additional information. Select all that apply. 1. Aspirin 2. Atorvastatin 3. Docusate sodium 4. Lisinopril 5. Metoprolol

Myocardial infarctions (MIs) damage heart muscle and require medications to improve heart function and prevent reinfarction (eg, aspirin). Aspirin, an antiplatelet agent, inhibits platelet aggregation, prevents thrombus formation, and reduces heart inflammation. Clients without signs of bleeding or low platelet levels may safely receive aspirin (Option 1). Atorvastatin is a lipid-lowering medication given to clients to lower cholesterol levels (ie, LDL cholesterol), which reduces plaque and reinfarction risk (Option 2). However, statins may cause rhabdomyolysis and require monitoring for muscle weakness and pain. Docusate sodium is a stool softener that reduces straining during bowel movements, thereby decreasing the workload on the heart. Straining can also cause bradycardia due to vagal response (Option 3). Lisinopril is an ACE inhibitor often prescribed to clients after an MI to prevent ventricular remodeling and progression of heart failure. Lisinopril may cause hyperkalemia and hypotension, and should be administered only to clients with normokalemia and normotension (Option 4). (Option 5) Metoprolol is a beta blocker prescribed to clients after MI to reduce the risk of reinfarction and heart failure. Metoprolol lowers blood pressure and heart rate; therefore, the nurse should hold the medication and notify the health care provider of hypotension or a heart rate <50/min.

he home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday(14%) 2. The client has a painful red area on the buttocks(13%) 3. The client has new dependent edema of the feet(44%) 4. The client has strong, foul smelling urine(27%)

New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment. (Option 1) Loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening. (Option 2) A painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly. (Option 4) Strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly.

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? 1. Assess and compare blood pressure in each arm(12%) 2. Assess character and quality of peripheral pulses(62%) 3. Assess for presence or absence of hair on lower extremities(2%) 4. Assess for presence of bowel sounds(21%)

Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm. Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require reoperation. (Option 1) Comparison of blood pressures in each arm may be helpful in an assessment of an upper aortic dissection or congenital aortic coarctation, but not in assessing an abdominal aortic aneurysm. (Option 3) Absence of hair growth on the lower extremities is more specific for peripheral artery disease. (Option 4) Although auscultation of bowel sounds is part of a basic assessment, it is not considered a key assessment preoperatively. It will become more of a priority postoperatively in assessment of ileus.

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first? 1. 36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur(5%) 2. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension(51%) 3. 67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min(32%) 4. 70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV(10%)

Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. (Option 1) These are symptoms typically seen in the client with endocarditis. The nurse should further assess the murmur to see if it has worsened or changed, but this should be done after the client with pericardial effusion is seen. (Option 3) The new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable; this client is not a priority over the client with possible tamponade. Atrial fibrillation is often a chronic arrhythmia and is managed with ventricular rate control and anticoagulation. (Option 4) Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic. IV diuretics can worsen the hypotension. The client is watching TV, an indication that the client is stable. The nurse can delegate to the unlicensed assistive personnel directions for the client to stay in bed due to the hypotension until the nurse can perform further assessment.

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply. 1. Blood pressure of 90/70 mm Hg 2. Bounding peripheral pulses 3. Decreased breath sounds on left side 4. Distant heart tones 5. Jugular venous distension

Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Signs and symptoms of cardiac tamponade include: -Hypotension with narrowed pulse pressure (Option 1) -Muffled or distant heart tones (Option 4) -Jugular venous distension (Option 5) -Pulsus paradoxus -Dyspnea, tachypnea -Tachycardia (Option 2) Bounding pulses may be present during fluid overload or hypertension. They may also be present with anxiety or fever. The client with possible tamponade will have evidence of decreased cardiac output and is more likely to have weak, thready pulses. (Option 3) Decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax.

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. 1. "I will apply moisturizing lotion on my legs every day." 2. "I will elevate my legs at night when I am sleeping." 3. "I will keep my legs below heart level when sitting." 4. "I will start walking outside with my neighbor." 5. "I will use a heating pad to promote circulation."

Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene). Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development (Option 2) Elevating the legs promotes venous return, but does not promote arterial circulation. (Option 5) Heating pads should not be used in clients with altered perfusion or sensation due to the increased risk for burns.

The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? 1. "At the end of the day, my shoes and socks are tight."(10%) 2. "I have a slow-healing sore right above my ankle."(29%) 3. "My legs ache when I stand for extended periods."(17%) 4. "When I sit down to rest and elevate my legs, the pain increases."(43%)

Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legsand improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation. (Options 1, 2, and 3) Chronic venous insufficiency refers to inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle. By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation.

The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time? Click on the exhibit button for additional information. 1. Call a code and begin chest compressions(3%) 2. Call the rapid response team and prepare for cardioversion(23%) 3. Document the findings in the chart and continue to monitor(24%) 4. Notify the cardiologist and prepare for temporary pacing(48%)

Radiofrequency ablation is performed through transvenous cardiac catheterization to ablate (ie, burn) electrical pathways causing supraventricular or ventricular tachydysrhythmias. Ablation performed near the atrioventricular (AV) node can damage conduction, causing varying degrees of AV block. Third-degree AV block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). On ECG, third-degree AV block presents as a regular rate and rhythm with disassociated P waves and QRS complexes. This type of AV block requires temporary or permanent pacing to restore electrical conduction and hemodynamic stability. (Option 1) The client's pulse and hemodynamic stability (eg, responsiveness) should be assessed before calling a code. Most complete heart blocks can be managed with temporary followed by permanent pacing. (Option 2) The rapid response team can be initiated depending on the client's condition. However, cardioversion is performed for ventricular or supraventricular tachydysrhythmias but is not indicated in heart block. (Option 3) Third-degree AV block is a life-threatening condition and requires intervention.

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. 1. Ecchymosis of the scrotum 2. Increased abdominal girth 3. Increased urinary output 4. Report of groin pain 5. Report of increased thirst and appetite loss

Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output (Options 1, 2, and 4). (Option 3) Urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension. (Option 5) Increased thirst and appetite loss are not signs of graft leakage.

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply. 1. Crackles in lung bases 2. Increased abdominal girth 3. Jugular venous distension 4. Lower extremity edema 5. Orthopnea

Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation. Clinical manifestations of right-sided heart failure include: Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option 4). Jugular venous distension (Option 3). Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option 2). Hepatomegaly due to hepatic venous congestion. (Options 1 and 5) Orthopnea (dyspnea with recumbency), paroxysmal nocturnal dyspnea (PND), and crackles in lung bases are clinical manifestations of left-sided heart failure. Blood is not effectively pumped into systemic circulation, resulting in the backup of blood into the pulmonary vessels that causes congestion of the pulmonary vessels and, potentially, pulmonary edema. Pulmonary hypertension and right-sided heart failure typically present with dyspnea on exertion rather than orthopnea or PND.

The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse? 1.Glucose 200 mg/dL (11.1 mmol/L)(5%) 2.Hematocrit 38% (0.38)(1%) 3.Potassium 3.4 mEq/L (3.4 mmol/L)(14%) 4.Troponin 0.7 ng/mL (0.7 mcg/L)(79%)

Serum cardiac markers are proteins released into the bloodstream from necrotic heart tissue after a myocardial infarction (MI). Troponin is a highly specific cardiac marker for the detection of MI. It has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. Serum levels of troponin increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline after 10-14 days. A troponin value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority and immediate focus of the nurse. Normal values: troponin I <0.5 ng/mL (<0.5 mcg/L); troponin T <0.1 ng/mL (<0.1 mcg/L). (Option 1) The glucose is elevated (normal random glucose 70-110 mg/dL [3.9-6.1 mmol/L]) but is not the priority in this situation. The nurse will need to assess whether the client has a history of diabetes and time of the last meal. (Option 2) Normal hematocrit for a male is 39%-50% [0.39-0.50] and 35%-47% [0.35-0.47] for a female. The hematocrit value is not the priority. (Option 3) The potassium is slightly below normal (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). This should be the nurse's second priority. A low potassium level can precipitate dysrhythmias.

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply. 1. "I need to eat less red meat and more fresh vegetables." 2. "I'll limit drinking soda to only one at a time as an occasional treat." 3. "I'm going to replace potato chips with fruit during meals and snacking." 4. "I'm really going to miss drinking as much milk as I normally do." 5. "Taking the salt shaker off the table should be enough to reduce my sodium intake."

The Dietary Approaches to Stop Hypertension (DASH) diet is often suggested to clients with hypertension due to its ability to reduce blood pressure. The diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats, which all contribute to increased blood pressure. The DASH diet focuses on: -Including fresh fruits and vegetables, and whole grains in the daily diet -Choosing fat-free or low-fat dairy products -Choosing meats lower in cholesterol (eg, fish, poultry) and alternate protein sources (eg, legumes) instead of red meats (Option 1) -Limiting intake of sweets, foods high in sodium (eg, potato chips, frozen meals, canned foods), and sugary beverages to the occasional treat (Options 2 and 3) (Option 4) Limiting milk intake is unnecessary; however, the nurse may need to educate the client about choosing low-fat or skim milk over whole milk. (Option 5) Taking the salt shaker off the table may be a good first step in reducing sodium intake. However, it will not be enough as salt is found in many foods.

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client? 1. A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg(8%) 2. A client just admitted from the emergency department with a BP of 150/72 mm Hg(20%) 3. A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin(35%) 4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg(35%)

The MAP refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is between 70-105 mm Hg. If the MAP falls below <60 mm Hg, vital organs may be underperfused and can become ischemic. MAP can be calculated using the formula below: Mean Arterial Pressure =Systolic Blood Pressure + (Diastolic Blood Pressure × 2) 3 A normal MAP is 70-105 mm Hg. The client with the BP of 106/42 mm Hg has a MAP of 63 mm Hg, in the abnormal range. The nurse should report this to the HCP and monitor the client closely. (Options 1, 2, and 3) These MAPs are within the 70-105 mm Hg normal range.

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? 1.No sexual activity for at least 6 weeks postoperatively 2.Notify health care provider (HCP) of redness, swelling, or drainage at the incision site 3.Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP 4.Take a shower daily without soaking chest and leg incisions

The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: 1. Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. 2. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). 3. Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. 4. Clarify no driving for 4-6 weeks or until the HCP approves. 5. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). 6. Notify the HCP if the following symptoms occur:Chest pain or shortness of breath that does not subside with restFever >101 F (38.3 C)Redness, drainage, or swelling at the incision sites (Option 2).

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? 1. Administer atropine 0.5 mg IV(19%) 2. Administer dopamine 5 mcg/kg/min IV(10%) 3. Initiate transcutaneous pacing(35%) 4. Notify the health care provider(34%)

The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRScomplexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client. (Option 1) Atropine is administered to clients with symptomatic bradycardia; however, this client's symptoms are caused by failure to capture. Therefore, obtaining capture via transcutaneous pacing should resolve the client's symptoms. (Option 2) Dopamine is an inotrope used to treat hypotension due to bradycardia. This client is bradycardic and hypotensive due to failure to capture. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. (Option 4) The health care provider needs to be notified, but the nurse should first use the transcutaneous pacemaker to stabilize the client.

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following? 1. Coughing and deep breathing(7%) 2. Left lateral position(17%) 3. Pursed-lip breathing(7%) 4. Sitting up and leaning forward(66%)

The most common cause of acute pericarditis is a recent viral infection. It is an inflammation of the visceral and/or parietal pericardium. Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. This position reduces pressure on the inflamed parietal pericardium, especially during lung inflation. The pain is different than that experienced during myocardial infarction. Assessment shows a pericardial friction rub (scratchy or squeaking sound). Treatment includes a combination of nonsteroidal anti-inflammatory drugs (NSAIDS) or aspirin plus colchicine. (Option 1) Pericarditis causes pain on inspiration, not expiration. This pleuritic-type pain also increases with coughing. (Option 2) The supine or lying-down position worsens pericarditis pain. (Option 3) The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease.

Which client is in need of follow-up education by the nurse? 1. Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping(26%) 2. Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out(9%) 3. Client with venous leg ulcer who refuses to wear elastic compression stockings during the day(57%) 4. Postsurgical client who points and flexes feet when lying in bed(6%)

The nurse needs to provide education to the client with a venous leg ulcer who refuses to wear compression stockings. Compression is essential for the treatment of chronic venous insufficiency, venous ulcer healing, and prevention of ulcer recurrence. The client will need individual evaluation to determine what level of compression is needed. Assessment of the ankle-brachial index (ABI) should be performed as well. An ABI of <0.9 suggests concurrent PAD and the need for lower levels of compression therapy. There are several options that the nurse can explore with the client to decide which compression device will work best in the situation (custom-fitted elastic compression stockings, elastic tubular support bandages, Velcro wrap, paste bandage with elastic wrap, or a multilayer bandage system). (Option 1) Dangling a limb over the side of the bed is a common practice among PAD clients to relieve pain. There is no need for this client to discontinue this practice as it allows gravity to maximize blood flow.

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline(49%) 2. 2 days postcoronary bypass graft surgery with a white blood cell count of 18,000/mm3 (18.0 × 109/L)(16%) 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion(19%) 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema(14%)

The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival. (Option 2) An elevated white blood cell count (>11,000/mm3 [11.0 x 109/L]) could be caused by an underlying infection or the stress of the surgery. This needs to be assessed as soon as possible, but it does not take priority over the possible limb loss with graft occlusion. (Option 3) A decreased ejection fraction (normal 55%-70%) results in decreased cardiac output and inability to meet oxygen demand, leading to shortness of breath and activity intolerance. The nurse should assess lung sounds. However, this is an expected finding, so the nurse does not need to assess this client first. (Option 4) Subcutaneous emphysema is air in the tissue surrounding the chest tube insertion site and can occur in a client with a pneumothorax. The nurse should assess lung sounds and palpate to determine the degree of emphysema. However, this is an expected finding, so the nurse does not need to assess this client first.

The nurse is preparing to perform cardioversion in a client in supraventricular tachycardia shown in the exhibit that has been unresponsive to drug therapy. The client has become hemodynamically unstable. Which step is most important in performing cardioversion?

The synchronizer switch must be turned on when cardioversion is planned. The synchronize circuit in the defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the electrocardiogram (ECG). This allows the unit to sense this client's rhythm and time the shock to avoid having it occur during the T wave. A shock delivered during the T wave could cause this client to go into a more lethal rhythm (eg, ventricular tachycardia, ventricular fibrillation). If this client becomes pulseless, the synchronize function should be turned off and the nurse should proceed with defibrillation. Synchronized cardioversion is indicated for ventricular tachycardia with a pulse, supraventricular tachycardia, and atrial fibrillation with a rapid ventricular response. (Options 1 and 4) Charging the defibrillator and selecting an energy level are important but not as essential as turning on the synchronize function. If the synchronize button is not activated, the unit will defibrillate without sensing this client's rhythm, potentially causing the client to go into a more lethal rhythm. (Option 3) If this client is awake and hemodynamically stable, sedation is indicated.

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. 1. Capillary refill is less than 3 seconds 2. Pulse pressure is narrowed 3. Systolic blood pressure drops only when standing 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020

This client's initial vital signs show tachycardia and hypotension, which are classic signs of hypovolemia. Normal capillary refill is less than 3 seconds and is an indication of normal hydration and perfusion (Option 1). Obligatory urine output is 30 mL/hr, and this client has 90 mL/hr. Urine output is one of the best indicators of adequate rehydration (Option 4). The urine specific gravity is within a normal range (1.003 to 1.030), which can indicate normal hydration (Option 5). (Option 2) Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock and would not indicate adequate rehydration. The client arrived with a narrow pulse pressure already. (Option 3) This is indicative of orthostatic vital signs. When a client stands, the body normally vasoconstricts to maintain the blood pressure from the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted, and there is no compensatory mechanism left to adjust to the position change.

The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? 1. A 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives(37%) 2. A 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56%(1%) 3. A 72-year-old client with a fever who is 2 days post coronary stent placement(7%) 4. An 80-year-old client who is 4 days postoperative from repair of a fractured hip(53%)

Venous thromboembolism includes both DVT and pulmonary embolism (PE). DVT is the most common form and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: Trauma (endothelial injury and venous stasis from immobility) Major surgery (endothelial injury and venous stasis from immobility) Prolonged immobilization (eg, stroke, long travel) causing venous stasis Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) Oral contraceptives (estrogen is thrombotic) Underlying malignancy (cancer cells release procoagulants) Smoking (produces endothelial damage by inflammation) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase blood viscosity) The 80-year-old 4-day postoperative client has the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age, and is at greatest risk for developing a DVT. (Option 1) Smoking cigarettes and using oral contraceptives increase plasma fibrinogen and coagulation factors and cause hypercoagulability of blood, but the client is not at greatest risk. Hormonal contraceptives are not recommended if the client is age >35 and also smokes. (Option 2) Elevated hemoglobin/hematocrit level (erythrocytosis) causes increased blood viscosity and hypercoagulability of blood, which increases the risk for DVT. However, the client is not at greatest risk. (Option 3) Anticoagulants and antiplatelet agents are administered before and after coronary stent placement. This client is at increased risk due to endothelial damage and advanced age but is not at greatest risk.

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? 1. Assess incision for bleeding or hematoma formation(27%) 2. Auscultate bilateral anterior and posterior lung sounds(16%) 3. Initiate continuous cardiac monitoring(53%) 4. Reestablish IV fluids and postoperative antibiotics(2%)1.

When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker. If the atrioventricular (dual-chambered) pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes (electrical capture). If the pacemaker is not working properly (eg, failure to capture, failure to sense), the health care provider should be contacted immediately (Option 3). The nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure. (Option 1) Checking for bleeding or hematoma formation at the insertion site is appropriate but should occur after attaching the cardiac monitor. (Option 2) Postoperative lung sounds are auscultated to assess for atelectasis, but lung assessments do not take priority over ensuring pacemaker functionality. (Option 4) IV fluids and postoperative antibiotics help to reestablish fluid volume and prevent infection, respectively, and should be initiated after cardiac monitoring.