MS2 Exam 1

The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best action?

Notify the healthcare provider.

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority?

assessing troponin 1 levels

An obese male client with history of heart failure is prescribed a beta blocker. Which of the following is important to teach regarding home drug therapy? Select all that apply.

"Take your medication at the same time daily." "Contact the health care provider if you have difficulty getting or maintaining an erection." "Change positions between sitting and standing carefully." "Check your pulse for a full minute before administering your medication."

Which client statement should the nurse evaluate as indicating the client's correct understanding of the causes of coronary artery disease (CAD)?

"The leading cause of CAD is atherosclerosis."

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as

a third heart sound (S3).

A client who has a history of bacterial endocarditis is scheduled to have oral surgery to remove a tooth. What should the nurse instruct the client to do?

Be sure the dentist prescribes a prophylactic antibiotic before the oral surgery.

A client admitted to the emergency department with atrial fibrillation has a heart rate of 160 bpm. The nurse should implement which prescription first?

Administer oxygen via nasal cannula.

During a shift report for a client with heart failure, the nurse going off shift reports that the client had sinus bradycardia during the shift and a creatinine of 3.5 mg/dL. Which action does the nurse perform when administering digoxin to this client?

Assess the digoxin level.

The nurse observes the cardiac rhythm (see ECG strip) for a client who is being admitted with a myocardial infarction. What should the nurse do first?

Check for a pulse.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention?

Control the pain and support breathing and oxygenation.

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:

Dependent edema.

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do?

Enroll in a supervised exercise training program.

A physician admits a client with a history of I.V. drug abuse to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has

Osler's nodes and splinter hemorrhages.

A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60 mm Hg. What should the nurse do first?

Prepare for transcutaneous pacing.

A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. What is the nurse's primary goal at this time?

Prepare the client for emergency surgery.

A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention?

Prepare the client for surgical intervention

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?

Prothrombin time (PT)

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching?

Risk for infection

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain.

A nurse is working in the intermediate care unit. After receiving change of shift report who should the nurse assess first?

a client with aortic stenosis who has a blood pressure of 84/52 mm Hg

The nurse is assigned to a client in the ICU. During the initial assessment, the nurse notes jugular vein distention and recognizes that the plan of care will follow which disorder?

heart failure

A community health nurse is involved in a teaching program to help prevent rheumatic fever in school-age children. Which is the most important intervention to decrease the incidence of the disease?

teaching clients to seek medical treatment for streptococcal pharyngitis

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 nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which point(s)? Select all that apply.

to report unexpected bleeding or bleeding that lasts a long time to understand that the client may bruise more easily and may experience bleeding gums. to know that clopidogrel works by preventing platelets from sticking together and forming a clot

A client is to have a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory value to the health care provider (HCP) before the stress test

troponin level

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?

weight gain of 2.5 kg (5.5 lb) in 24 hours

The nurse is teaching a client with a demand pacemaker. What should the nurse tell the client about how the device functions by providing stimuli to the heart muscle:? The pacemaker will provide a stimulus:

when the heart rate falls below a specified level.

A client is receiving cilostazol for peripheral artery disease causing intermittent claudication. Which statement by the client indicates to the nurse that this medication is effective?

"I am able to walk further without leg pain."

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?

"I sleep on three pillows each night."

Which statement indicates that the parents understand the need for their child to receive long-term antibiotic therapy after an episode of rheumatic fever?

"It will prevent recurring acute rheumatic fever."

A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?

"Rehabilitation will help me function as well as I physically can."

A client has atrial fibrillation. The nurse should monitor the client for which condition?

cerebrovascular accident

A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the client is admitted to the coronary care unit?

Begin telemetry monitoring.

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history?

atrial fibrillation and a mild stroke one month ago

Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which contradiction to administering the drug?

history of cerebral hemorrhage

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of

acute pulmonary edema.

The nurse is assessing an individual with peripheral artery disease. Which finding indicates complete arterial obstruction in the lower left leg?

coldness of the left foot and ankle

An older adult is admitted to the hospital with nausea and vomiting. The client has a history of heart failure and is being treated with digoxin. The client has been nauseated for a week and began vomiting 2 days ago. Laboratory values indicate hypokalemia. Because of these clinical findings, the nurse should assess the client carefully for:

digoxin toxicity.

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.

dyspnea, crackles, tachycardia

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

elevated ST segment

The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor?

gangrene

The nurse is assessing a client admitted to the hospital for surgery to repair an abdominal aortic aneurysm. Before surgery, the nurse should assess the client for which factor that puts the client at risk for rupture?

high blood pressure

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

history of aortic valve replacement

The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation. The nurse should anticipate which intervention?

immediate defibrillation

A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation?

irregularly irregular heart rate

A client has mitral stenosis and will have a valve replacement. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which prescription would pose the greatest health hazard to this client at this time?

medication therapy

A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply.

orthopnea, cough, crackles

The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply.

serum troponin, serum myoglobin

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?

stabilizing heart rate and blood pressure and easing anxiety

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

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

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 action from the nurse?

a change in the intensity of the pulse from the baseline