NUR Exam 2 PREPU

You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment?

"Have you had any episodes of dizziness or fainting?" Ask if the client has episodes of dyspnea, dizziness, or fainting. Options B, C, and D are incorrect. Being nauseous, mottling of the hands, and pain radiating into the lower extremities are not indications of cardiac problems.

The nurse is conducting patient teaching about cholesterol levels in the body. When discussing the patient's elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, the patient shows an understanding of the significance of these levels by stating what?

"Increased LDL and decreased HDL increase my risk of coronary artery disease."

The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?

Assess the client ADPIE; When a nurse notes an abnormal rhythm on a telemetry monitor, the first action is to assess the client. After client assessment, the nurse is able to make an informed decision on the next nursing action.

Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response?

Assess the grandmother for adventitious lung sounds Sudden onset of confusion may be the first symptom of an infection, such as pneumonia or urinary tract infection. The nurse needs to fully assess the situation before acting (such as telling the family this is a result of aging). Donepezil is used for Alzheimer's disease, which does not have acute onset. A recommendation for placement in a nursing home is premature without a full assessment at this time.

In what position should a nurse place the head of the bed to obtain the most accurate reading of jugular vein distension?

30 degrees The nurse should measure jugular vein distention with the head of the bed elevated between 15 and 30 degrees. This position allows the nurse to obtain the vertical distance between the sternal angle and the point of highest pulsation. The nurse can't observe increased pressure when the client is supine or when the head of the bed is at 60 degrees because the point that marks the pressure level is above the jaw and, therefore, not visible. In high Fowler's position, the veins are barely discernible above the clavicle.

The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?

Chordae Tendinae

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

Contractility

The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit?

Count the heart rate at the apex. The nurse determines the pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. The pulse quality refers to its palpated volume. Pulse rhythm is the pattern of the pulsations and the pauses between them.

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate?

Distract the client with a familiar object or music.

A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing?

Dypyridamole If the patient is unable to exercise, a pharmacologic stress test is performed by injecting a vasodilating agent, dipyridamole or adenosine, to mimic the physiologic effects of exercise. The stress test may be combined with an echocardiogram or radionuclide imaging techniques to examine myocardial function during exercise and rest. Digoxin would not be used for stress testing. Thallium 201 and Cardiolite are radioisotopes used in myocardial perfusion scanning.

The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. What explanation will the nurse offer to explain the urination?

Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys.

The nurse auscultates the apex beat at which anatomical location?

Fifth intercostal space; midclavicular line

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition?

Heart failure An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following a therapeutic regimen?

High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl.

In preparation for transesophageal echocardiography (TEE), the nurse must:

Inform the patient that blood pressure (BP) and electrocardiogram (ECG) monitoring will occur throughout the test The patient will have BP and ECG monitored throughout the test and must be NPO 6 hours before the procedure. The patient is sedated to make him or her comfortable, but will not be heavily sedated. Also, the patient will have an IV line initiated before the procedure.

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate?

International normalized ratio (INR) The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of warfarin.

The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider?

K+ 3.1 mEq/L All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation.

A nurse can auscultate for heart sounds more easily if the client is

Leaning forward The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This position enables the nurse to listen for heart sounds without the sound of expiration interfering. Using the supine position to visually inspect the precordium allows the nurse to observe the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. Placing the client in a left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems.

During a physical examination, a nurse asks a client to hold their breath briefly, and then uses a stethoscope to auscultate over the carotid arteries. Which finding is normal when auscultating over these arteries?

No sounds over either carotid artery Absence of sounds over either carotid artery indicates unobstructed blood flow. Auscultation of any sounds (bruits) is abnormal and the nurse should report this finding to the physician.

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration?

Orthostatic hypertension Orthostatic hypotension or persistent hypotension is present in dehydration, as are poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration is severe, the client may also be restless, confused, and thirsty.Most instances of crackles is indicative of excess fluid volume, not dehydration.Shortness of breath or a bounding pulse may be indicative of excess fluid, not dehydration.

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?

Posterior tibial To evaluate the posterior tibial pulse, the nurse palpates the inner aspect of the ankle, below the medial malleolus. The nurse palpates medially in the antecubital space to evaluate the brachial pulse; midway between the superior iliac spine and symphysis pubis to assess the femoral pulse; and along the top of the foot, over the instep, to evaluate the dorsalis pedis pulse.

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure?

Pulse pressure

The nurse uses which term for the normal pacemaker of the heart?

SA Node (Sinoatrial node)

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first?

Take the clients blood pressure The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

When auscultating a client's chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound?

The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromised?

The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromised? There are four chambers to the heart. The right and left ventricles are the heart's major pumping chamber. The right ventricle pumps to the lungs to oxygenate the blood. The left ventricle pumps blood to the tissues and cells. The pulmonary artery and aorta are not of the heart.

A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient?

The patient had a vagal response. When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response. Myocardial infarction is damage to the heart and clients will experience pain or shortness of breath. Anxiety causes the heart rate to increase. The client with an abdominal aortic aneurysm will experience back or abdominal pain, not a decrease in heart rate.

The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?

The thin fibrous sac encasing the heart

The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first?

Use a Dopple Ultrasound device When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse is not palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the HCP may be necessary if there is a change in the client's condition.

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

Wheezes with wet lung sounds If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. For abnormal and normal breath sounds, the nurse auscultates the lungs. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. With left-sided congestive heart failure, auscultation does not reveal a high pitched sound.

The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension?

supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting position to a standing position. The following is an example of BP and HR measurements in a client with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure.