Perfusion prep exam
A nurse is teaching nitroglycerin to a client with hospitalized client with coronary artery disease who is being discharged. The nurse tells the client that nitroglycerin has which of the following actions? Choose all that apply.
-Reduces myocardial oxygen consumption -Dilates blood vessels -Decreases ischemia -Relieves pain Side effects of nitroglycerin include: - throbbing headache - flushing - tachycardia - hypotension - dizziness
A patient taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the patient no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the physician ordering? Isosorbide dinitrate (Dilatrate) Metoprolol (Lopressor) Valsartan (Diovan) Furosemide (Lasix)
Valsartan (Diovan) If the patient cannot continue taking an ACE inhibitor because of the cough, an elevated creatinine level, or hyperkalemia, an ARB or a combination of hydralazine and isosorbide dinitrate is prescribed (Table 29-3 p 824)
A patient has been experiencing increasing SOB and fatigue. The health care provider has prescribed a diagnostic test in order to determine what type of heart failure the patient is having. What diagnostic test does the nurse anticipate preparing the patient for? chest x-ray echocardiogram electrocardiogram ventriculogram
echocardiogram
A nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: tracheal coarse crackles fine crackles friction rubs
fine crackles (not coarse crackles) Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Coarse crackles are typically caused by secretion accumulation in the airways.
What lifestyle factors will the nurse discuss with the client who has a blood pressure of 130/88? Select all that apply.
physical activity alcohol moderation weight reduction the DASH diet dietary sodium This blood pressure classifies as stage 1 hypertension. Lifestyle modifications to prevent and manage hypertension include weight reduction, adoption of the DASH diet, reduction of dietary sodium, physical activity, and moderation of alcohol consumption.
A nurse is caring for a client with heart failure. The nurse knows that the client has LSHF when the client makes which statement?
"I sleep on three pillows each night." Orthopnea is a classic sign of LSHF. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of RSHF.
A 55-year-old man newly diagnosed with hypertension returns to his physician's office for a routine follow-up appointment after several months of treatment with Lopressor (metoprolol). During the nurse's initial assessment the patient's blood pressure (BP) is recorded as 180/90 mm Hg. The patient states he does not take his medication as prescribed. The best response by the nurse is which of the following?
"The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?" The nurse needs to understand why the patient is not taking his medication. Lopressor is a beta-blocker. All patients should be informed that beta-blockers might cause sexual dysfunction and that other medications are available if problems with sexual function occur.
The nurse is caring for a client with heart failure. What are the management goals for the client with heart failure? Select all that apply.
- Promoting a healthy lifestyle. - Increasing cardiac output by strengthening muscle contractions. - Lowering the risk for hospitalization. The management of a client with heart failure includes promotion of a healthy lifestyle, increasing cardiac output by strengthening muscle contractions, and lowering the risk for hospitalization. The goal in treating heart failure is to decrease preload and afterload, both of which increase stress on the ventricular wall, causing an increase in the workload of the heart. There is no need to reduce circulating blood volume for clients with heart failure. (I included this)
A client is admitted to the emergency room with a blood pressure reading of 200/130 mm Hg. What are this client's therapeutic goals? Select all that apply.
- Reduction of mean BP by 25% within the first hour. - Achievement of 160/100 within 2-6 hours. - Target goal pressure over a period of days. The therapeutic goals are reduction of the mean BP by up to 25% within the first hour of treatment, a further reduction to a goal pressure of about 160/100 mm Hg over a period of 2 to 6 hours, and then a more gradual reduction in pressure to the target goal over a few days.
The nurse providing care for a client post PTCA knows to monitor the client closely. For what complications should the nurse monitor the client? Select all that apply.
-Abrupt closure of the coronary artery -Bleeding at the insertion site -Retroperitoneal bleeding -Arterial occlusion Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute kidney injury. Venous insufficiency is not a postprocedure complication of a PTCA.
Therapeutic range of digoxin digitalis
2.0 mg/ml
Best way to determine ventilation & oxygenation status in LSHF? pulse oximetry breath sounds end-tidal CO2 Arterial blood gases
ABG
A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result? A) Acute pulmonary edema B) Right-sided HF C) Right ventricular hypertrophy D) Left-sided HF
Acute pulmonary edema With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.
A nurse is preparing a presentation for a local community group about risk factors for coronary heart disease. Which of the following would the nurse include as a nonmodifiable risk factor? Select all that apply.
African-American ethnicity Gender Explanation: Nonmodifiable risk factors include family history of heart disease, gender, increased age, and African-American ethnicity. Cigarette smoking, physical inactivity, and diabetes are modifiable risk factors.
The nurse is assigned to care for a patient with heart failure. What classification of medication does the nurse anticipate administering that will improve symptoms as well as increase survival?
Angiotensin converting enzyme inhibitor (ACE)
When starting a client on oral or I.V. diltiazem, for which potential complication should the nurse monitor? diltiazem (CCB)
Atrioventricular block The chief complications of diltiazem are hypotension atrioventricular blocks heart failure elevated liver enzyme levels Other reported reactions include flushing, nocturia, and polyuria, but not renal failure. Although flushing may occur, it's an adverse reaction, not a potential complication.
A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours +1 - depression barely detectable - foot/leg: normal +2 - depression less than 5 mm - foot/leg: normal +3 - depression deeper 5-10 mm - foot/leg: swollen +4 - depression even deeper (over 1 cm) - foot/leg: severely swollen
The nurse is caring for a client with systolic heart failure whose previous adverse reactions rule out the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs?
Combination of hydralazine and isosorbide dinitrate A combination of hydralazine and isosorbide dinitrate may be an alternative for clients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.
A patient with hypertension is waking up several times a night to urinate. The nurse knows that what laboratory studies may indicate pathologic changes in the kidneys due to the hypertension? (Select all that apply) A. creatinine B. blood urea nitrogen (BUN) C. complete blood count (CBC) D. urine for culture and sensitivity E. AST and ALT
Creatinine Blood urea nitrogen (BUN) Pathologic changes in the kidneys (indicated by increased BUN and serum creatinine levels) may manifest as nocturia (getting up during the night to urinate).
The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. The nurse offers which explanation?
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.
A nurse is teaching about risk factors that increase the probability of heart disease to a community group. Which risk factors will the nurse include in the discussion? Select all that apply.
Family history of coronary heart disease Age greater than 45 years for men African-American descent Elevated C-reactive protein Risk factors for coronary heart disease (CHD) include: - family history of CHD - men 45+ years - women 65+ years - African-American race - BMI of 25+ - elevated C-reactive protein
A client informs the nurse, "I can't adhere to the dietary sodium decrease that is required for the treatment of my hypertension." What can the nurse educate the client about regarding this statement?
It takes 2 to 3 months for the taste buds to adapt to changes in salt intake. The diet changes usually consists of restricting sodium and fat intake, increasing fruits and vegetables, and implementing regular physical activity. Explaining that it takes 2-3 months for the taste buds to adapt may help the client adjust to reduced salt intake.
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do?
Recommend he get his BP rechecked within 2 weeks. The nurse should recommend the client have BP rechecked within 2 weeks because 150/90 isn't normal.
A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply a) Reduces myocardial oxygen consumption b) Decreases the urge to use tobacco c) Dilates blood vessels d) Decreases ischemia e) Relieves pain
Reduces myocardial oxygen consumption Dilates blood vessels Decreases ischemia Relieves pain Nitroglycerin dilates blood vessels and reduces the amount of blood returning to the heart, which reduces the workload of the heart and myocardial oxygen consumption. As the dilated vessels allow more blood supply to the heart, ischemia and pain are reduced. Nitroglycerin does not affect the urge to use tobacco.
The triage nurse in the Emergency Department (ED) is admitting a client with a history of Class III heart failure. What symptoms would the nurse expect the client to exhibit?
The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. Class III (Moderate): There is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea.
Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply. a) Embolization b) Bleeding c) Dissection of the vessel d) Hematoma e) Stent migration
• Hematoma • Embolization • Dissection of the vessel • Bleeding • Stent migration Explanation: Complications from PTA include hematoma, embolization, dissection of the vessel, bleeding, intimal damage (dissection), and stent migration. Page 859
A nurse providing education about hypertension to a community group is reviewing consequences of the disease. Which of the following would the nurse identify as target organs for hypertensive damage? Choose all that apply. a) Stomach b) Kidneys c) Brain d) Eyes e) Heart
Kidneys Brain Eyes Heart
The client ask the nurse to explain the difference between arteriosclerosis and atherosclerosis. Which is the best explanation provided by the nurse?
"Arteriosclerosis is a condition that produces structural changes in the arteries, and atherosclerosis is a type of arteriosclerosis. Arteriosclerosis is a complex condition that produces structural changes to the arteries usually associated with loss of elasticity. Atherosclerosis is a specific type and most common cause of arteriosclerosis. Both disorders affect the ability of the vessels to deliver blood and are considered occlusive disorders, but the causes differ.
Your client is being prepared for echocardiography when he asks you why he needs to have this test. What would be your best response?
"Electrocardiography is a way of determining the functioning of the left ventricle of your heart."
The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment questions, asked by the nurse, are appropriate? Select all that apply. A) "Have you recently drunk a caffeinated beverage?" B) "Did you have a beer after work?" C) "Do you smoke?" D) "Do you have a friend accompanying you?" E) "Are you married and with children?"
"Have you recently drunk a caffeinated beverage?" "Do you smoke?" The nurse would assess for common factors for BP to be elevated. Factors that can affect BP include smoking or drinking coffee within 30 minutes of the reading. One beer after work should not affect the blood pressure reading. The client would be referred for another BP reading and, if elevated, referred to a physician.
The nurse has completed a teaching session on self-administration of sublingual nitroglycerin. Which client statement indicates that the teaching has been effective?
"I can take nitroglycerin before sex so I won't develop chest pain". Nitroglycerin can be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (i.e., before exercise, stair-climbing, or intercourse), it is best taken before pain develops.
The nurse is admitting a pt. with HF. What pt. statement indicates that fluid overload was occurring at home? A- "I eat six small meals a day when I am hungry" B- "My food has tasted bland w/o salt" C- "I cut back on going up the steps during the day" D- "My best time of the day is the morning"
"I cut back on going up the steps during the day" Cutting back on activity like climbing stairs is an indication of a lessened ability to exercise.
A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. For a client without diabetes mellitus, the target blood pressure is 140/90 or lower. Because this client has diabetes mellitus, the target blood pressure will be which of the following? 145/95 or lower 150/95 or lower 130/80 or lower 125/85 or lower
130/80 or lower
When monitoring a patient who has HYPERTENSION & CHRONIC KIDNEY DISEASE, the target pressure for this individual should be less than which blood pressure reading? a) 120/70 mm Hg b) 110/60 mm Hg c) 130/80 mm Hg d) 140/90 mm Hg
140/90 (the goal is actually 130/80, but this says LESS THAN) For clients with diabetes or chronic kidney disease, the target pressure is LESS THAN 140/90
A nurse educator is providing information to a small group of clients about hypertension. A participant asks what her target BP should be. The nurse is aware of the target goals of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). Which of the following reflects the goal BP for people without co-morbidities?
140/90 or lower The goal of hypertension treatment is to prevent complications and death by achieving and maintaining the arterial blood pressure at 140/90 or lower. The JNC7 specifies a lower goal pressure of 130/80 for people with diabetes or chronic kidney disease.
Heparin therapy is usually considered therapeutic when the client's activated partial thromboplastin time (aPTT) is how many times normal? A. .25 to .75 B. .75 to 1.5 C. 2.0 to 2.5 D. 2.5 to 3.0
2.0 to 2.5 2.0 to 2.5 = therapeutic 2.5 to 3 = too high .25 to .75 = too low .75 to 1.5 = too low
A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient? A) He will remain on bed rest for 48 to 72 hours after the procedure. B) He will be given vitamin K infusions to prevent bleeding following PCI. C) A sheath will be placed over the insertion site after the procedure is finished. D) The procedure will likely be repeated in 6 to 8 weeks to ensure success.
A sheath will be placed over the insertion site after the procedure is finished. Feedback: A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Patients resume activity a few hours after PCI and repeated treatments may or may not be necessary Anticoagulants, not vitamin K, are administered during PCI.
The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess the patient for signs and symptoms of which other health problem? A) Migraines B) Atrial-septal defect C) Atherosclerosis D) Thrombocytopenia
Atherosclerosis Feedback: Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines.
A nurse is educating a client about monitoring blood pressure readings at home. Which of the following will the nurse be sure to emphasize? -"Avoid smoking cigarettes for 8 hours prior to taking blood pressure." -"Sit quietly for 5 minutes prior to taking blood pressure." -"Sit with legs crossed when taking your blood pressure." -"Be sure the forearm is well supported above heart level while taking blood pressure."
Avoid talking during the measurement. both feet on the ground Rest quietly for at least 5 minutes before Support forearm at heart level during measurement Instructions for measuring BP at home include: (1) Avoid nicotine or caffeine for 30 minutes before measuring blood pressure. (2) Sit quietly for 5 minutes before the measurement. (3) Have the forearm supported at heart level (4) Have both feet on the ground during the measurement of the blood pressure.
A patient is seen in the ED with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?
B-type natriuretic peptide (BNP) Severity of HF: BNP Type of HF: echocardiogram Cause of HF: stress test and/or cardiac cath
A community health nurse teaching a group of adults about preventing and treating hypertension. The nurse should encourage these participants to collaborate with their primary care providers and regularly monitor which of the following? A) Heart rate B) Sodium levels C) Potassium levels D) Blood lipid levels
Blood lipid levels Hypertension often accompanies other risk factors for atherosclerotic heart disease, such as dyslipidemia (abnormal blood fat levels), obesity, diabetes, metabolic syndrome, and a sedentary lifestyle. Individuals with hypertension need to monitor their sodium intake, but hypernatremia is not a risk factor for hypertension. In many patients, heart rate and potassium levels do not correlate closely with BP.
While reviewing the assessment data of a male client, a nurse suspects that the client may have metabolic syndrome based on which of the following? Select all that apply.
Blood pressure of 160/92 mm Hg Fasting blood glucose level of 130 mg/dL Waist circumference of 48 inches Explanation: Metabolic syndrome: triglyceride levels over 150 mg/dL, blood pressure over 130/85 mm Hg, fasting blood glucose level over 110 mg/dL, HDL level less than 50 mg/dL, and a waist circumference over 40 inches.
Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles? A. Cardiac tamponade B. Hypothermia C. Hypertension D. Fluid overload
Cardiac tamponade Cardiac tamponade is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing the blood from filling the ventricles. Fluid overload is exhibited by high pulmonary artery wedge pressure, central venous pressure, and pulmonary artery diastolic pressure, as well as crackles in the lungs. Hypertension results from postoperative vasoconstriction. Hypothermia is a low body temperature that leads to vasoconstriction.
A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?
Class I (Mild) _______________ Class I (Mild): - no limitation of activity - no discomfort Class II (Mild) - discomfort with increased activity - comfortable at rest Class III (Moderate) - marked limitation of activity - discomfort with below ordinary activity - comfortable at rest Class IV (Severe): - discomfort increases during any/all activity - discomfort/insufficiency at rest
The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply.
Confusion Bradycardia A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia.
A patient with a diagnosis of HF is started on a beta-blocker. What is the nurses priority role during gradual increases in the patients dose? A) Educating the patient that symptom relief may not occur for several weeks B) Stressing that symptom relief may take up to 4 months to occur C) Making adjustments to each days dose based on the blood pressure trends D) Educating the patient about the potential changes in LOC that may result from the drug
Educating the patient that symptom relief may not occur for several weeks An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. (p 823) Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.
Understanding atherosclerosis, the nurse identifies which of the following to be both a risk factor for the development of the disorder and an outcome? A. Obesity B. Hypertension C. Hyperlipidemia D. Glucose intolerance (This question can be reversed... hypertension and atherosclerosis) Rationale is the same
Hypertension Increases in diastolic and systolic blood pressure are associated with an increased incidence of atherosclerosis, often an inherited factor. Elevation of blood pressure results when the vessels cannot relax and impairs the ability of the artery to dilate. Hyperlipidemia, diabetes, and obesity are all risk factors for atherosclerosis but do not result from the disorder.
The treatment for heart failure is directed toward all of the following except:
Increasing preload and afterload. Increasing cardiac output by strengthening muscle contraction or decreasing peripheral resistance. Decreasing the oxygen needs of the heart. Reducing the amount of circulating blood volume. Increasing preload and afterload.
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchange related to increased blood flow B. Ineffective peripheral tissue perfusion related to venous congestion C. Risk for injury related to edema D. Excess fluid volume related to peripheral vascular disease
Ineffective peripheral tissue perfusion related to venous congestion Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT.
The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all that apply.
Let the tablet dissolve in the mouth and keep the tongue still. tablet can be crushed between the teeth but not swallowed; Renew the supply every 6 months Take the tablet in anticipation of activity that can produce pain Call emergency services if, after taking three tablets (one every 5 minutes), pain persists. Nitroglycerine is very unstable and should be carried securely in its original container (capped, dark, glass bottle). The tablets should never be removed and stored in metal or plastic pillboxes. Nitroglycerine is also volatile and is inactivated by heat, moisture, air, light, and time. Therefore, storage and replacement is recommended every 6 months. (p. 403, Box 14-3).
A client has just received a diagnosis of hypertension after the completion of diagnostics. What can the client do to decrease the consequences of hypertension? Select all that apply. a) Use smokeless tobacco. b) Lose weight. c) Manage stress effectively. d) Get plenty of rest.
Lose weight Manage stress effectively
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?
Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing an increased heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone and antidiuretic hormone, causing sodium and water retention and arterial vasoconstriction.
The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? A) Monitor her blood pressure daily B) Assess her radial pulses daily C) Monitor her weight daily D) Monitor her bowel movements
Monitor her weight daily Feedback: To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.
The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common among patients who are being treated for this health problem? A) Deficient knowledge regarding the lifestyle modifications for management of hypertension B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy C) Deficient knowledge regarding BP monitoring D) Noncompliance with treatment regimen related to medication costs
Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. For many patients, this is related to adverse effects of medications. Medication cost is relevant for many patients, but adverse effects are thought to be a more significant barrier.
While receiving a heparin infusion to treat deep vein thrombosis, a client reports bleeding in the gums when brushing teeth. What should the nurse do first?
Notify the health care provider. Because heparin can cause bleeding gums that may indicate excessive anticoagulation, the nurse should notify the health care provider, who will evaluate the client's condition. The health care provider should order laboratory tests such as partial thromboplastin time before concluding that the client's bleeding is significant. The ordered heparin dose may be therapeutic rather than excessive, so the nurse shouldn't discontinue the heparin infusion unless the health care provider orders this after evaluating the client. Protamine sulfate is given to counteract heparin.
The nurse is reviewing the medical record of a patient who returns to the clinic for a follow-up visit. On several previous visits, the patient's blood pressure readings were as follows: 124/80 mm Hg; 132/86 mm Hg; 130/88 mm Hg. The patient's blood pressure today is 128/82 mm Hg. The nurse would identify the patient as belonging to which blood pressure category?
Prehypertension Explanation: The patient's blood pressure readings fall within the prehypertension category, with a systolic blood pressure between 120 to 139 mm Hg and a diastolic blood pressure between 80 to 89 mm Hg. High BP stage 1 readings fall between 140 to 159 mm Hg for systolic pressure and 90 to 99 mm Hg for diastolic pressure. High BP stage 2 readings fall at systolic 160 mm Hg or higher and diastolic 100 mm Hg or higher. Hypertensive crisis is characterized by readings above 180 mm Hg systolic or 110 mm Hg diastolic.
The nurses comprehensive assessment of a patient who has HF includes evaluation of the patients hepatojugular reflux. What action should the nurse perform during this assessment? A) Elevate the patients head to 90 degrees. B) Press the right upper abdomen. C) Press above the patients symphysis pubis. D) Lay the patient flat in bed.
Press the right upper abdomen. Hepatojugular reflux, a sign of RSHF, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. (p 826)
The nurse is providing education about the nutrient content of the Therapeutic Lifestyle Changes (TLC) diet to a community group. What information will the nurse provide? Select all that apply.
Protein should be approximately 15% of total calories. Carbohydrates should be 50%-60% of total calories. Dietary fiber should be 20-30 grams per day. According to the nutrient content of the TLC diet, cholesterol should make up less than 200 mg/day, carbohydrates should make up 50% to 60% of the total calories, dietary fiber should be 20 to 30 grams per day, protein should make approximately 15% of the total calories, and fat should make up 25% to 30% of the total calories.
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? Extend survival. Improve functional status Limit physical activity. Relieve patient symptoms. Prevent endocarditis.
Relieve patient symptoms. Extend survival. Improve functional status The overall goals of management of heart failure are to relieve the patient's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of heart failure and preventing it is not a major goal of care.
Which of the following findings indicates that hypertension is progressing to target organ damage? a) Blood urea nitrogen (BUN) level of 12 mg/dL b) Chest x-ray showing pneumonia c) Retinal blood vessel damage d) Urine output of 60 cc/mL over 2 hours
Retinal blood vessel damage
A diastolic blood pressure of 92 mm Hg is classified as
Stage 2 hypertension The November 2017 guidelines released by the American College of Cardiology and the AHA are: Normal blood pressure: - Systolic under 120 - Diastolic under 80 Elevated blood pressure: - Systolic between 120 - 129 - Diastolic under 80 Stage 1 HTN: - Systolic between 130 - 139 - Diastolic between 80 - 89 Stage 2 HTN: - Systolic 140 + - Diastolic 90 +
The client asks the nurse why a stress test is needed. What statement best explains the rationale for the health care provider to order a cardiac stress test?
The health care provider wants to identify if the heart failure is from coronary artery disease. Cardiac stress testing or cardiac catheterization determines whether CAD and cardiac ischemia are causing the heart failure. (p. 823) Explaining that heart failure is causing weakness and fatigue does not answer the need for the stress test. It does not diagnose the client's stage of heart failure.
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
There is excess fluid volume in the interstitial space in areas affected by gravity. Dependent pitting edema (excess fluid in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area.
The nurse is assessing a postoperative patient who has a PTCA. Which possible complication should the nurse monitor for? (Select all that apply) A. abrupt closure of the artery B. arterial dissection C. coronary artery vasospasm D. aortic dissection E. nerve root pressure
abrupt closure of the artery arterial dissection coronary artery vasospasm Complications DURING PTCA include: - acute myocardial infarction - serious dysrhythmias (e.g., ventricular tachycardia) - cardiac arrest - coronary artery events - dissection - perforation - abrupt closure - vasospasm Complications AFTER PTCA may include: - abrupt closure of the coronary artery - bleeding at the insertion site - retroperitoneal bleeding - hematoma - arterial occlusion
When assessing a client with LSHF the nurse expects to note:
air hunger With LSHF, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of RSHF.
An client who has been diagnosed with arteriosclerosis is confused by what this means. The nurse explains that arteriosclerosis is:
an expected part of the aging process Arteriosclerosis is loss of elasticity or hardening of the arteries that accompanies the aging process. Arteriosclerosis is a contributing factor to vascular occlusive disease. Arteriosclerosis does not involve scar tissue formation. Hyperlipidemia, or high levels of blood fat, triggers atherosclerotic changes.
The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which of the following measures should the nurse complete to prevent deep venous thrombosis (DVT) and possible pulmonary embolism (PE) development? Select all that apply. A. avoid elevating the knees on the bed B. apply anti embolism stockings C. initiate passive exercises D. encourage the crossing of legs E. place pillows in the popliteal space
avoid elevating the knees on the bed apply anti embolism stockings initiate passive exercises Preventive measures for venous stasis include: - sequential pneumatic compression devices - discouraging crossing of legs - avoiding elevating the knees on the bed - omitting pillows in the popliteal space - passive exercises followed by active exercises
The nurse assesses a client's blood pressure reading of 150/90 mm Hg along with several abnormal laboratory results. What data supports the medical diagnosis of metabolic syndrome? Select all that apply.
blood pressure reading greater than 140/90 mm Hg insulin resistance abdominal obesity dyslipidemia A blood pressure reading greater than 140/90 mm Hg, dyslipidemia and/or abdominal obesity, and insulin resistance are classic signs of metabolic syndrome. Pathologic changes in the kidneys, indicated by increased blood urea nitrogen and serum creatinine levels, are not part of the metabolic syndrome that is a risk factor for hypertension. However, with advanced cardiovascular disease, these signs may occur.
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?
chest x-ray
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
forcing blood into the deep venous system. Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Elevating the extremity decreases edema but doesn't prevent DVT.
Before adminstering hydralazine & isosorbide dinitrate, BP reads 90/60. What is the nursing priority? Isosorbide dinitrate (nitrate) Hydralazine (vasodilator) - combination medicine used to treat heart failure. - dilate/widens vessels, facilitating pump & flow (esp in blacks) - NO low BP
hold the med and call the provider
A client's elevated cholesterol levels are being managed with atorvastatin daily. What is a common side effect the nurse will teach the client that will require monitoring? A. hyperglycemia B. severe muscle pain C. hyperuricemia D. increased liver enzymes
increased liver enzymes Myopathy and increased liver enzymes are significant side effects of the statin Lipitor. Severe muscle pain is an adverse effect of statins, but it does not require monitoring. Hyperuricemia occurs when too much uric acid is present in the blood; it is not a side effect of the statins. Hyperglycemia is increased blood glucose, which is not a side effect of the statins.
A nurse completed a client physical examination for an insurance company. The nurse determined the client has increased blood pressure, increased blood glucose, levels and obesity. What condition for coronary artery disease does the nurse consider next?
metabolic syndrome Metabolic syndrome includes 3 of 6 conditions that are recognized as major risk factors for CAD. Insulin resistance is part of the syndrome, but the patient may not yet have diabetes. Risk Factors are: - central obesity - C-reactive protein elevated (proinflammation) - dyslipidemia - fibrinogen elevated (prothrombotic) - insulin resistance - hypertension (130/85)
The nurse understands that an overall goal of hypertension management is that
there is no indication of target organ damage Prolonged BP elevation gradually damages blood vessels throughout the body, particularly in target organs such as the heart, kidneys, brain, and eyes. The overall goal of management is that the client does not experience target organ damage.
A client who is resting quietly reports chest pain to the nurse. The cardiac monitor indicates the presence of reversible ST-segment elevation. What type of angina is the client experiencing? A. silent angina B. stable angina C. intractable angina D. variant angina
variant angina Angina Types: Variant/Prinzmetal's angina = pain during rest. Stable angina = pain during activity. Silent angina = no symptoms/pain Intractable angina = incapacitating pain. Unstable angina = unpredictable / unrelenting
