PN Exam

What links make up the adult Chain of Survival in emergency cardiovascular care?

- Immediate recognition of cardiac arrest and activation of the emergency response system - Early cardiopulmonary resuscitation with an emphasis on chest compressions - Rapid defibrillation - Effective advanced life support - Integrated post-cardiac arrest care

A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse determines the following: a temperature of 103° F (39.4° C), body chills, and leukocytosis. The client begins to have difficulty breathing. In what order should the nurse perform the following actions? 1) Open the airway. 2) Call the physician. 3) Start an I.V. access site. 4) Explain the situation to the family.

1. Open the airway 2. Start an IV access site 3. Call physician 4. Explain situation to the family An open airway is essential to survival. The nurse should first ensure an open airway. Next, the nurse should start an I.V. and then notify the physician. Finally, the nurse should inform the family of the situation and, if appropriate, allow them to remain with the client.

A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that do not precede a beat. What intervention would have the highest priority? a) Assess the client's cardiac output. b) Call the primary healthcare provider c) Apply a magnet over the pacemaker. d) Call a code.

A. Assess CO. Extra pacemaker spikes that do not precede a beat may indicate failure to capture, in which the pacemaker fires, but the heart does not conduct the beat. The priority nursing intervention would be to assess the client to see if the client is tolerating the failure to capture or if the client has a decrease in cardiac output. Until the nurse knows how the client is tolerating this, it will not be useful to call the primary healthcare provider or call a code. Assessment is the first step in the nursing process, and the nurse should assess the client, not just the rhythm strip. Applying a magnet is not an appropriate action of failure to capture, but for loss of pacing.

In palpating the patient's pedal pulses, the nurse determines the pulses are absent. What factor could contribute to this result? A. Atherosclerosis B. Hyperthyroidism C. Arteriovenous fistula D. Cardiac dysrhythmias

A. Atherosclerosis Atherosclerosis can cause an absent peripheral pulse. The feet would also be cool and may be discolored. Hyperthyroidism causes a bounding pulse. Arteriovenous fistula gives a thrill or vibration to the vessel, although this would not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which of the following? a) A full breakfast as desired without coffee, tea, or energy drinks. b) Only coffee or tea if needed. c) No food or fluids. d) A liquid breakfast of fruit juice, oatmeal or smoothie.

A. Beverages containing caffeine, such as coffee, tea, cola drinks, and energy drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be NPO.

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively? a) Elevating the hand and wrapping it in a warm towel b) Placing an ice pack on the hand c) Wrapping the arm in an elastic bandage from wrist to elbow d) Administering an as-needed analgesic

A. Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.

A 64-year-old patient with a history of myocardial infarction is scheduled for a transesophageal echocardiogram to visualize a suspected clot in the left atrium. What information should the nurse include when teaching the patient about this diagnostic study? A. IV sedation may be administered to help the patient relax. B. Food and fluids are restricted for 2 hours before the procedure. C. Ambulation is restricted for up to 6 hours before the procedure. D. Contrast medium is injected into the esophagus to enhance images

A. IV sedation may be administered to help pt relax IV sedation is administered to help the patient relax and ease the insertion of the tube into the esophagus. Food and fluids are restricted for at least 6 hours before the procedure. Smoking and exercise are restricted for 3 hours before exercise or stress testing, but not before TEE. Contrast medium is administered IV to evaluate the direction of blood flow if a septal defect is suspected.

Which of the following nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Assisting the patient to ambulate to the bathroom to void d. Informing the patient that he will be sleeping from the general anesthesia e. Instructing the patient about the risks of the radioactive isotope injection

A. Monitor VS and ECG B. Check catheter insertion site and distal pulses The nursing responsibilities after cardiac catheterization include assessment of the puncture site for hematoma and bleeding; assessment of circulation to the extremity used for catheter insertion and of peripheral pulses, color, and sensation of the extremity; and monitoring vital signs and electrocardiographic rhythm.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should: a) withhold food and fluids. b) introduce a nasogastric (NG) tube. c) insert an oral airway. d) position the client on his side.

A. Withhold food and fluids Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.

What adverse effects should the nurse monitor with patients receiving IV nitroglycerin?

Adverse effects associated with nitroglycerin infusions include hypotension, tachycardia, flushing, and headache

According to the 2010 AHA Guidelines for CPR and ECC, the BLS sequence of steps is now a) B-C-A (Breathing, Chest compressions, Airway) b) C-A-B (Chest compressions, Airway, Breathing) c) A-B-C (Airway, Breathing, Chest Compressions)

Answer = B; C-A-B (Chest compressions, Airway, Breathing)

Why is aspirin given to a patient experiencing angina?

Aspirin is used as an antithrombotic agent to prevent platelet aggregation around thrombi and atherosclerotic lesions

A client is in hypovolemic shock. The nurse should position the client: a) Supine. b) Supine with the legs elevated 15 degrees. c) Semi-Fowler's. d) Trendelenburg's.

B - A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation. The supine position does not promote venous return. Semi-Fowler's position would not facilitate venous return. Trendelenburg's position was formerly recommended but has been found to inhibit respiratory expansion and possibly to cause increased intracranial pressure.

A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priority action? a) Obtain an order for furosemide 80 mg IV push. b) Obtain an order for calcium gluconate 2 g IV push over 2-5 minutes. c) Increase the rate of the client's IV fluid to 150 ml/hour. d) Arrange for an emergency hemodialysis session.

B - All the actions listed will reduce the serum magnesium concentration. The calcium gluconate will react the quickest to reduce the critical level.

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to safely remove the femoral sheath when the partial thromboplastin time (PTT) is: a) 100 seconds or less. b) 50 seconds or less. c) 125 seconds or less. d) 75 seconds or less.

B. 50 secs or less Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 50 seconds or less before the sheath is removed. Removing the sheath before the PTT drops below 50 seconds can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? a) Blood urea nitrogen (BUN) level of [29 mg/dl (10.4 mmol/L)] b) Serum potassium level of [3 mEq/L (3.0 mmol/L)] c) Urine specific gravity of 1.025 d) Serum sodium level of [132 mEq/L 132 mmol/L)]

B. A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal.

A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client? a) The client verbalized the importance of increasing fluid intake. b) The client's intake and output are balanced. c) The client's skin remains dry and intact throughout the hospital stay. d) The client performs oral hygiene every 4 hours.

B. I&O are balanced During the planning step of the nursing process, the nurse identifies expected client outcomes, establishes priorities, and develops the care plan. This outcome provides measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements do not resolve the problem of fluid volume deficiency

A nurse is preparing to teach a group of women in a community volunteer group about heart disease. What should the nurse include in the teaching plan? A. Women are less likely to delay seeking treatment than men. B. Women are more likely to have noncardiac symptoms of heart disease. C. Women are often less ill when presenting for treatment of heart disease. D. Women experience more symptoms of heart disease at a younger age than men.

B. Women are more likely to have noncardiac sx of heart disease Women often have atypical angina symptoms and nonpain symptoms. Women experience the onset of heart disease about 10 years later than men. Women are often more ill on presentation and delay longer in seeking care than men.

The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first: a) Administer atropine 0.5 mg IV push. b) Prepare for transcutaneous pacing. c) Take the client's blood pressure. d) Auscultate for abnormal heart sounds.

C. Take the client's BP. 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.

The 5 links in the AHA adult Chain of Survival are recognition and activation, early CPR, rapid defibrillation, a) relief of choking, and integrated post-cardiac arrest care b) effective advanced life support, and relief of choking c) rapid transportation to a healthcare facility, and integrated post-cardiac arrest care d) effective advanced life support, and integrated post-cardiac care

D

When monitoring a client recently admitted for treatment of cocaine addiction, a nurse notes sudden increases in the arterial blood pressure and heart rate. Which medication should the nurse prepare to administer? a) Norepinephrine b) Lidocaine c) Nitroglycerin d) Nifedipine

D -

A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of highest concern for the nurse initiating the nitroglycerin drip? a) Serum potassium is 3.5 mEq/L (3.5 mmol/l). b) Heart rate is 61. c) ST elevation is present on the electrocardiogram. d) Blood pressure is 88/46.

D - Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process? a) Collaborating with the client to set exercise goals b) Formulating nursing diagnoses c) Planning to monitor the client's vital signs every shift. d) Providing education about documenting blood pressure readings

D. Providing education Implementation involves providing actual nursing care. Education is an intervention that occurs during the implementation phase. Goal setting and formulation of nursing diagnosis do not occur during the implementation phase of the nursing process.

A patient receives a permanent pacemaker. Which safety precaution is correct? a) avoid vigorous arm and shoulder movement b) stay away from microwave ovens c) avoid going through airport metal detectors d) avoid MRI

D. Pt w/ a pacemaker should avoid undergoing MRI b/c the magnet could disrupt pacemaker function and cause injury. Disruption does not occur w/ microwave ovens. Pt must avoid vigorous arm & shoulder movement only for the 1st 6wks after pacemaker implantation. Airport metal detectors do not harm pacemakers. Pt should pass through the metal detector w/o stopping. The magnet could trigger the metal detector.

Why is a firm surface important for CPR?

If a firm surface is under the victim, the force you use will be more likely to compress the chest and create blood flow rather than simply push the victim into the mattress or other soft surface.

What do you do if you do not definitely feel a pulse within 10 seconds at the beginning of BLS?

If you do not definitely feel a pulse, begin CPR, starting with compressions (C-A-B sequence)

What causes left-sided heart failure?

Left ventricular dysfunction, which prevents normal blood flow and causes blood to back up into the left atrium and into the pulmonary veins

Which nursing intervention is most important in preventing septic shock? a) Administering I.V. fluid replacement therapy as ordered. b) Maintaining asepsis of indwelling urinary catheters. c) Monitoring red blood cell counts for elevation. d) Obtaining vital signs every 4 hours for all clients.

Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering I.V. fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

Found in cardiac and skeletal muscles, and it is used as an indicator in early myocardial injury.

Myoglobin

How do nitroglycerin infusions differ from other IV infusions?

Nitroglycerin infusions are typically titrated based on the patient's pain and other hemodynamic indicators such as BP and HR. Also, nitroglycerin must be administered via specialized IV tubing and should always be delivered via infusion pump.

Why is Nitroglycerin given to patients having chest pain?

Nitroglycerin is a drug that dilates both arteries and veins. This may result in some dilation of the coronary arteries, which will allow more blood to reach the oxygen-deprived myocardial tissue. Additionally, nitroglycerin causes venous dilation which decreases cardiac afterload and the O2 demand of the myocardium.

When should thrombolytic therapy be started for it to be effective in a patient with MI?

Patient experiencing MI must arrive at hospital within 20 mins to 12 hours for thrombolytic therapy to be effective

What is the role of lidocaine after STEMI? a) prevention of VT/VF b) prevention of PVCs c) not recommended d) recurrent ischemic pain

Prophylactic lidocaine to prevent VT/VF in the acute MI client is NOT recommended. Recommended prophylactic measures include early administration of an IV beta blocker and treatment hypokalemia and hypomagnesemia.

Which medication should the nurse anticipate administering in the event of a heparin overdose?

Protamine sulfate, a heparin antagonist. It is administered intravenously very slowly (over at least 10 minutes).

When should compressions be started after recognition of cardiac arrest?

Start compressions within 10 seconds of recognition of cardiac arrest

The 2010 AHA Guidelines for CPR and ECC removed the step of "look, listen, and feel" from the BLS sequence. A. True B. False

TRUE, rescuers should check the victim for response and breathing simultaneously.

What is the minimum that chest compressions can be delayed during BLS?

The delay in breaths should be minimal, only the time required to deliver the first cycle of 30 chest compressions, or approx. 18 secs or less

How long do you have to determine the presence or absence of a pulse when beginning BLS?

You may take up to 10 seconds to attempt to feel for a pulse. If within 10 secs you don't feel a pulse or are not sure if you feel a pulse, begin chest compressions.

What does a pulse deficit indicate?

cardiac dysrhythmias

Alternative for patients who cannot use aspirin

clopidogrel (Plavix)

Trendelenburg position

head is low and body & legs are elevated

Complication of an MI that occurs when the pumping power of the heart has diminished

heart failure

The most common form of heart failure

left-sided heart failure

Characterized by chest pain, which may vary from mild to severe, and is aggravated by inspiration, coughing, and movement of the upper body

pericarditis

A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. A) Urine output. B) Postoperative pain. C) Incision site. D) Peripheral pulses.

pulses, incision site, urine output, pain. Because assessment of the presence and quality of the pedal pulses in the affected extremity is essential after surgery to make sure that the bypass graft is functioning, this step should be done first. The nurse should next ensure that the dressing is intact, and then that the client has adequate urine output. Lastly, the nurse should determine the client's level of pain.

Results when the infarcted myocardial wall is thin and bulges out during contraction

ventricular aneurysm

Alternative for patients who cannot use aspirin or clopidogrel

warfarin (Coumadin)

A client with a suspected pulmonary embolus is brought to the emergency department complaining of shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply. a) Low-grade fever b) Tachycardia c) Frothy sputum d) Thick green sputum e) Blood-tinged sputum f) Bradycardia

• Low-grade fever • Tachycardia • Blood-tinged sputum A pulmonary embolism (PE) is a blockage to one or more arteries in the lungs. In addition to pleuritic chest pain and dyspnea, a client with a pulmonary embolus may present with a low-grade fever, tachycardia, and blood-tinged sputum. Thick green sputum would indicate infection, and frothy sputum would indicate pulmonary edema. A client with a pulmonary embolus is tachycardic (to compensate for decreased oxygen supply), not bradycardic.

A nurse is caring for a client in the immediate post-cardiac catheterization period. Which interventions should the nurse include in the client's care? Select all that apply. a) Restrict the client to bed rest for 2 to 6 hours. b) Perform range-of-motion (ROM) exercises. c) Assess all peripheral pulses frequently. d) Monitor vital signs every 15 minutes for the first hour. e) Assess the insertion site.

• Monitor vital signs every 15 minutes for the first hour. • Restrict the client to bed rest for 2 to 6 hours. • Assess the insertion site. Key word is "immediate," indicating that care may be different throughout the recovery period. In the immediate period, the client's vital signs are typically monitored every 15 minutes for the first hour, then every 30 minutes for 2 hours or until vital signs are stable, and then every 4 hours or according to facility policy. All peripheral pulses do not require frequent assessment. (Always reflect on the word "all" in the selection.) The pulses in the affected extremity are usually assessed with every vital signs check. Clients typically remain in bed for 2 to 6 hours unless a special closure is used. The insertion site extremity is kept straight following the procedure, so ROM exercises would not be performed.

While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following? a) Dyspnea. b) Bradycardia. c) Pain in her calf. d) Hypertension.

A - A major complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immediate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis. Hypotension, not hypertension, would suggest a possible pulmonary embolism. It also could suggest possible hemorrhage secondary to intravenous heparin therapy. Bradycardia for the first 7 days in the postpartum period is normal.

A client is given amiodarone in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect? a) The number of premature ventricular contractions is decreasing. b) The ventricular rate is increasing. c) The fine ventricular fibrillation changes to coarse ventricular fibrillation. d) The absent pulse is now palpable.

A - Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.

When teaching the client about complications of atrial fibrillation, the nurse should instruct the client to avoid which of the following? a) Stasis of blood in the atria b) Increased cardiac output c) Decreased pulse rate d) Elevated blood pressure

A - Atrial fibrillation occurs when the sinoatrial node no longer functions as the heart's pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is associated with an increased pulse rate.

The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse? a) Immediate defibrillation b) Insertion of an IV line c) Administration of digoxin d) Scheduling a pacemaker insertion

A - When ventricular fibrillation is verified, the first intervention is defibrillation. It is the only intervention that will terminate this lethal dysrhythmia. Digoxin will not help in this situation. An IV line will need to be established, but it is not the priority. A pacemaker may be needed, but not until the client is stabilized.

When performing cardiopulmonary resuscitation (CPR), which of the following indicates that external chest compressions are effective? a) Palpable pulse. b) Pupillary dilation. c) Cool, dry skin. d) Mottling of the skin.

A - With CPR, effectiveness of external chest compressions is indicated by palpable peripheral pulses, the disappearance of mottling and cyanosis, the return of pupils to normal size, and warm, dry skin. To determine whether the victim of cardiopulmonary arrest has resumed spontaneous breathing and circulation, chest compressions must be stopped for 5 seconds at the end of the first minute and every few minutes thereafter.

When a person's blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of A) baroreceptors that inhibit the sympathetic nervous system, causing vasodilation. B) chemoreceptors that inhibit the sympathetic nervous system, causing vasodilation. C) baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation. D) chemoreceptors that stimulate the sympathetic nervous system, causing an increased heart rate.

A. Baroreceptor that inhibit the SNS, causing vasodilation Baroreceptors in the aortic arch and carotid sinus are sensitive to stretch or pressure within the arterial system. Stimulation of these receptors sends information to the vasomotor center in the brainstem. This results in temporary inhibition of the sympathetic nervous system and enhancement of the parasympathetic influence, which cause a decrease in heart rate and peripheral vasodilation.

When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently? a) Dehydration. b) Tachycardia. c) Nausea and vomiting. d) Iron-deficiency anemia.

B - Assessing for signs and symptoms associated with cardiac decompensation is the priority. Class III heart disease during pregnancy has a 25% to 50% mortality. These clients are markedly compromised, with marked limitation of physical activity. They frequently experience fatigue, palpitations, dyspnea, or anginal pain. A pulse rate greater than 100 bpm or a respiratory rate greater than 25 breaths/minute may indicate cardiac decompensation that could result in cardiac arrest. Additional symptoms include dyspnea, peripheral edema, orthopnea, tachypnea, rales, and hemoptysis.

A patient is admitted to the hospital due to a myocardial infarction. Which of the following intervention devices would increase coronary perfusion and decrease cardiac workload? a) dobutamine b) intra-aortic balloon pump c) pacemaker d) therapeutic hypothermia

B. An intra-aortic balloon pump inflates during diastole to increase perfusion to the coronary arteries and deflates during systole to decrease afterload. The timed inflation and deflation contribute to increased myocardial O2 supply while decreasing myocardial O2 demand. Pacemakers do not increase coronary perfusion OR decrease workload. Dobutamine will increase cardiac workload by increasing contractility and cardiac output. Therapeutic hypothermia will decrease O2 demands, but will not improve coronary perfusion.

A neonate is 4 hours old. Nursing assessment reveals a heart murmur. The nurse should: a) Continue routine care. b) Further assess for signs of distress. c) Feed the neonate. d) Call the primary health care provider immediately.

B. Further assess for signs of distress Further assessment for signs of distress is necessary. At 4 hours of age, a transient murmur may be heard as the fetal shunts close. This finding is normal. If no other distress is noted, the primary health care provider doesn't need to be called. The result can be noted on the chart. Further assessment is needed to know if continuing routine care and feeding are appropriate and safe for the neonate.

The rapid response team has been called to manage an unwitnessed cardiac arrest in a client's hospital room. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is: a) 1 to 2 minutes. b) 8 to 10 minutes. c) 4 to 6 minutes. d) 12 to 15 minutes.

C - After a person is without cardiopulmonary function for 4 to 6 minutes, permanent brain damage is almost certain. To prevent permanent brain damage, it is important to begin CPR promptly after a cardiopulmonary arrest.

When assessing a child after heart surgery to correct tetralogy of Fallot, which of the following should alert the nurse to suspect a low cardiac output? a) Bounding pulses and mottled skin. b) Extremities warm to the touch and pale skin. c) Capillary refill of 2 seconds and blood pressure of 96/67 mm Hg. d) Altered level of consciousness and thready pulse.

D - With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refill; and decrease in level of consciousness.

A client is admitted to the emergency department with sudden onset of chest pain. Which of the following orders should the nurse implement immediately? Select all that apply. a) Administer acetaminophen b) Administer aspirin. c) Administer morphine. d) Provide oxygen. e) Administer nitroglycerin. f) Insert a Foley catheteter

• Provide oxygen. • Administer nitroglycerin. • Administer aspirin. • Administer morphine. When emergently managing chest pain, the nurse can use the memory mnemonic MONA to plan care: morphine, oxygen, nitroglycerin, and aspirin. A Foley catheter is not included in the emergent management of chest pain and can be inserted when the pain has been relieved and the client is stable. Acetaminophen is not used to manage chest pain.

A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply. a) Skin pink in color b) Normal sensation c) Skin discoloration d) Strong, bounding pulses e) Skin temperature changes f) Edema

• Skin discoloration • Skin temperature changes • Edema Lack of oxygen to nourish tissues at the capillary level causes edema, discoloration, and changes in skin temperature. Pulses will be weak or absent, and the client will experience altered sensation. Pink skin color; strong, bounding pulses; and normal sensation are signs of adequate perfusion

A patient is admitted to the cardiac unit after having a myocardial infarction. Prioritize the nurse's next actions. 1. Insert an IV 2. Hook the patient up to a cardiac monitor 3. Initiate thrombolytic therapy 4. Provide the patient with water a) 1, 2, 3, 4 b) 1, 3, 2, 4 c) 2, 1, 3, 4 d) 3, 2, 1, 4

2. Hook up pt to a cardiac monitor 1. Insert IV 3. Initiate thrombolytic therapy 4. Provide pt with water Standard nursing interventions for a MI includes administration of nitroglycerin and morphine, placement of a cardiac monitor, administration of 2-4 L of oxygen, and IV catheter insertion. The nurse should first hook the pt up to a cardiac monitor in order to continuously assess the heart rhythm. An IV should be initiated to provide treatment. Thrombolytic therapy may not be ordered by the physician depending on the pt's hx. While pt may be allowed to drink water, the nurse should be alert to the potential for fluid overload and HF.

A nurse has found a client unconscious and not breathing. Please arrange interventions in order of priority. 1. Provide 30 compressions 2. Perform head tilt-chin lift 3. Activate emergency response system 4. Provide two ventilations 5. Perform chest compressions at a rate of at least 100/minute

3. Activate emergency response system 5. Perform chest compressions at a rate of at least 100/min 1. Provide 30 compressions 2. Perform head tilt-chin lift 4. Provide 2 ventilations After determining that the client is not breathing, the emergency response system should be the first action. Chest compressions should be rapid (at least 100 per minute) to provide circulation; after 30 compressions, the client's jaw should be positioned to open the airway and two breaths should be provided.

The patient asks you what an ejection fraction (EF) is. Which statement is the appropriate explanation? A. It provides information about left ventricular function during heart contraction. B. It helps to determine electrical impulse conduction through the heart. C. It allows visualization of the heart anatomy and coronary circulation. D. Provides information on cardiac wall movement and valves.

A - The EF is the percentage of end-diastolic blood volume that is ejected during systole. It provides information about the function of the left ventricle during systole.

The auscultatory area in the left midclavicular line at the level of the fifth intercostal space (ICS) is the A. aortic valve area. B. mitral valve area. C. tricuspid valve area. D. pulmonic valve area.

A - The mitral valve can be assessed by auscultation at the left midclavicular line at the fifth ICS.

A patient has a severe blockage in his right coronary artery. Which cardiac structure is mostly likely to be affected by this? A. Atrioventricular (AV) node B. Left ventricle C. Coronary sinus D. Pulmonary valve

A - The right coronary artery (RCA) supplies blood to the right atrium, the right ventricle, and a portion of the posterior wall of the left ventricle. In 90% of people, the RCA supplies blood to the AV node, the bundle of His, and part of the cardiac conduction system.

Which nursing responsibilities are priorities when caring for a patient returning from cardiac catheterization (select all that apply)? A. Monitoring vital signs and the electrocardiogram (ECG) B. Checking the catheter insertion site and distal pulses C. Assisting the patient to ambulate to the bathroom to void D. Informing the patient that he will be sleeping because of general anesthesia E. Instructing the patient about the risks of the radioactive isotope injection

A and B - The nursing responsibilities after cardiac catheterization include assessing the puncture site for hematoma and bleeding; assessing circulation to the extremity used for catheter insertion and peripheral pulses, color, and sensation of the extremity; and monitoring vital signs and ECG rhythm.

You are caring for a patient immediately after a transesophageal echocardiogram (TEE). Which assessments are appropriate for this patient (select all that apply)? A. Assess for return of the gag reflex. B. Assess the groin for hematoma or bleeding. C. Monitor vital signs and oxygen saturation. D. Position the patient supine with the head of the bed flat. E. Assess lower extremities for circulatory compromise.

A and C The patient undergoing TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, eliminating the gag reflex until the effects wear off. You must therefore assess for return of the gag reflex before allowing the patient to eat or drink. Vital signs and oxygen saturation are also important assessment parameters resulting from the use of sedation. TEE does not involve invasion of the circulatory blood vessels, and it is not necessary to monitor the patient's groin or lower extremities in relation to this procedure.

After teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says A) "I would like to add weight lifting to my exercise program." B) "I can only keep my blood pressure normal with medication." C) "I can change my diet to decrease my intake of saturated fats." D) "I will change my lifestyle to reduce activities that increase my stress."

A) Adding wt lifting to exercise program Risk factors for coronary artery disease include elevated serum levels of lipids, elevated blood pressure, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, certain psychologic states, and elevated homocysteine levels. Weight lifting is not a cardioprotective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes five or more times each week.

You are providing care for a patient who has decreased cardiac output related to heart failure. You recognize that cardiac output is A. calculated by multiplying the patient's stroke volume by the heart rate. B. the average amount of blood ejected during one complete cardiac cycle. C. determined by measuring the electrical activity of the heart and the patient's heart rate. D. the patient's average resting heart rate multiplied by the patient's mean arterial blood pressure.

A) CO = SV x HR Cardiac output is determined by multiplying the patient's stroke volume by heart rate, identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 beats per minute; and respiratory rate of 30 shallow breaths per minute. What should the nurse do first? a) Activate the Rapid Response Team (RRT). b) Place the client in the Trendelenburg position. c) Call the neurosurgeon. d) Consult the neurologic Clinical Nurse Specialist (CNS).

A. Activate Rapid Response Team. Rapid response teams (RRTs), or medical emergency teams, provide a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. Calling the neurosurgeon or consulting the CNS may not result in a rapid response. The Trendelenburg position is usually used in treating shock, but because the client has had brain surgery, the head should not be lower than the trunk.

The nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What action should the nurse take after realizing the mistake? a) Assess the client and notify the physician. b) Give the prescribed 0.125 mg as soon as possible. c) Hold the next dose of digoxin. d) No action is needed because of the small dose difference.

A. Assess client and notify physician This is a medication error. The priority is to assess the client and then to notify the physician of the error and seek further guidance from the physician. The other options do not describe the steps the nurse should take to ensure client safety following a medication error. The other options include decisions and judgments that are outside of the nurse's scope of practice.

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action? a) Assess the client's orientation and vital signs. b) Activate the rapid response team. c) Administer a bolus of lidocaine. d) Call the physician.

A. Assess orientation and VS. The priority action is to assess the client and determine whether the rhythm is life-threatening. More information, including vital signs, should be obtained and the physician should be quickly notified. A bolus of lidocaine may be ordered to treat this arrhythmia. This is not a code-type situation unless the client has been determined to be in a life-threatening situation.

A premature neonate is experiencing severe respiratory distress in the delivery room. Once bag/mask ventilation and oxygen are provided, the condition of the infant deteriorates further. The abdomen appears sunken, low body temperature, cyanotic, and nasal flaring. Which action should be strongly considered? a) assist with endotracheal intubation and assist ventilation b) give pancuronium bromide intravenously to increase pulmonary blood flow c) initiate continuous positive airway pressure d) place in hood oxygen and achieve an oxygen saturation greater than 90%

A. Assist w/ ET intubation and assist ventilation. For a premature infant, respiratory distress syndrome can be largely prevented by the administration of synthetic surfactant through an ET tube. Ventilations are pressure-cycled to control the force of the air delivery. The infant is suctioned before surfactant administration. Afterwards, the infant's airway should NOT be suctioned for as long as possible to avoid suctioning out the surfactant.

The nurse is assessing a client with an atrial septal defect (ASD). Which requires immediate nursing intervention? a) Client not taking his angiotensin-converting enzyme inhibitor this morning b) Client having an uneven smile and facial droop c) Fixed split S2, which does not vary with respiration d) Client having tachycardia at a rate of 100 beats/min

A. Client having an uneven smile and facial droop A fixed S2 split is the hallmark of ASD. The neurologic finding of a facial droop could indicate embolization and stroke; the nurse should notify the healthcare provider immediately. If the client has missed a medication, the nurse should measure the vital signs and administer the medication as soon as possible; however, symptoms of stroke are the priority. The nurse should further assess tachycardia to determine the underlying cause, such as pain or fever, before intervening.

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize her client care assignment. The nurse has an ancillary staff member available to help her care for her clients. Which of these clients should the registered nurse assess first? a) The client with heart failure who is having some difficulty breathing. b) The anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today. c) The client admitted during the previous shift with new-onset controlled atrial fibrillation, who has her call light on. d) The coronary bypass client asking for pain medication for "11 of 10" pain in her donor site.

A. Client w/ HF who is having difficulty breathing The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs her analgesic, but that does not take priority over a client with difficulty breathing.

A client returns to the medical-surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/minute, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply a) Cyanotic mucous membrane. b) Warm, dry skin. c) Intake and output. d) Vital sign changes. e) Oxygen saturation.

A. Cyanotic mucous membrane C. I&O D. VS changes E. O2 Saturation When assessing a postoperative client for perfusion and the manifestation of shock, nursing assessment should include an inspection for cyanotic mucous membranes; cold, moist, pale skin; and the level of oxygen saturation in relation to hemoglobin. The nurse should also compare the client's postoperative vital signs with his preoperative vital signs to determine how much physiologic stress has occurred during the intraoperative period. A client who is perfusing well would have warm, dry skin. A client well hydrated would have good skin turgor. The nurse would also assess fluid status using the intake and output record. If hemoglobin and hematocrit were available, the values would be included in the assessment.

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse's first action should be to: a) Determine whether the tube is obstructing the airway. b) Deflate the esophageal portion of the tube. c) Increase the oxygen flow rate. d) Remove the tube.

A. Determine whether tube is obstructing airway. If the gastric balloon should rupture or deflate, the esophageal balloon can move and partially or totally obstruct the airway, causing respiratory distress. The client must be observed closely. No direct action should be taken until the condition is accurately diagnosed

10/14 7 AM - Intake: 500 mL, Output: 1000 mL 3 PM - Intake: 1000 mL, Output: 1500 mL 11 PM - Intake: 1000 mL, Output 1700 mL 10/15 7 AM: Intake: 1500 mL, Output: 2500 mL A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the accompanying chart). Which action should the nurse take? a) Increase fluids. b) Administer an antiemetic. c) Restrict fluids. d) Administer a stool softener.

A. INCREASE fluids The client's intake and output record indicates that the client's output exceeds intake. The goal is to restore fluid balance by increasing fluid intake. The client will likely receive intravenous fluids with electrolytes. The nurse should not restrict fluids. If the client has diarrhea, the health care provider may also prescribe an antidiarrheal drug, not a stool softener. Because the client does not appear to be losing fluids from vomiting, the nurse should not administer an antiemetic.

Which of the responsibilities related to the care of a client with a Foley catheter is appropriate for the nurse to delegate to the nursing assistant? Select all that apply. a) Provide Foley catheter and perineal care each shift b) Empty drainage bag and record output at specified times. c) Perform bladder irrigation as ordered. d) Apply catheter-securing device to the client's leg. e) Ensure the urine drainage bag is below the level of the bladder at all times.

A. Provide Foley cath and perineal care each shift B. Empty drainage bag and record output at specified times D. Apply catheter-securing device to client's leg. E. Ensure drainage bag is below level of bladder at all times. While the scope of practice for nurse assistants may vary by state, province, or territory, as well as place of employment, general duties include recording input and output, including emptying and recording urine output from a Foley catheter. A nurse assistant with proper training may apply a securing device to maintain safety, provide regular Foley catheter and perineal care, and ambulate a client with a catheter, continually monitoring that the collection bag remains below the level of the bladder to help prevent infection. Activities such as irrigating or flushing a catheter should not be assigned to a CNA--these activities involve nursing assessment skills.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take? a) Question the physician about the order. b) Administer the medication as ordered. c) Inform the client that he should discuss his MI with the physician. d) Discontinue the medication.

A. Question the physician. Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician

An elderly client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should a) Withhold the metformin prior to the cardiac catheterization. b) Limit the amount of protein in the diet prior to the cardiac catheterization. c) Administer the metformin with only a sip of water prior to the cardiac catheterization. d) Give the metformin before breakfast as prescribed.

A. Withhold the Metformin prior to cardiac cath The nurse should withhold the metformin prior to any procedure requiring dye such as a cardiac catheterization because of the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system. The physician may order sliding scale insulin during this time if needed. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.

A client has a history of heart failure and has been taking several medications, including furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which condition? a) Hyperkalemia. b) Digoxin toxicity. c) Fluid deficit. d) Pulmonary edema.

B. Dix toxicity Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine, 5 mcg/kg/minute I.V. Which classification best describes dobutamine? a) Direct-acting alpha-active agent b) Direct-acting beta-active agent c) Indirect-acting dual-active agent d) Indirect-acting beta-active agent

B. DoButamine = Direct-acting Beta-active Adrenergic agents are classified according to their method of action and the type of receptor on which they act. Direct-acting agents act on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual-acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors. Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent.

A nurse regularly inspects a client's I.V. site to ensure patency and prevent extravasation during dopamine therapy. What is the treatment for dopamine extravasation? a) Elevating the affected limb, applying cold compresses, and administering hyaluronidase as ordered b) Elevating the affected limb, applying warm compresses, and administering phentolamine as ordered c) Maintaining the limb in a dependent position and massaging it every 15 minutes d) Asking the physician to make an incision and allowing the affected area to drain

B. Elevate affected limb, apply WARM compresses, and administer PHENTOLAMINE as ordered If extravasation occurs with dopamine administration, the nurse should elevate the affected limb, apply warm compresses, and administer phentolamine as ordered. She shouldn't massage the limb or apply cold compresses. Physicians don't generally order hyaluronidase for dopamine extravasation. An incision isn't required or appropriate to drain the affected area.

A client is receiving fluid replacement with lactated Ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 97.2 (36.2° C); heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 ml for the last 2 hours. The IV rate is currently at 375 ml/hr. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for: a) Furosemide. b) IV rate increase. c) Fresh frozen plasma. d) Dextrose 5%.

B. IV rate increase. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.

A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia A) will always progress to myocardial infarction. B) will be relieved by rest, nitroglycerin, or both. C) indicates that irreversible myocardial damage is occurring. D) is frequently associated with vomiting and extreme fatigue.

B. Ischemia will be relieved by rest, nitroglycerin, or both Chronic stable angina is chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. The chest pain is relieved by rest or by rest and medication (e.g., nitroglycerin). The ischemia is transient and does not cause myocardial damage.

The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which is the nurse's best action? a) Document the finding in the medical record b) Notify the healthcare provider c) Teach the client about risks for coronary artery disease d) Determine whether the rhythm is irregular, coinciding with inspiration and expiration

B. NOTIFY HCP. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle; elevated ST sements indicate that the client is experiencing a myocardial infarction. The healthcare provider should be notified. Teaching should be delayed until the client is stable. An irregular heart rhythm that varies with respiration—sinus arrhythmia—is a normal variation of sinus rhythm; there is no intervention needed.

The nurse is caring for a patient who is two days post-MI. The patient reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which of the following actions would be a priority? a. Notify the physician STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow oxygen by face mask and auscultate breath sounds. d. Medicate the patient with PRN analgesic and reevaluate in 30 minutes.

B. Obtain VS and Auscultate for a pericardial friction rub Acute pericarditis is inflammation of the visceral and/or parietal pericardium; it often occurs 2 to 3 days after an acute myocardial infarction. Chest pain may vary from mild to severe and is aggravated by inspiration, coughing, and movement of the upper body. Sitting in a forward position often relieves the pain. The pain is usually different from pain associated with a myocardial infarction. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium.

Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? a) Completing the admission history. b) Administering pain medication. c) Maintaining hydration. d) Teaching about planned diagnostic tests.

B. Pain meds Administering pain medication would have the highest priority DURING THE FIRST HOUR after the client's admission. Completing the admission history can be done after the client's pain is controlled. Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief. It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable

A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse? a) Encourage ambulation and administer bronchodilators and steroids as ordered b) Position in Fowler's position, initiate oxygen, and administer bronchodilators as ordered. c) Position in high Fowler's position and administer bronchodilators as ordered. d) Place in supine position, initiate oxygen, and administer bronchodilators as ordered.

B. Position in Fowler's, initiate O2, and administer bronchodilators Priority actions are important to maximize effective ventilation because of the narrowing and spasms of the bronchioles and excessive secretions. It is important to position the client in the high Fowler's position and to oxygenate. The use of bronchodilators help counteract the bronchospasms. Other positions, such as supine and recovery, are not as effective as Fowler's. Ambulation increases the demand for oxygen, so is incorrect

A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client? a) Promoting incisional healing. b) Using incentive spirometry every 2 hours while awake. c) Performing leg exercises every shift. d) Maintaining a weight-reduction diet

B. Using incentive spirometry every 2hours while awake. A major goal of postoperative care for the client who has had an incisional cholecystectomy is the prevention of respiratory complications. Because of the location of the incision, the client has a difficult time breathing deeply. Use of incentive spirometry promotes chest expansion and decreases atelectasis. Performing leg exercises each shift is not frequent enough; they should be performed hourly. Maintaining a weight reduction diet may be appropriate for the client, but it is not the highest priority in the immediate postoperative phase. Promoting wound healing is important, but respiratory complications are most common after a cholecystectomy. (

A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dl (18 mmol/l) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The physician has ordered 1000 ml 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and: a) Suggest adding potassium to the fluids. b) Verify the order for 5% dextrose in water. c) Request an increase in the volume of intravenous fluids. d) Determine if the client should be placed in isolation.

B. Verify dextrose order. The client needs fluid volume replacement due to the dehydration. However, the nurse should verify the order for I.V. dextrose with the physician due to the risk of hyperglycemia that dextrose would present when administered to a client with diabetes. The potassium level is within normal limits. The client does not have restrictions on oral fluids and the nurse can encourage the client to drink fluids. The client does not need to be placed in isolation at this time

Which statement is accurate regarding blood work results in assessing cardiac function? A. C-reactive protein (CRP) is an independent risk factor for autoimmune diseases. B. Homocysteine is acquired from high dietary consumption of cholesterol. C. B-type natriuretic peptide (BNP) helps to differentiate between cardiac and respiratory causes of dyspnea. D. Myoglobin is the biomarker of choice in the diagnosis of myocardial infarction (MI).

C - There are three natriuretic peptides. BNP is found in ventricles. BNP has emerged as the marker of choice for determining whether there is a cardiac or respiratory cause of dyspnea. CRP is a protein produced by the liver during periods of acute inflammation. It is emerging as an independent risk factor for coronary artery disease (CAD). Homocysteine is an amino acid produced during protein catabolism. Elevated levels can be hereditary or acquired from dietary deficiencies of B6, B12, or folate. Troponin is the biomarker of choice in the diagnosis of MI. Myoglobin is found in cardiac and skeletal muscles, and it is used as an indicator in early myocardial injury.

The patient is positioned sitting upright and learning forward. After exhalation, you auscultate a high-pitched scratchy heart sound intermittently at the apex. What is the best interpretation of this sound? A. The patient has a I/VI heart murmur. B. An S4 atrial gallop is heard. C. Pericardial friction rub is caused by pericarditis. D. Normal splitting of the S2 cardiac sound is heard.

C - pericardial friction rub Pericardial friction rubs are sounds caused by friction that occurs when inflamed surfaces of the pericardium (pericarditis) move against each other. They are high-pitched, scratchy sounds that are heard best at the apex with the patient upright and leaning forward and after expiration. A murmur is caused by turbulent blood flow across diseased heart values; a I/VI murmur is barely audible. An S4 heart sound is a low-frequency vibration that precedes the S1. Normal splitting of S2 is best heard at the pulmonic area during inspiration.

A client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. The nurse should report which of the following to the health care provider? a) Lack of adventitious lung sounds. b) Oxygen saturation of 96% on room air. c) Arterial oxygen level of 46 mm Hg. d) Respirations of 12.

C. Arterial oxygen level of 46. Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg to the health care provider. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.

Immediately after receiving an injection of bupivacaine, the client becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate at this time? a) Reassure the client that it is normal to feel restless before a procedure. b) Ask the client explain these feelings. c) Assess the client's vital signs. d) Administer epinephrine.

C. Assess VS. The nurse should assess the client's vital signs because he is most likely having a reaction to the bupivacaine. If the client's vital signs are abnormal, immediate intervention may be necessary. Although the nurse may ask the client to continue to describe how he is feeling, this is not likely to be a psychosocial reaction. Simple reassurance is inappropriate in most clinical situations and can be dangerous if physiologic causes of restlessness are overlooked. The nurse should not administer epinephrine until vital signs have been assessed.

A patient is recovering from an uncomplicated MI. Which of the following rehabilitation guidelines is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks. b. Plan a diet program that aims for a 1- to 2-pound weight loss per week. c. Begin an exercise program that aims for at least five 30-minute sessions per week. d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity.

C. Begin exercise program that aims for at least five 30 min sessions/week Physical activity should be regular, rhythmic, and repetitive, with the use of large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Instruct the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes.

A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? a) The client with a history of heart failure who has bibasilar crackles and pitting edema in both feet b) The client with a history of cardioversion for sustained ventricular tachycardia 2 days ago c) The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block d) The client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday

C. Client admitted with 1st degree block who now reveals 2nd degree block. The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client who underwent cardioversion 2 days ago has likely had the underlying reason for the sustained ventricular tachycardia corrected. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first is not necessary. The client who underwent PCI with stenting was at risk for reperfusion arrhythmias and/or bleeding from the arterial puncture site but could be considered to be stable 24 hours post procedure

A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? a) The dobutamine may need to be decreased. b) The client is experiencing an exacerbation of the heart failure. c) The dosage of the dobutamine needs to be increased. d) The client is experiencing an allergic reaction to the dobutamine.

C. Dosage may need to be decreased. Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client shows not symptoms of allergic reaction or heart failure.

At 8 a.m.(0800), a nurse assesses a client who's scheduled for surgery at 10 a.m.(1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next? a) Check to see that the client had a chest X-ray the previous day as ordered. b) Sign the preoperative checklist for this client. c) Immediately notify the physician of these findings. d) Check the client's serum electrolyte levels and complete blood count (CBC).

C. Immediately notify physician The nurse should notify the physician immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse should then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse should sign the preoperative checklist after notifying the physician of the client's condition and learning whether the physician will proceed with the scheduled surgery.

Physician prescription: Continuous external fetal and contraction monitoring IV of D5LR @ 125 mL/h I&O catheterization for urinalysis and culture & sensitivity Betamethasone 12mg IM daily x 12 days A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician prescriptions (see chart). Which of the following prescriptions should the nurse initiate first? a) Administer betamethasone. b) Start the intravenous infusion. c) Initiate fetal and contraction monitoring. d) Obtain the urine specimen

C. Initiate fetal and contraction monitoring. The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other prescriptions. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if prescribed.

The most common finding in individuals at risk for sudden cardiac death is A) aortic valve disease. B) mitral valve disease. C) left ventricular dysfunction. D) atherosclerotic heart disease.

C. Left ventricular function Left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are the strongest predictors of sudden cardiac death (SCD).

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? a) Venturi mask b) Simple mask c) Nonrebreather mask d) Nasal cannula

C. Nonrebreather mask A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

The nurse discovers that a young client has been given a dose of morphine four times the ordered dose. Which of the following is the immediate priority action for the nurse to take? a) Notify the parents of the medication error. b) Bring emergency resuscitation equipment to the child's room. c) Obtain an order for naloxone and administer it promptly. d) Ensure that the error is corrected on the medication record.

C. Obtain order for naloxone and administer it promptly. Naloxone is an opioid antagonist that is given as an antidote for morphine. An antidote is an agent that neutralizes a poison or counteracts its effects. This should be the immediate priority for the nurse.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? a) Oxygen saturation of 93% b) Respiratory rate of 16 breaths/minute c) Runs of ventricular tachycardia d) Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg

C. Runs of ventricular tachycardia. Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

The nurse is caring for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first? a) Administer oxygen. b) Notify the physician. c) Switch the transfusion to normal saline solution. d) Take the child's vital signs.

C. Switch to NS solution. The child is having a reaction to the blood transfusion. The priority is to stop the blood transfusion but maintain an open venous access for medication or high fluid volume delivery. Thus, switching the transfusion to normal saline solution would be done first. Since the child is having difficulty breathing, applying oxygen would be the next action. Additionally, vital signs are taken to determine the extent of circulatory involvement. Then the physician would be notified and, if necessary, the crash cart would be obtained.

When the nurse administers I.V. midazolam hydrochloride, the client demonstrates signs of an overdose. The nurse should next collaborate with the surgical team to: a) Titrate flumazenil. b) Shock the client with ECG paddles. c) Ventilate with an oxygenated Ambu bag. d) Administer 0.5 ml 1:1000 epinephrine.

C. Ventilate. The nurse should have an Ambu bag in the client's room because midazolam hydrochloride can lead to respiratory arrest if it is administered too quickly. The client does not need to be shocked back into a normal rhythm or receive epinephrine unless cardiac compromise developed after the respiratory arrest. The client would receive titrated dosing of flumazenil to reverse the midazolam, but first the nurse should ventilate the client.

Day 1) Wt: 160 lbs; BP: 120/80 Day 2) Wt: 162 lbs; BP: 130/88 Day 3) Wt: 165 lbs; BP: 140/90 The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices, including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days (as shown on the attached chart). The nurse calls the client to follow up. The nurse should ask the client which of the following first: a) "How are you feeling today?" b) "Did you calibrate the scales before using them?" c) "How much fluid did you drink during the last 24 hours?" d) "Are you having shortness of breath?"

D. Are you having SOB? The client has gained 5 lb (2.3 kg) in 3 days with a steady increase in blood pressure. The client is exhibiting signs of heart failure and if the client is short of breath, this will be another sign. Asking how the client is feeling is too general and a more focused question will quickly determine the client's current health status. The scales should be calibrated periodically, but a 5-lb (2.3-kg) weight gain, along with increased blood pressure, is not likely due to problems with the scale. The weight gain is likely due to fluid retention, not drinking too much fluid.

After completing assessment rounds, which of the following should the nurse discuss with the physician first? a) A client with pancreatitis whose family requests to speak with the physician regarding the treatment plan. b) A depressed client with cirrhosis who has refused to eat for the past 2 days. c) A client with stable vital signs following a cholecystectomy who has been receiving IV ciprofloxacin for 1 day and has developed a rash on the chest and arms. d) A client with hepatitis whose pulse was 84 and regular and is now 118 and irregular.

D. Client with hepatitis A change in a client's baseline vital signs should be brought to the physician's attention immediately. In this case, the client's heart rate has increased and the rhythm appears to have changed; the physician may order an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the physician information using the SBAR format. The nutritional as well as psychological needs of a client must be addressed but are not first priority. A rash that develops after a new antibiotic is started must be brought to the physician's attention; however, this client is stable and is not the first priority. The nurse is responsible to facilitate discussion between the client, the client's family, and the physician but only after all immediate physical and psychological needs of all clients have been met.

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which of the following is the appropriate nursing intervention? a) Reassessing vital signs in 15 minutes b) Increasing the rate of IV fluids c) Inserting a Foley catheter to monitor urine output d) Contacting the physician

D. Contact physician. The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.

Which of the following assessments would be most appropriate for the nurse to make while the dialysis solution is dwelling within the client's abdomen? a) Assess for urticaria. b) Monitor electrolyte status. c) Check capillary refill time. d) Observe respiratory status.

D. During dwell time, the dialysis solution is allowed to remain in the peritoneal cavity for the time ordered by the physician (usually 20 to 45 minutes). During this time, the nurse should monitor the client's respiratory status because the pressure of the dialysis solution on the diaphragm can create respiratory distress. The dialysis solution would not cause urticaria or affect circulation to the fingers. The client's laboratory values are obtained before beginning treatment and are monitored every 4 to 8 hours during the treatment, not just during the dwell time

A client is to start chemotherapy to treat lung cancer. A venous access device is placed to administer chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. Vital signs are BP 80/30, P 132, R 28, T 103 degrees F (39.4 degrees C), and oxygen saturation 84%. The central line insertion site is inflamed. After calling the rapid response team, what should the nurse do next? a) Obtain a portable ECG monitor. b) Place cold, wet compresses on the client's head. c) Administer a prescribed antipyretic. d) Insert a peripheral intravenous fluid line and infuse normal saline.

D. Insert peripheral IV line & infuse NS. The client is experiencing severe sepsis, and it is essential to increase circulating fluid volume to restore blood pressure and cardiac output. Applying a wet compress, administering an antipyretic, and monitoring the client's cardiac status may be beneficial for this client, but they are not the highest priority action at this time. These three interventions may require the nurse to leave the client, which is not advisable at this time.

A client recovering from an abdominal hysterectomy has pain in her right calf. The nurse should: a) Have the client flex and extend her leg and note the presence of pain. b) Raise the right leg and lower it to detect changes in skin color. c) Palpate the calf to note pain. d) Measure the circumference of both calves and note the difference.

D. Measure circumference of both calves and note the difference. After abdominal pelvic surgery, the client is especially prone to thrombophlebitis. Measuring calf circumference can help detect edema in the affected leg. The calf should not be rubbed or palpated because a clot could be loosened and travel to the lungs as a pulmonary embolism. Homans' sign, which is calf pain on dorsiflexion of the foot when the leg is raised, is sometimes associated with thrombophlebitis. Having the client flex and extend the leg does not provide useful assessment data; the leg will not change color when raised and lowered.

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the physician immediately? a) Mouth breathing b) Foul odor from the mouth c) Irregular respirations while awake d) Moderate intercostal retractions

D. Moderate intercostal retractions Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician. Mouth breathing and a foul odor from the mouth aren't cause for concern. Irregular respirations while awake aren't an unusual finding in a young child.

Assessing a neonate at 8 hours of age, the nurse records the following findings on the chart below: Vital signs. Time 11:00. Respiration 92, no nasal flaring, retractions grunting. Heart rate 128, no murmur noted. Temperature 98.9°F (37.2°C). At 11:30, the nurse notices the neonate has central cyanosis and the respiratory rate is now 102, no nasal flaring, no retractions, or grunting was noted and breath sounds were clear. The nurse should: a) Suction nose and mouth. b) Change the neonate's position. c) Encourage the baby to cry. d) Notify the physician.

D. Notify physician. The neonate is experiencing quiet tachypnea with central cyanosis, which is a sign of possible congenital heart disease, so notifying the physician is the correct answer. The baby is showing no signs of increased work of breathing, except increased respiratory rate. Breath sounds are clear; therefore, suctioning is not necessary and may cause further distress due to trauma to the nasal passage. Changing the neonate's position would have no impact on the cyanosis. Encouraging the baby to cry would increase the distress by decreasing oxygen consumption

While making rounds, the nurse finds a client with COPD sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, the nurse's first action should be to: a) Call for a defibrillator. b) Call the rapid response team. c) Push the "code blue" (emergency response) button. d) Open the client's airway.

D. Open the client's airway. The nurse has already called for help and established unresponsiveness, so the next action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether further intervention is required. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be necessary nor the appropriate action once the client's airway has been opened.

A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which of the following a) Increased pulse. b) Nausea. c) Abdominal cramps. d) Tarry stools.

D. Tarry stools Black, tarry stools indicate the presence of a slow upper gastrointestinal bleed. The longer the blood is in the system, the darker it becomes as the hemoglobin is broken down and iron is released. Vital sign changes, such as an increased pulse, are not evident with slow gastrointestinal bleeds. Nausea and abdominal cramps can occur but are not definitive signs of gastrointestinal bleeding.

The goal for the administration of a fibrinolytic

The goal is for the fibrinolytic to be administered as soon as possible, within 30 mins of the patient's arrival to a facility without an interventional cardiac catheterization laboratory, ideally within the 1st hour after onset of MI sx, & preferably within the 1st 6hrs after onset of sx.

The most serious complication of PCI

The most serious complication of PCI is dissection of the newly dilated coronary artery. If the damage is extensive, the coronary artery could rupture, causing cardiac tamponade, ischemia and infarction, decreased CO, and possible death.

List nursing & medical interventions the nurse should implement when caring for a client who may be developing acute respiratory distress syndrome (ARDS)

1) Administer high liter oxygen and monitor pulse ox & ABGs 2) If pulse ox readings & ABG results continue to drop while pt is receiving supplemental O2, it is ARDS 3) Prepare to place pt on ventilator (only treatment) along w/ treating underlying cause 4) Implement interventions for ventilator care 5) Some pts respond positively to being placed in the prone position 6) Address nutritional needs 7) Assess pt's respiratory status

The nurse is caring for a client on a ventilator with an endotracheal intubation. List interventions the nurse should implement for the ventilator care.

1) Check ventilator settings w/ prescribed settings (TV, Rate, PEEP, FiO2, Mode of Ventilation: control, assist-control, intermittent mandatory (IMV), SIMV, PSV 2) Check ET tube placement 3) Maintain proper cuff inflation 4) Check all ventilator connections 5) Have manual resuscitative bag at beside (Ambu bag) 6) Ensure all ventilator alarms are on and answered promptly 7) Empty condensed water from water traps 8) Complete respiratory assessment (pt's respiratory status, pulse ox, ABGs, lung sounds, LOC, ect.) 9) Assess pt's reaction to muscle-paralyzing agents 10) Ensure upper extremity restraints are on properly and assess for neurovascular compromise 11) Suction w/ end-line suction as needed 12) Collaborate with respiratory therapist

The nurse is caring for a client who is taking procainamide (Pronestyl-SR). The nurse monitors for which sign(s) and symptom(s) that could indicate potential medication toxicity? Select all that apply. 1. Confusion 2. Dizziness 3. Drowsiness 4. Bradycardia 5. Decreased urination

1, 2, 3, 5. Procainamide is classified as an antidysrhythmic medication. S&S of medication toxicity include confusion, dizziness, drowsiness, tachydysrhythmias, decreased urination, and nausea and vomiting. Test-taking strategy: Note the subject, S&S indicating medication toxicity. Recalling that, in general, changes in LOC are typically signs of medication toxicity will direct you to options 1, 2, and 3. From the remaining options, it is necessary to be familiar with the S&S of toxicity in order to answer this question correctly.

A client on telemetry reports that he has been having chest pain. The hospital unit has standing orders that allow the nurse to begin treating the client before notifying the physician. Place the following nursing actions in proper chronological order. Use all options. 1. Evaluate the effectiveness of the treatment given. 2. Document the effectiveness of the treatment given. 3. Report findings to the physician. 4. Administer sublingual nitroglycerin. 5. Check vital signs, particularly blood pressure.

5) Check vital signs, particularly BP 4) Administer sublingual nitroglycerin 1) Evaluate effectiveness of treatment 2) Document 3) Report Oxygen administered at 2 to 4 L/minute via nasal cannula is a first-line treatment for myocardial oxygen deficit, which is evidenced by the client's chest pain. The nurse should then check vital signs, particularly blood pressure, before administering sublingual nitroglycerin. The nurse should then evaluate the effectiveness of the treatment given, document it, and report it to the physician.

The nurse is caring for a client with a third heart sound. Which action is indicated? a) Assess the client's lungs for crackles b) Place the client flat in bed c) Place the client on a cardiac monitor d) Observe for sluggish skin turgor

A - A third heart sound indicates fluid volume excess (FVE) or heart failure; crackles are an additional finding and will further refine the assessment. Placing the client with FVE or heart failure flat in bed may cause respiratory distress by decreasing expansion. A cardiac monitor will determine heart rhythm, but it will not give information related to FVE. Sluggish skin turgor is a sign of fluid volume deficit or dehydration.

A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: a) check the client's pedal pulses frequently. b) keep the client's knee on the affected side bent for 6 hours. c) apply pressure to the puncture site for 30 minutes. d) remove the dressing on the puncture site after vital signs stabilize.

A - After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse should leave this dressing in place for several hours — and only remove it if instructed to do so.

The nurse monitors the serum electrolyte levels of a client who is taking digoxin. Which of the following electrolyte imbalances is a common cause of digoxin toxicity? a) Hypokalemia. b) Hypomagnesemia. c) Hyponatremia. d) Hypocalcemia.

A - Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

The family member of the client experiencing a cardiac arrest refuses to leave the client's room. Which intervention should the administrative supervisor implement? a) Stay with the family member and explain what the team is doing b) Call hospital security to escort the family member out of the room c) Ask the HCP whether the family member can stay d) Ignore the family member unless she becomes hysterical

A - If the family is not causing a disruption in the code, then the supervisor should remain near the family member and explain what the interventions being implemented mean to the family member. The supervisor should be ready to escort the family member out of the code if the family member becomes disruptive.

The nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing interventions should the nurse include in the care plan for the next 8 hours? Select all that apply. a) Keep the extremity straight. b) Monitor the vital signs every 4 hours. c) Check the dressing and access site for bleeding. d) Allow use of the bedside commode. e) Maintain pressure over the femoral access site. f) Allow the client to sit upright for meals.

A - Keep extremity straight C - Check dressing and access site for bleeding E - Maintain pressure over femoral access site Pressure should be applied at the access site to control bleeding and promote clot formation. The dressing and access site must be observed frequently for bleeding and hematoma formation. When the femoral access site is used, the head of the bed may not be raised greater than 30 degrees and the affected leg must be kept extended. Therefore, the client may not sit upright for meals or use the bedside commode. Following this procedure, the nurse should monitor vital signs every 15 minutes for the first hour, every 30 minutes for the next 2 hours, and every 4 hours after that.

A nurse working in a pediatric cardiac unit is teaching the parents of a child with a cardiac disorder about cardiac arrest among children. Which statement by the parents informs the nurse that the teaching has been successful? a) "We will be alert to respiratory problems to decrease the risk of cardiac arrest." b) "We will decrease the risk of cardiac arrest by limiting exercise for our child." c) "We will prevent dehydration to minimize the risk of cardiac arrest." d) "We will check for medication incompatibilities to prevent cardiac arrest."

A - Respiratory failure is the leading cause of cardiac arrest among infants and children. Cardiac arrest is typically caused by the progressive tissue hypoxia and acidosis associated with respiratory failure. Although medication incompatibilities and hypovolemia from dehydration have the potential to deteriorate into serious situations, more common cardiac event situations arise from respiratory failure in this population.

A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. The client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair, the client has severe pain and numbness in her left leg. The nurse should first: a) Assess color and temperature of the left leg. b) Administer pain medication. c) Assess for edema in the left leg. d) Encourage the client to change her position.

A - The client is likely suffering from an embolus as a result of abdominal surgery. The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Administering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation. Encouraging the client to change her position does not adequately address the need for gathering more data

A client is receiving dopamine hydrochloride for treatment of shock. The nurse should: a) Monitor blood pressure continuously. b) Administer pain medication concurrently. c) Monitor for signs of infection. d) Evaluate arterial blood gases at least every 2 hours.

A - The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.

Which sign is an early indicator of heart failure in an infant with a congenital heart defect? a) Tachycardia b) Tachypnea c) Poor weight gain d) Pulmonary edema

A - The earliest sign of heart failure in infants is tachycardia (sleeping heart rate greater than 160 beats/minute) as a direct result of sympathetic stimulation. Tachypnea (respiratory rate greater than 60 breaths/minute in infants) occurs later in response to decreased lung compliance. Poor weight gain is a result of the increased energy demands to the heart and breathing efforts, not an early sign of heart failure itself. Pulmonary edema occurs as the left ventricle fails and blood volume and pressure increase in the left atrium, pulmonary veins, and lungs; it isn't an early sign of heart failure

The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation. The nurse should anticipate which of the following interventions? a) Immediate defibrillation b) An IV line for emergency medications c) An IV push of digoxin d) Synchronized cardioversion

A - When ventricular fibrillation is verified, the first intervention is defibrillation, which is the only intervention that will terminate this lethal dysrhythmia. Digoxin is not indicated for V-fib. An IV will be one of the priorities, but not first. The client would need to have a functional rhythm for synchronized cardioversion to be performed.

The nurse is explaining to the client the risk factors of heart failure. Which of the following risk factors are considered extrinsic factors? a) congenital defects b) coronary artery disease c) diet and weight d) dysrhythmias e) hypertension f) pregnancy

A - congenital defects C - diet and weight E) HTN F) pregnancy Factors external to the heart include conditions that increase afterload like HTN. HTN forces the ventricle to work harder to eject blood. Ventricle eventually fails after prolonged high pressures. The most common cause of HF is CAD. CAD reduces blood flow thru the coronary arteries and therefore reduces O2 delivery to the myocardium. Pregnancy increases the body's demand for O2 and is 1 of the extrinsic factors affecting HF. The workload on the heart increases in an effort to move blood. Diets w/ a high glycemic index (GI) or glycemic load (GL) may contribute to the risk of CHD, along w/ a high intake of red meat and high-fat dairy products, & obesity. Congenital defects (left-to-right shunts) increase preload, the initial stretching of the myocardial muscle fiber length before contraction. This is 1 of the extrinsic factors that can lead to HF. Dysrhythmias are 1 of the INTRINSIC causes of HF. Other intrinsic factors are valve disease and cardiomyopathy.

Which cardiovascular effects of aging should you anticipate when providing care for older adults (select all that apply)? A. Arterial stiffening B. Increased blood pressure C. Increased maximal heart rate D. Decreased maximal heart rate E. Increased recovery time from activity E. Increased recovery time from activity

A, B, D, E. Well-documented cardiovascular effects of the aging process include arterial stiffening, possible increased blood pressure, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease rather than increase with age.

What are considered significant findings related to cardiac disease (select all that apply)? A. Paroxysmal nocturnal dyspnea B. Body mass index (BMI) of 22 kg/m2 C. History of streptococcal throat infections D. Nocturia E. Otitis media

A, C, and D Attacks of shortness of breath, especially at night, that awaken the patient are associated with heart failure. History of improperly treated streptococcal sore throat can cause heart valve damage. Nocturia is a common finding with cardiovascular patients. A BMI of 22 kg/m2 is normal. There is no relationship between otitis media and cardiac disease.

Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which of the following clinical finding? a) Alterations in levels of consciousness. b) Fluctuations of fluid in the collection chamber of the chest drainage system. c) Strong peripheral pulses in all four extremities. d) A urine output of 60ml in 4 hours.

A. Alterations in LOC Clinical signs of low CO and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in LOC. An adequate urine output for a child over 1 year should be 1ml/kg/hour. Therefore 60ml/4hr is satisfactory. Strong peripheral pulses indicate adequate CO. Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the third postoperative day, the fluctuation ceases indicating the lungs have fully expanded.

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant? a) Your child will need oxygen at home. b) Keep feedings small, but frequent. c) There are no restrictions on play. d) It is dangerous to let your child cry.

B - Because children with heart defects fatigue so quickly, frequent small meals are suggested to ensure that the child receives adequate nutrition. Rough play would be considered too physically demanding on the child. Most children do not need oxygen at home.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a) Excess fluid volume related to peripheral vascular disease b) Ineffective peripheral tissue perfusion related to venous congestion c) Impaired gas exchange related to increased blood flow d) Risk for injury related to edema

B - 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. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

The nurse is administering propranolol to a client for control of migraine headaches. The client's pulse rate is 56 bpm. What should the nurse do next? a) Ask for a relative to contact. b) Assess blood pressure. c) Contact the physician immediately. d) Administer oxygen.

B - One of the actions of propranolol, a drug used in the treatment of migraine headaches, is to decrease the heart rate. The nurse should assess the client's blood pressure to evaluate overall circulatory response to the medication. Until the blood pressure value is assessed, there is no immediate need to contact the physician. The nurse should complete the blood pressure assessment before administering the drug. There is no immediate need to administer oxygen or contact a relative because a slowed pulse rate is an expected action of propranolol

A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation? a) Diuresis b) Tachycardia c) Uterine pain d) Weight loss

B - Tachycardia can indicate cardiac decompensation. Weight gain, not loss, may be a sign of heart failure. Diuresis and resulting weight loss are normal after giving birth. Uterine pain may result from the uterus contracting as it shrinks and isn't an immediate concern.

During a cardiac cauterization into the right side of the heart, a pulmonary artery wedge pressure is obtained. What is the purpose of this measurement? A. Determine efficiency of the right heart contraction B. Assess function of the left side of the heart C. Identify coronary lesions D. Measure the heart's afterload

B - The catheter is advanced into the vena cava, the right atrium, and the right ventricle. The catheter is further inserted into the pulmonary artery, and pressures are recorded. The catheter is then advanced until it is wedged in position and looks forward through the pulmonary capillary bed to the pressure in the left side of the heart (wedge pressure). The wedge pressure is used to assess the function of the left side of the heart.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following? a) Breathe slowly after each contraction. b) Remain in a side-lying position with the head elevated. c) Request local anesthesia for vaginal birth. d) Avoid the use of analgesics for the labor pain.

B - The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor.

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? a) Monitoring the platelet count b) Assessing troponin 1 levels c) Monitoring the white blood cell count d) Assessing B-type natriuretic peptide levels

B - Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority.

A 59-year-old man has presented to the emergency department with chest pain. Which component of his subsequent blood work most clearly indicates a myocardial infarction (MI)? A. CK-MB B. Troponin C. Myoglobin D. C-reactive protein (CRP)

B - Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.

Auscultation of a patient's heart reveals a murmur. This assessment finding is a result of A. increased viscosity of the patient's blood. B. turbulent blood flow across a heart valve. C. friction between the heart the myocardium. D. a deficit in heart conductivity that impairs normal contractility.

B - Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? a) Monitoring urine output once a shift b) A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. c) Initiating an antibiotic within 3 hours of the injury d) Infusion of dextrose and water at 50 mL per hour to avoid overload of the circulatory system

B. A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. A client with electrical burns based on energy and potential damage to the heart needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much later. Urine output needs hourly monitoring based on myoglobin release.

After undergoing a cardiac catheterization, the patient returns to the nursing unit. After assessing the femoral insertion site, the nurse should avoid: a) assessing the motor function of the patient's foot on the affected side b) elevating the head of the bead c) providing oral fluids d) resuming all medications

B. Elevating the HOB. After cardiac cath using the femoral artery, the pt should remain on FLAT bedrest & be reminded NOT to flex or move affected extremity. Doing so may result in hemorrhage or arterial occlusion. Fluids are encouraged after any procedure that uses contrast dye. After a cardiac cath, pt must keep the affected extremity straight, so the nurse can place pt in reverse Trendelenburg to facilitate drinking. Assessing motor function of the pt's foot is important to confirm adequate perfusion. Meds should be resumed to treat all other diseases & conditions.

Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first: a) Assess the urine output. b) Place a large bore IV. c) Insert a nasogastric tube. d) Position onto the left side.

B. Place large bore IV. The symptoms suggest an abdominal aortic aneurysm that is leaking or rupturing. An IV should be inserted for immediate volume replacement. With hypovolemia, the urine output will be diminished. Repositioning may potentiate the problem. A nasogastric tube may be considered with severe nausea and vomiting to decompress the stomach.

When collecting subjective data related to the cardiovascular system, which of the following should be obtained from the patient (select all that apply)? a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies

B. Smoking hx C. Religious preference D. # of pillows used to sleep The health history should include assessment of tobacco use. The patient should be asked about any cultural or religious beliefs that may influence the management of the cardiovascular problem. Patients with heart failure may need to sleep with the head elevated on pillows or sleep in a chair.

A 55-year-old man with aortic valve stenosis is being admitted for valve replacement surgery. Which assessment finding should the nurse expect? A. Pulse deficit B. Systolic murmur C. Distended neck veins D. Splinter hemorrhages

B. Systolic murmur The turbulent blood flow across a diseased valve results in a murmur. Aortic stenosis produces a systolic murmur. A pulse deficit indicates a cardiac dysrhythmia, most commonly atrial fibrillation. Distended neck veins may be caused by right-sided heart failure. Splinter hemorrhages occur in patients with infective endocarditis

A client is to start chemotherapy to treat lung cancer. A venous access device is placed to administer chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. Vital signs are BP 80/30, P 132, R 28, T 103 degrees F (39.4 degrees C), and oxygen saturation 84%. The central line insertion site is inflamed. After calling the rapid response team, what should the nurse do next? a) Administer a prescribed antipyretic. b) Insert a peripheral intravenous fluid line and infuse normal saline. c) Obtain a portable ECG monitor. d) Place cold, wet compresses on the client's head.

B. The client is experiencing severe sepsis, and it is essential to increase circulating fluid volume to restore blood pressure and cardiac output. Applying a wet compress, administering an antipyretic, and monitoring the client's cardiac status may be beneficial for this client, but they are not the highest priority action at this time. These three interventions may require the nurse to leave the client, which is not advisable at this time

A client is given amiodarone in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect? a) The ventricular rate is increasing. b) The absent pulse is now palpable. c) The number of premature ventricular contractions is decreasing. d) The fine ventricular fibrillation changes to coarse ventricular fibrillation.

C - Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.

The nurse is caring for a child with a cyanotic heart disease. The mother tells the nurse that she often finds the child in a squatting position and asks if this is normal. Which of the following responses by the nurse is most appropriate? a) "This is a developmentally appropriate way to build strong leg muscles." b) "This position increases blood flow to the lower extremities." c) "This position may help control breathlessness after exercise." d) "Squatting helps to lower the heart rate and conserve energy."

C - Children with congenital heart disease squat or assume a knee-to-chest position to trap blood in the lower extremities. This allows them to more easily oxygenate the blood remaining in the upper body. This is a method children use to relieve dyspnea after exercise or exertion.

Which of the following is a characteristic of high-quality CPR in adults? a) minimizing recoil b) compressing at a depth of about 1 inch c) compressing at a depth of at least 2 inches d) checking for a pulse every minute

C - Guidelines for high-quality CPR includes a compression depth of AT LEAST 2 inches (5 cm) in ADULTS.

A nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he complains of dizziness. What is the nurse's priority action? a) Notify the attending physician. b) Administer a 500 ml IV bolus of normal saline solution (0.9% NaCl). c) Administer atropine 0.5 mg IV push as ordered. d) Administer lidocaine 100 mg IV push as ordered.

C - I.V. push atropine is used to treat symptomatic bradycardia. The attending physician should be notified after the patient is stabilized. A normal saline bolus will treat the hypotension, but will not address the underlying problem. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.

When assessing the cardiovascular system of a 79-year-old patient, you expect to find A. a narrowed pulse pressure. B. diminished carotid artery pulses. C. difficulty in isolating the apical pulse. D. an increased heart rate in response to stress.

C - Myocardial hypertrophy and the downward displacement of the heart in an older adult may result in difficulty isolating the apical pulse.

A client who's 30 weeks pregnant has a corrected atrial septal defect and minor functional limitations. Which pregnancy-related physiologic change places her at greatest risk for more severe cardiac problems? a) Decreased cardiac output b) Decreased heart rate c) Increased plasma volume d) Increased blood pressure

C - Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels.

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a) Difficulty breathing or swallowing b) Tachycardia, tachypnea, and hypotension c) Hemiplegia, seizures, and decreased level of consciousness (LOC) d) Nausea, vomiting, and profuse sweating

C - Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action should be to: a) Obtain a portable chest radiograph. b) Call for the physician. c) Start an I.V. line. d) Draw blood for laboratory studies.

C - Start IV line Advanced cardiac life support recommends that at least one or two I.V. lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the I.V. line.

Metoprolol is added to the pharmacologic therapy of a woman with diabetes diagnosed with stage 2 hypertension and initially treated with furosemide and ramipril. An expected therapeutic effect is: a) Improvement in blood sugar levels. b) Lessening of fatigue. c) Decrease in heart rate. d) Increase in urine output.

C - The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output.

The portion of the vascular system responsible for hemostasis is the A. thin capillary vessels. B. endothelial layer of the arteries. C. elastic middle layer of the veins. D. smooth muscle of the arterial wall.

C - The innermost lining of the arteries is the endothelium. The endothelium maintains hemostasis, promotes blood flow, and under normal conditions, inhibits blood coagulation.

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: a) Control chest pain. b) Reduce coronary artery vasospasm. c) Revascularize the blocked coronary artery. d) Control the arrhythmias associated with MI.

C - The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area.

If the Purkinje system is damaged, conduction of the electrical impulse is impaired through the A. atria. B. AV node. C. ventricles. D. bundle of His.

C - VENTRICLES. The action potential of the electrical impulse diffuses widely through the walls of both ventricles by means of Purkinje fibers.

The main benefit of changing the BLS sequence of steps is that a) rescuers no longer need to give breaths b) it slows the time of compressions so the rescuer does not begin CPR too quickly c) rescuers can start chest compressions sooner

C - rescuers can start chest compressions sooner

The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be which of the following? a) Decrease anxiety b) Administer sublingual nitroglycerin c) Enhance myocardial oxygenation d) Educate the client about his symptoms

C -Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration is not the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.

When looking at the electrocardiogram (ECG) of the patient, the nurse knows that the QRS complex recorded on the ECG represents which part of the heart's beat? A. Depolarization of the atria B. Repolarization of the ventricles C. Depolarization from AV node throughout ventricles D. The length of time it takes for the impulse to travel from the atria to the ventricles

C. Depolarization from AV node throughout ventricles The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.

A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? a) The client is experiencing an allergic reaction to the dobutamine. b) The dosage of the dobutamine needs to be increased. c) The dobutamine may need to be decreased. d) The client is experiencing an exacerbation of the heart failure.

C. Dobutamine may need to be decreased. Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client shows not symptoms of allergic reaction or heart failure.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? a) Encourage the client to cough and deep breathe b) Contact the physician. c) Elevate the head of the bed 30 to 45 degrees. d) Auscultate the lungs to detect abnormal breath sounds.

C. Elevate HOB Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

A relative of a multigravida client who gave birth vaginally 2 hours ago notifies the nurse that the client is pale and shaky. Which are the priority assessments for the nurse to make? a) Temperature and level of consciousness b) Blood glucose level and vital signs c) Fundus and lochia d) Uterine infection and pain

C. fundus and lochia A pale and shaking patient could be experiencing hypovolemic shock resulting from blood loss. A primary cause of blood loss after childbirth is uterine atony. Therefore, the priority assessment should be of the uterine fundus for firmness and location. In addition the amount of vaginal bleeding (lochia) should also be assessed. An immediate intervention for uterine atony is fundal massage, which will help the uterus contract and therefore stop additional bleeding. Assessing the client's level of consciousness does not require additional time and can be done while the nurse assesses the fundus and lochia. Obtaining vital signs, blood glucose level, and temperature is important, but should be done after the fundus has been assessed and massaged or obtained by a second responder. Assessing for uterine infection and pain should be done after the initiation of treatment for hypovolemic shock. (

Why do you need to allow the chest to recoil completely after each compression during BLS?

Chest recoil allows blood to flow into the heart and is necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces the blood flow created by chest compressions.

Which instruction given to a patient who is about to undergo Holter monitoring is most appropriate? A. You may remove the monitor only to shower or bathe. B. You should connect the monitor whenever you feel symptoms. C. You should refrain from exercising while wearing this monitor. D. You must keep a diary of all your activities and symptoms.

D - A Holter monitor is worn for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.

The nurse is assessing a client with an atrial septal defect (ASD). Which requires immediate nursing intervention? a) Client having tachycardia at a rate of 100 beats/min b) Client not taking his angiotensin-converting enzyme inhibitor this morning c) Fixed split S2, which does not vary with respiration d) Client having an uneven smile and facial droop

D - A fixed S2 split is the hallmark of ASD. The neurologic finding of a facial droop could indicate embolization and stroke; the nurse should notify the healthcare provider immediately. If the client has missed a medication, the nurse should measure the vital signs and administer the medication as soon as possible; however, symptoms of stroke are the priority. The nurse should further assess tachycardia to determine the underlying cause, such as pain or fever, before intervening.

When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take? a) Explain that this finding may indicate a cardiac disorder. b) Contact the client's primary health care provider. c) Consult with a cardiologist. d) Document the finding, which is normal during pregnancy.

D - Document the finding; it is normal during pregnancy During pregnancy, a systolic ejection murmur over the pulmonic area is a common finding. Typically, it results from increases in blood volume and cardiac output, along with changes in heart size and position. Other cardiac rhythm disturbances also may occur during pregnancy and don't require treatment unless the client has concurrent heart disease. The nurse should document the finding and check for the murmur during the next visit. The nurse need not consult a cardiologist or the primary care health provider and shouldn't tell the client that this finding indicates a cardiac disorder.

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: a) Causing an increased myocardial oxygen demand. b) Antispasmodic effects on the pericardium. c) Improved conductivity in the myocardium. d) Vasodilation of peripheral vasculature.

D - Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a) Nausea, vomiting, and profuse sweating b) Tachycardia, tachypnea, and hypotension c) Difficulty breathing or swallowing d) Hemiplegia, seizures, and decreased level of consciousness (LOC)

D - Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage

A nurse is caring for a 2-year-old child with tetralogy of Fallot (TOF) who is scheduled for surgery in 24 hours. What intervention is the most important for the nurse to include in the plan of care? a) Meperidine for pain b) Oxygen at 2L/nasal cannula c) Encourage activity in the playroom d) Position the child with knees to the chest

D - TOF consists of four congenital anomalies: pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. Interventions for care include high flow oxygen, morphine, beta-blockers and positioning with knees to chest.

According to the 2010 AHA Guidelines for CPR and ECC, the recommended rate for performing chest compressions for victims of all ages is a) at least 40 compressions per minute b) at least 60 compressions per minute c) at least 80 compressions per minute d) at least 100 compressions per minute

D - The 2010 AHA Guidelines for CPR and ECC specify that the compressions can be given at a rate of "at least 100 per minute", a change from "approximately 100 per minute."

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to the physician? a) Pain during sexual activity. b) Pain during or after a physical activity. c) Pain during an argument. d) A change in the pattern of the chest pain.

D - The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn-mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.

What is the nurse's priority action for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention? a) Apply supplemental oxygen at 4 L/min. b) Notify the attending physician. c) Administer furosemide 40 mg IV as ordered. d) Reposition the client so his lower legs dangle off the bed.

D - The client's presentation suggests congestive heart failure. Cardiac output is compromised. Dangling the legs will cause pooling of blood in the lower extremities, allowing some relief to the overloaded heart. Oxygenation will improve with improved cardiac output. Furosemide will decrease the fluid, but will take some time to work. Notifying the attending should occur after the client is rescued.

A nurse notes that the client's PR interval is .17 and the QRS complex is .10. What action should the nurse take next? a) Request a 12-lead electrocardiogram. b) Administer the ordered nitroglycerin paste. c) Give 2 liters of oxygen via nasal cannula. d) Document the findings.

D - These are normal findings. The nurse should document the findings. A 12-lead ECG would be ordered if the client needs further evaluation in the event of an abnormal finding. Administering nitroglycerin is a routine intervention and not related to the measured PR and QRS intervals. Oxygen administration is not indicated in the presence of normal findings.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to: a) eat three well-balanced meals per day. b) exercise 1 hour before each meal. c) take a vitamin and mineral supplement. d) divide daily food intake into five or six meals.

D - To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue.

A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following? a) Cardiac output b) Cardiac index c) Right atrial blood flow d) Left end-diastolic pressure

D - When wedged, the catheter "points" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowly inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end-diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution, not wedge pressure. Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area, and is considered a more accurate reflection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter

The first link in the AHA adult Chain of Survival is a) rapid defibrillation b) early high-quality bystander CPR c) effective advanced life support, including stabilization and transport d) immediate recognition of cardiac arrest and activation of the emergency response system

D - immediate recognition of cardiac arrest and activation of the emergency response system

A 74-year-old woman who is admitted with severe dyspnea has a history of heart failure and chronic obstructive lung disease. Which diagnostic study would the nurse expect to be elevated if the cause of dyspnea was cardiac related? A. Serum potassium B. Serum homocysteine C. High-density lipoprotein D. b-type natriuretic peptide (BNP)

D. BNP Elevation of b-type natriuretic peptide (BNP) indicates the presence of heart failure. Elevations help to distinguish cardiac vs. respiratory causes of dyspnea. Elevated potassium, homocysteine, or HDL levels may indicate increased risk for cardiovascular disorders but do not indicate that cardiac disease is present.

On return from surgery, the patient is wearing intermittent sequential compression stockings that he does not want to keep on. How should the nurse explain their necessity to the patient while he is on bed rest? A. The socks keep the legs warm while the patient is not moving much. B. The socks maintain the blood flow to the legs while the patient is on bed rest. C. The socks keep the blood pressure down while the patient is stressed after surgery. D. The socks provide compression of the veins to keep the blood moving back to the heart.

D. The socks provide compression of the veins to keep the blood moving back to the heart. Intermittent sequential compression stockings provide compression of the veins while the patient is not using skeletal muscles to compress the veins, which keeps the blood moving back to the heart and prevents blood pooling in the legs that could cause deep vein thrombosis. The warmth is not important. Blood flow to the legs is not maintained. Blood pressure is not decreased with the use of intermittent sequential compression stockings.

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which of the following is the appropriate nursing intervention? a) Reassessing vital signs in 15 minutes b) Increasing the rate of IV fluids c) Inserting a Foley catheter to monitor urine output d) Contacting the physician

D. contact physician The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.

A client with chest pain is admitted to the telemetry unit. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. The nurse should do the following interventions in which order from first to last? 1. Administer the ordered dose of morphine. 2. Obtain a history of which drugs the client has used recently. 3. Take vital signs. 4. Position electrodes on the chest.

Position electrodes Take VS Administer ordered dose of morphine Obtain hx of recent drugs The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine, which is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.

Which is a correct aspect of a cardiac assessment? A. Auscultate the carotid artery to hear a thrill. B. The point of maximal impulse is at the fifth left intercostal space. C. Erb's point is located at the right second intercostals space. D. S1 and S2 cardiac sounds are best heard with the bell of the stethoscope.

When the patient is supine, the mitral valve area is the point of maximal impulse (PMI), which is also known as the apical pulse. It reflects the pulsation of the apex of the heart and is located at the left midclavicular line in the fifth intercostal space. A thrill is assessed by touch, a bruit is heard by auscultation, and Erb's point is located at the third left intercostal space, near the sternum. It is where the S2 heart sound is normally heard best. S1 and S2 are best heard with the diaphragm of the stethoscope because they are high-pitched sounds.

The nurse is knowledgeable about Sinoatrial Node Dysrhythmias if she selects which of the following causes of Sinus Tachycardia? a. emotional and physical stress b. fever c. heart failure d. increased intracranial pressure e. infection f. myocardial infarction

a. emotional and physical stress b. fever c. heart failure e. infection Sinus Tachycardia is defined as a sinus rhythm with a rate of greater than 100 bpm. Causes of ST include: fever, emotional & physical stress, HF, fluid volume loss, hyperthyroidism, Hypercalcemia, caffeine, nicotine, exercise, and some medications. In the vast majority of cases, sinus tachycardia results from some underlying condition, such as exercise, infection, or CHF, which alters the autonomic nervous system. Sinus bradycardia may result from the following: Valsalva's maneuver, some drugs like digitalis, MI, hyperkalemia, hypothyroidism, severe hypoxia, and increased ICP

a complication that can occur in the first 24 hours after PCI

abrupt closure

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of PE? Select all that apply. a) A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy. b) A client who has recently been admitted with a broken femur and is awaiting surgery. c) A client who has a large venous stasis ulcer on the right ankle area. d) A client who is on complete bed rest following extensive spinal surgery. e) A client who has a pleural effusion secondary to lung cancer. f) A client who is receiving supplemental oxygen following shoulder surgery.

• A client who is on complete bed rest following extensive spinal surgery. • A client who has a large venous stasis ulcer on the right ankle area. • A client who has recently been admitted with a broken femur and is awaiting surgery. • A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy. Bed rest, poor venous circulation, fractures, and hormone replacement therapy can cause formation of a thromboembolus, placing these clients at risk for developing a PE. A deep vein thrombosis could break loose in the leg and travel to the lungs as a pulmonary embolus. The clot would then lodge in the pulmonary arteries or arterioles and impede blood flow. The client who is on complete bed rest is at risk for venous stasis, and the client who has a venous stasis ulcer is already demonstrating this condition. The client with a broken femur is at risk for a fat embolus, another form of PE. The client on estrogen replacement therapy is at increased risk for thromboembolic disorders. Pleural effusion and lung cancer usually have no effect on thrombus formation, and oxygen therapy does not cause venous stasis or increase the risk of a PE

Which of the following outcomes is desired when a client with arterial insufficiency has poor tissue perfusion in the extremities? Select all that apply. a) Decreased muscle pain with activity. b) Participation in self-care measures. c) Improved respiratory status. d) Extremities warm to touch. e) Lungs clear to auscultation

• Extremities warm to touch. • Decreased muscle pain with activity. The desired outcome for the client with poor circulation to the extremities is evidence of adequate blood flow to the area. The temperature of the involved extremity is an important indicator for a client with peripheral vascular disease. The temperature will indicate the degree to which the blood supply is getting to the extremity. Warmth indicates adequate blood flow. Pain is also an indicator of blood flow. Pain, such as muscle pain, suggests ischemia and lack of oxygen that results when the oxygen demand becomes greater than the supply. Thus, a decrease in muscle pain with activity would suggest improvement in blood flow to the area. Improved respiratory status and clear lungs are unrelated to the poor tissue perfusion. Although participation in self-care measures is always helpful, this outcome is not a result of establishing circulation to the extremities.

Eptifibitide

(Integrelin) - A glycoprotein IIb/IIIa inhibitor (antiplatelet agent) used to prevent platelet aggretation around thrombi and atherosclerotic lesions

The nurse enters a client's room and finds the client slumped over in a chair. What actions should the nurse take? Place in sequential order. Use all the options. 1 . Place the client on a firm surface 2. Establish unresponsiveness 3. Check pulse 4. Begin cycles of 30 compressions and 2 breaths 5. Activate resuscitation team

2, 5, 1, 3, 4 2. Establish unresponsiveness 5. Activate resuscitation team 1. Place client on a firm surface 3. Check pulse 4. Begin cycles of 30 compressions and 2 breaths The nurse should first establish unresponsiveness. After unresponsiveness is confirmed, the nurse should activate the resuscitation team. Next, the nurse should place the client on a firm surface, and check for a pulse. If there is no pulse, the nurse should begin cycles of 30 compressions and 2 breaths.

When a person's blood pressure rises, the homeostatic mechanism that compensates for the elevation involves stimulation of A. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation. B. chemoreceptors that inhibit the sympathetic nervous system, causing vasodilation. C. baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation. D. chemoreceptors that stimulate the sympathetic nervous system, increasing the heart rate.

A - baroreceptors that inhibit the SNS, causing VASODILATION Baroreceptors in the aortic arch and carotid sinus are sensitive to stretch or pressure within the arterial system. Stimulation of these receptors sends information to the vasomotor center in the brainstem. This results in temporary inhibition of the sympathetic nervous system and enhancement of the parasympathetic influence, decreasing the heart rate and peripheral vasodilation.

A patient is admitted to the CCU with a diagnosis of unstable angina. Which of the following medications would the nurse expect the patient to receive (select all that apply)? a. antiplatelet therapy. b. fibrinolytic therapy. c. β-adrenergic blockers. d. prophylactic antibiotics. e. intravenous nitroglycerin.

A. Antiplatelet therapy B. Fibrinolytic therapy E. IV nitroglycerin In addition to oxygen, several medications may be used to treat unstable angina (UA): nitroglycerin, aspirin (chewable), and morphine. For patients with UA with negative cardiac markers and ongoing angina, a combination of aspirin, heparin, and a glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin]) is recommended. Angiotensin-converting enzyme (ACE) inhibitors decrease myocardial oxygen demand by producing vasodilation, reducing blood volume, and slowing or reversing cardiac remodeling.

A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine sulfate I.V. by patient-controlled analgesia (PCA) 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should: a) Take the client's blood pressure. b) Administer oxygen. c) Discontinue the PCA pump. d) Assist the client back to bed.

A. Take BP. The nurse should take the client's blood pressure. She is likely experiencing orthostatic hypotension. The PCA pump does not need to be discontinued because, as soon as the blood pressure stabilizes, the pain medication can be resumed. Administering oxygen is not necessary unless the oxygen saturation also drops. The client should sit in the chair until the blood pressure stabilizes.

In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include which of the following (select all that apply)? A) diffuse involvement of plaque formation in coronary veins. B) abnormal levels of cholesterol, particularly low-density lipoproteins C) accumulation of lipid and fibrous tissue within the coronary arteries D) development of angina due to decreased blood supply to the heart muscle E) chronic vasoconstriction of coronary arteries leading to permanent vasospasm.

B. Abnormal levels of cholesterol C. Accumulation of lipid and fibrous tissue within the coronary arteries D. Development of angina due to decreased blood supply to the heart muscle Atherosclerosis is the major cause of (CAD) and is characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery. The endothelial lining of the coronary arteries becomes inflamed from the presence of unstable plaques and the oxidation of low-density lipoprotein (LDL) cholesterol. Fibrous plaque causes progressive changes in the endothelium of the arterial wall. The result is a narrowing of the vessel lumen and a reduction in blood flow to the myocardial tissue.

The patient is confused about how there can be a blockage in the left anterior descending artery (LAD), but there is damage to the right ventricle. The nurse can help the patient understand this with which explanation? A. "The one vessel curves around from the left side to the right ventricle." B. "The LAD supplies blood to the left side of the heart and part of the right ventricle." C. "The right ventricle is supplied during systole primarily by the right coronary artery." D. "It is actually on your right side of the heart, but we call it the left anterior descending vessel."

B. The LAD supplies blood to the left side of the heart and part of the right ventricle The best response is explaining that the lower portion of the right ventricle receives blood flow from the left anterior descending artery as well as the right coronary artery during diastole.

While auscultating the patient's heart sounds with the bell of the stethoscope, the nurse hears these sounds. How should the nurse document what is heard? A. Diastolic murmur B. Third heart sound (S3) C. Fourth heart sound (S4) D. Normal heart sounds (S1, S2)

B. Third heart sound (S3) The third heart sound is heard closely after the S2 and is known as a ventricular gallop because it is a vibration of the ventricular walls associated with decreased compliance of the ventricles during filling. It occurs with left ventricular failure. Murmurs sound like turbulence between normal heart sounds and are caused by abnormal blood flow through diseased valves. The S4 heart sound is a vibration caused by atrial contraction, precedes the S1, and is known as an atrial gallop. The normal S1 and S2 are heard when the valves close normally.

While assessing the cardiovascular status of a patient, you perform auscultation. Which practice should you implement into the assessment during auscultation? A. Position the patient supine. B. Ask the patient to hold his or her breath. C. Palpate the radial pulse while auscultating the apical pulse. D. Use the bell of the stethoscope when auscultating S1 and S2.

C - Rationale To detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. The diaphragm of the stethoscope is more appropriate than the bell when auscultating S1 and S2. A sitting or side-lying position is most appropriate for cardiac auscultation. It is not necessary to ask the patient to hold his or her breath during cardiac auscultation.

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which of the following functions? a) Advocacy b) Clinical coordination c) Delegation d) Networking

C. Delegation The professional nurse is responsible for delegating routine nursing measures to non-licensed personnel. The nurse needs to make the decision as to which aspects can be delegated and which clients need to be assessed and cared for by professional nurses. The definitions of the other terms do not pertain to this situation

Nurse Progress Notes (Time - 12:30 AM) Urinary output for the last 4 hours: 90 mL Capillary Refill: >3 seconds Blood Pressure: 128/82 Extremities: Cool An older adult had a myocardial infarction (MI) 4 days ago. At 9:30 am, the client's blood pressure is 102/64. After reviewing the client's progress notes (see chart), the nurse should first: a) Give a fluid challenge/bolus. b) Assist the client to walk. c) Notify the health care provider. d) Administer furosemide as prescribed.

C. Notify HCP. All of the 12 pm assessments are signs of decreased CO and can be an ominous sign in a pt who has recently experienced an MI; the nurse should notify the HCP of these changes. CO and BP may continue to fall to dangerous levels, which can induce further coronary ischemia and extension of the infarct. While the pt is currently hypotensive, giving a fluid challenge/bolus can precipitate increased workload on a damaged heart and EXTEND the MI. Exercise or walking for this pt will increase both the HR and stroke volume, both of which will increase CO, but the increased CO will increase O2 needs especially in the heart muscle and can induce further coronary ischemia and extension of the infarct. The pt is hypotensive. Although the pt has decreased urinary output, this is the body's response to a decreasing CO, and it is not appropriate to administer furosemide.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? a) Serum sodium level of [132 mEq/L 132 mmol/L)] b) Urine specific gravity of 1.025 c) Blood urea nitrogen (BUN) level of [29 mg/dl (10.4 mmol/L)] d) Serum potassium level of [3 mEq/L (3.0 mmol/L)]

D. A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal

A client comes to the emergency department reporting of 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 of the following should the nurse do first when the client is admitted to the coronary care unit? a) Obtain a health history. b) Evaluate the client's pain. c) Auscultate heart sounds. d) Begin telemetry monitoring.

D. Begin telemetry monitoring. Telemetry monitoring should be started as soon as possible. Life-threatening arrhythmias are the leading cause of death in the first hours after MI. The other options are secondary in importance to assessing abnormal, life-threatening rhythms.

While the nurse is working in a homeless shelter, assessment of a 6-month-old infant reveals a respiratory rate of 52 breaths/minute, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which of the following actions would be most appropriate? a) Send the infant for a chest radiograph. b) Administer a nebulizer treatment. c) Provide teaching about cold care to the mother d) Refer the infant to the emergency department.

D. Refer infant to ED Based on the assessment findings of increased respiratory rate, retractions, and wheezing, this infant needs further evaluation, which could be obtained in an emergency department. Without a definitive diagnosis, administering a nebulizer treatment would be outside the nurse's scope of practice unless there was an order for such a treatment. Sending the infant for a radiograph may not be in the nurse's scope of practice. The findings need to be reported to a primary health care provider who can then determine whether or not a chest radiograph is warranted. The infant is exhibiting signs and symptoms of respiratory distress and is too ill to send out with just instructions on cold care for the mother.

Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction? a) Liquids as desired. b) Nothing by mouth. c) Three regular meals per day. d) Small, easily digested meals.

D. Small, easily digested meals Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.

When is the risk for restenosis after PCI the greatest?

In the first 30 days following the procedure

The nurse is assessing a patient after returning from surgery. After reviewing the patient's lab results, the nurse should notify the physician of: a. Magnesium 1.1 mEq/L b. Phosphorus 3.8 c. Potassium 3.6 mEq/L d. Sodium 146 mEq/L

Magnesium 1.3-2.1 mEq/L Phosphorus 3-4.5 mg/dL Sodium 135-145 mEq/L Potassium 3.5-5.0 mEq/L A. The pt's magnesium level is low, putting the pt at risk for ventricular arrhythmias such as Torsades de pointes. Although the sodium level is slightly elevated, it is not critical. A slight decrease in magnesium has more serious consequences.

The nurse has reinforced a pressure dressing on a client who is post-operative mastectomy and notes there is considerable sanguineous drainage in the hemovac. Which of the following assessments should the nurse report to the physician? Select all that apply. a) Warm, dry skin; radial pulse of 86 bpm b) Cold, clammy skin; blood pressure 120/80 mm Hg c) Blood pressure 86/50 mm Hg; pulse weak and thready at 120 bpm d) Weak, thready pulse at 88 bpm; blood pressure 140/80 mm Hg e) Fever of 102F, no urine output for 2 hours

• Blood pressure 86/50 mm Hg; pulse weak and thready at 120 bpm (C) • Fever of 102F, no urine output for 2 hours (E) A weak, thready pulse may be a sign of hemorrhage. A fever with no urine output may also indicate a problem with the kidneys and possible infection. Cold, clammy skin can indicate compensation if the BP is adequate. Warm, dry skin with a pulse of 86 bpm is an expected outcome.