Week 2 - High Risk Cardiac
A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? - "I should eat foods high in saturated fat." - "Before taking my medication, I will count my radial pulse rate." - "I will exercise once per week for an hour at the health club." - "I will stop taking my medication when my blood pressure is within a normal range."
"Before taking my medication, I will count my radial pulse rate." A beta blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration.
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? - 0.45% sodium chloride - Dextrose 5% in 0.9% in sodium chloride - Dextrose 10% in water - 0.9% sodium chloride
0.9% sodium chloride Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products.
A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hours. Available is a blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min? (round the answer to the nearest whole number. used a leading zero if it applies. do not use a trailing zero.)
10 gtt/min
The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication? - 160-190 mg/dL - 280-300 mg/dL - 210-240 mg/dL - 250-275 mg/dL
160-190 mg/dL Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.
The nurse is caring for a client with Raynaud syndrome. What is an important instruction for a client who is diagnosed with this disease to prevent an attack? - Avoid situations that contribute to ischemic episodes. - Avoid fatty foods and exercise. - Report changes in the usual pattern of chest pain. - Take over-the-counter decongestants.
Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud syndrome and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.
A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)? - Anxiousness, restlessness, and lightheadedness - Chest discomfort not relieved by rest or nitroglycerin - Cool, clammy skin and a diaphoretic, pale appearance - Intermittent nausea and emesis for 3 days
Chest discomfort not relieved by rest or nitroglycerin Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.
The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient? - Increases the heart rate - Decreases the sinoatrial node automaticity - Creates a positive inotropic effect - Increases the atrioventricular node conduction
Decreases the sinoatrial node automaticity Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect)
A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? - Bradycardia with S-T segment depression - Relief of chest pain with deep inspiration - Dyspnea with hiccups - Chest pain that increases when sitting upright
Dyspnea with hiccups The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.
A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? - Elevated ST segment - Absent Q wave - Widened QRS complex - Prolonged PR interval
Elevated ST segment Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.
Which is a modifiable risk factor for coronary artery disease (CAD)? - Family history - Increasing age - Hyperlipidemia - Male gender
Hyperlipidemia Other modifiable risk factors for CAD include tobacco use, hypertension, diabetes, metabolic syndrome, obesity, and physical inactivity. Increasing age, male gender, and family history are nonmodifiable risk factors for CAD.
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (select all that apply) - Jugular vein distension - Moist crackles - Postural hypotension - Increased heart rate - Fever
Jugular vein distension Moist crackles Increased heart rate The increase in venous pressure due to excessive circulating blood volume results in neck vein distension. This is an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses.
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? - The client exhibits a heart rate above 100 beats/minute. - The client demonstrates ability to tolerate more activity without chest pain. - The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking. - The client states that sublingual nitroglycerin usually relieves his chest pain.
The client demonstrates ability to tolerate more activity without chest pain. The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hours? - Infective endocarditis - Pericarditis - Ventricular dysrhythmias - Pulmonary emboli
Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.
The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the emergency room. What is the most important cardiac marker for the client? - myoglobin - creatine kinase - troponin - lactate dehydrogenase
troponin This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin tests can show evidence of muscle injury, but the studies are less specific indicators of myocardial damage than troponin.
A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postprocedure plan of care? - Instruct the client on a long-term cardiac conditioning program. - Administer scheduled doses of acetaminophen. - Check for peak laboratory markers of myocardial damage. - Monitor for bleeding.
Monitor for bleeding. Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client remains on bed rest until hemostasis is assured.
Which method to induce hemostasis after sheath removal after percutaneous transluminal coronary angioplasty (PTCA) is most effective? - Application of a vascular closure device such as Angio-Seal or VasoSeal - Direct manual pressure - Application of a pneumatic compression device (e.g., FemoStop) - Application of a sandbag to the area
Application of a vascular closure device such as Angio-Seal or VasoSeal Application of a vascular closure device has been demonstrated to be very effective. Direct manual pressure to the sheath introduction site and application of a pneumatic compression device after PTCA have been demonstrated to be effective; the former was the first method used to induce hemostasis after PTCA. Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding
After percutaneous transluminal coronary angioplasty (PTCA), the nurse confirms that a client is experiencing bleeding from the femoral site. What will be the nurse's initial action? - Notify the health care provider. - Review the results of the latest blood cell count, especially the hemoglobin and hematocrit. - Apply manual pressure at the site of the insertion of the sheath. - Decrease anticoagulant or antiplatelet therapy.
Apply manual pressure at the site of the insertion of the sheath. The immediate nursing action would be to apply pressure to the femoral site. Reviewing blood studies will not stop the bleeding. The nurse cannot decrease anticoagulation therapy independently. If the bleeding does not stop, the health care provider needs to be notified
The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD? - Assess the client's mental and emotional status. - Assess the characteristics of chest pain. - Assess the skin of the client. - Assess for any kind of drug abuse.
Assess the characteristics of chest pain. The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? - P waves occurring at 0.16 seconds before each QRS complex - Atrial rate of 300/min with QRS complex of 80/min - Ventricular rate of 82/min with an atrial rate of 80/min - An irregular ventricular rate of 125/min with a wide QRS pattern
Atrial rate of 300/min with QRS complex of 80/min The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.
A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of recieving blood transfusions. For which of the following complications should the nurse monitor? - Hypokalemia - Lead poisoning - Hypercalcemia - Iron toxicity
Iron toxicity The client who has received several blood transfusions is at risk for development of hemosiderosis, which is excess storage of iron in the body. The excessive iron can come from overuse of supplements or from receiving frequent blood transfusions, as in sickle cell anemia.
A nurse is reviewing a client's repeat laboratory results 4 hrs after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? - Prothrombin time - WBC count - Platelet count - Hematocrit
Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.
A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is? - Associated with nausea and vomiting - Relieved by rest and nitroglycerin - Described as crushing and substernal - Accompanied by diaphoresis and dyspnea
Relieved by rest and nitroglycerin One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data
A client reports chest pain that occurs when playing tennis but resolves when sitting down. The nurse knows these symptoms are common for which type of angina? - Intractable - Stable - Unstable - Variant
Stable Angina is usually caused by atherosclerotic disease and most often is associated with a significant obstruction of at least one major coronary artery. Normally, the myocardium extracts a large amount of oxygen from the coronary circulation to meet its continuous demands. When demand increases, flow through the coronary arteries needs to be increased. When there is a blockage in a coronary artery, flow cannot be increased and ischemia results. There are different types of angina. Stable angina is predictable and consistent pain that occurs on exertion and is relieved by rest or nitroglycerin. This is the type of angina the client is describing. Variant angina is pain at rest with reversible ST-segment elevation and is thought to be caused by a spasm of a coronary artery. In unstable angina, the symptoms increase in frequency and severity and may not be relieved with rest or nitroglycerin. Intractable angina pectoris causes severe incapacitating chest pain.
When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina? - Unstable - Refractory - Intractable - Variant
Unstable Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.
The nurse is caring for a client after cardiac surgery. What is the most immediate concern for the nurse? - bilateral rales and rhonchi - weight gain of 6 ounces - potassium level of 6 mEq/L - serum glucose of 124 mg/dL
potassium level of 6 mEq/L Changes in serum electrolytes should be immediately reported, especially a potassium level of 6 mEq/L. An elevated blood sugar is common postoperatively, and the weight gain is not significant. The abnormal breath sounds are of concern, but the electrolyte imbalance is the most immediate condition that needs to be addressed
Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles? - Hypertension - Fluid overload - Hypothermia - Cardiac tamponade
Cardiac tamponade Cardiac tamponade is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing the blood from filling the ventricles. Fluid overload is exhibited by high pulmonary artery wedge pressure, central venous pressure, and pulmonary artery diastolic pressure, as well as crackles in the lungs. Hypertension results from postoperative vasoconstriction. Hypothermia is a low body temperature that leads to vasoconstriction.
The client asks the nurse to explain the difference between arteriosclerosis and atherosclerosis. Which is the best explanation the nurse can give to the client? - "Arteriosclerosis is a loss of elasticity of the arteries that accompanies the aging process, whereas atherosclerosis is a condition in which the arteries fill with plaque." - "Both are disorders in which the lining of the vessels become narrowed due to plaque." - "Arteriosclerosis is when the vessels become dilated and weakened, whereas atherosclerosis is the deposit of fatty substances in the vessel lining." - "Both terms refer to the same disorder and can be used interchangeably."
"Arteriosclerosis is a loss of elasticity of the arteries that accompanies the aging process, whereas atherosclerosis is a condition in which the arteries fill with plaque." Arteriosclerosis refers to the loss of elasticity or hardening of the arteries that accompanies the aging process, whereas atherosclerosis is a condition in which the lumen of arteries fills with fatty deposits called plaque. The two terms do not refer to the same disorder, nor can they be used interchangeably. The other responses provide the client with inaccurate information.
A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98, heart rate 102, respirations 22, and SpO2 95%. Which of the following actions should the nurse take? - Administer antihypertensive medication for blood pressure. - Monitor that urinary output is 20 mL/hr. - Withhold pain medication to prepare for surgery. - Take vital signs every 2 hr.
Administer antihypertensive medication for blood pressure. The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.
A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take? - Check for hypertension. - Auscultate for loud, bounding heart sounds. - Auscultate blood pressure for pulsus paradoxus. - Check for a pulse deficit.
Auscultate blood pressure for pulsus paradoxus. The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.
A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? - Chest pain is relieved soon after resting. - Nitroglycerin relieves chest pain. - Physical exertion does not precipitate chest pain. - Chest pain lasts longer than 15 min.
Chest pain lasts longer than 15 min. The client who has unstable angina will have chest pain lasting longer than 15 min. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? - Coarse crackles - Wheezes - Rhonchi - Friction rub
Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.
The nurse is to administer morphine sulfate to a client with chest pain. What initial nursing action is required prior to administration? - Count the respiratory rate for bradypnea. - Check the radial pulse for dysrhythmias. - Measure the blood pressure for hypertension. - Measure urinary output for dehydration.
Count the respiratory rate for bradypnea. The nurse should always check the respiratory rate prior to administering morphine sulfate. The drug should be withheld, and the health care provider notified, if the respiratory rate is below 16 breaths/minute.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? - Decreased capillary refill - Dyspnea - Orthopnea - Dependent edema
Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to development of dependent edema.
A nurse in a clinical is assessing the lower extremities and ankles of a client who has a history of peripheral artery disease. Which of the following findings should the nurse expect? - Pitting edema - Areas of reddish-brown pigmentation - Dry, pale skin with minimal body hair - Sunburned appearance with desquamation
Dry, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.
When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality? - Hypercalcemia - Hyponatremia - Hyperkalemia - Hypomagnesemia
Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without a change in T wave formation.
A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply. - Obesity - Gender - Race - Hyperlipidemia - Tobacco use
Hyperlipidemia Obesity Tobacco Use Modifiable risk factors for coronary artery disease include hyperlipidemia, tobacco use, hypertension, diabetes mellitus, metabolic syndrome, obesity, and physical inactivity. Nonmodifiable risk factors include family history, advanced age, gender, and race.
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching? - Hospitalization is required when administering each treatment. - The maximum effect of the medication will occur in 6 months. - Hypertension is a common adverse effect of this medication. - Blood transfusions are needed with each treatment.
Hypertension is a common adverse effect of this medication. The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.
Which is the most important postoperative assessment parameter for a client recovering from cardiac surgery? - Blood glucose concentration - Mental alertness - Activity intolerance - Inadequate tissue perfusion
Inadequate tissue perfusion The nurse must assess the client for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood glucose and mental status, tissue perfusion is the higher priority. Assessing for activity intolerance, while important later in the recovery period, is not essential in the immediate postoperative period for clients undergoing cardiac surgery.
The nurse notes that the post cardiac surgery client demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025). What will the nurse anticipate the health care provider will order? - Decrease intravenous fluids - Irrigate the urinary catheter - Increase intravenous fluids - Prepare the client for dialysis
Increase intravenous fluids Urine output of less than 25 mL/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. The health care provider may increase intravenous fluids. Irrigating the urinary catheter will be done if there is a suspected blockage. Dialysis is not indicated by urinary volumes.
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? - Increased cardiac output - Increased pulmonary congestion - Decreased left atria pressure - Decreased pulmonary artery pressure
Increased pulmonary congestion Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure.
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions shoulder the nurse include in the plan? - Administer ferrous sulfate supplementation. - Increase dietary intake of folic acid. - Initiate weekly injections of vitamin B12. - Initiate a blood transfusion.
Initiate weekly injections of vitamin B12. The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract.
An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. Changes in which leads of a 12-lead ECG indicate damage to the left ventricular septal region? - Leads V3 and V4 - Leads II, III, and aVF - Leads V1 and V2 - Leads I, aVL, V5, and V6
Leads V3 and V4 Leads V3 and V4 record electrical events in the septal region of the left ventricle. Leads I, aVL, V5, and V6 record electrical events on the lateral surface of the left ventricle. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle. Leads V1 and V2 record electrical events on the anterior surface of the right ventricle and the anterior surface of the left ventricle.
A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize? - Restrict alcohol intake to two drinks per day. - Store the drug in a cool, well-lit place. - Lie down or sit in a chair for 5 to 10 minutes after taking the drug. - Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.
Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? - Midsternal chest pain - Thrill - Pitting edema in lower extremities - Lower back discomfort
Lower back discomfort Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
A nurse reviews a client's medication history before administering a cholinergic blocking agent. Adverse effects of a cholinergic blocking agent may delay absorption of what medication? - Nitroglycerin - Diphenhydramine - Digoxin - Amantadine
Nitroglycerin A cholinergic blocking agent may cause dry mouth and delay the sublingual absorption of nitroglycerin. The nurse should offer the client sips of water before administering nitroglycerin. Amantadine, digoxin, and diphenhydramine can interact with a cholinergic blocking agent but not through delayed absorption. Amantadine and diphenhydramine enhance the effects of anticholinergic agents.
A client presents to the ED reporting anxiety and chest pain after shoveling heavy snow that morning. The client says that nitroglycerin has not been taken for months but upon experiencing this chest pain did take three nitroglycerin tablets. Although the pain has lessened, the client states, "They did not work all that well." The client shows the nurse the nitroglycerin bottle; the prescription was filled 12 months ago. The nurse anticipates which order by the physician? - Chest x-ray - Nitroglycerin SL - Ativan 1 mg orally - Serum electrolytes
Nitroglycerin SL Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6 months to ensure full potency. The client's tablets were expired, and the nurse should anticipate administering nitroglycerin to assess whether the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the client's chest pain.
A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client? - Omega-3 fatty acids - Antioxidants - Vitamins A, D, and C - Beta-carotene
Omega-3 fatty acids Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels.
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? - Plethoric appearance of facial skin - Glossitis and weight loss - Jaundice with an enlarged liver - Petechiae and ecchymosis
Petechiae and ecchymosis The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.
A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? - Position the client supine with his legs elevated when in bed. - Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr. - Tell the client to sit with his legs dependent after ambulating. - Instruct the client to wear knee-length socks for 2 weeks after surgery.
Position the client supine with his legs elevated when in bed. The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.
A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having? - Calcium - Magnesium - Sodium - Potassium
Potassium Hyperkalemia (high potassium) can result in the following ECG changes: tall peaked T waves, wide QRS, and bradycardia. The nurse should be prepared to administer a diuretic or an ion-exchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose. Imbalances in the other electrolytes listed would not result in peaked T waves.
A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? - Potassium 2.8 mEq/L - Digoxin level 0.7 ng/mL - Hemoglobin 9.8 g/dL - Calcium 8.0 mg
Potassium 2.8 mEq/L A flattened T wave or the development of U waves is indicative of a low potassium level.
A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? - Obtain blood samples to test platelet function. - Prepare for replacement of the missing clotting factor. - Administer aspirin for the client's pain. - Place the bleeding joint in the dependent position.
Prepare for replacement of the missing clotting factor. Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints.
A nurse is transfusing a unit of B-positive fresh frozen plasma to a patient whose blood type is O-negative. Which of the following actions should the nurse take? - Continue to monitor for manifestations of a transfusion reaction. - Remove the unit of plasma immediately and start an IV infusion of normal saline solution. - Continue the transfusion and repeat the type and crossmatch. - Prepare to administer a dose of diphenhydramine IV.
Remove the unit of plasma immediately and start an IV infusion of normal saline solution. A client who receives FFP that is not compatible can experience a hemolytic transfusion reaction. The nurse should stop the transfusion and infuse 0.9% sodium chloride solution with new tubing.
A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and has hives 30 minutes after the infusion begins. Which of the following actions should the nurse take first? - Maintain the IV access with 0.9% sodium chloride. - Stop the infusion of blood. - Send the blood container and tubing to the blood bank. - Obtain a urine sample.
Stop the infusion of blood. The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.
A nurse is caring for a client who has a demand pacemaker inserted with the rate at 72 bpm. Which of the following findings should the nurse expect? - Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. - The client is experiencing premature ventricular complexes at 12/min. - Telemetry monitoring shows pacing spikes with no QRS complexes. - The client is experiencing hiccups.
Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min, because the client's intrinsic rate overrides the set rate of the pacemaker.
A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? - Weight gain 1 kg (2.2 lb) in 1 day - Pitting edema +1 - Client report of nocturnal cough - B-Type Natriuretic Peptide (BNP) level of 100 pg/mL
Weight gain 1 kg (2.2 lb) in 1 day A weight gain of 1 kg (2.2 lb) in 1 day alerts the nurse that the client is retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening.
Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? - Withhold anticoagulant therapy. - Inform client of diagnostic tests. - Remove hair from skin insertion sites. - Assess distal pulses.
Withhold anticoagulant therapy. The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.
A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) to a client who has anemia. Which of the following actions should the nurse take first? - Hang an IV infusion of 0.9% sodium chloride with the blood. - Check the client's identification number with the number on the blood. - Witness the informed consent. - Obtain pretransfusion vital signs.
Witness the informed consent. The nurse should apply the least invasive priority-setting framework. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, as witnessing the informed consent is the least invasive, it is the action that should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion to a client.
The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain? - a destroyed part of the heart muscle - incomplete blockage of a major coronary artery - a lack of oxygen in the heart muscle cells - complete closure of an artery
a lack of oxygen in the heart muscle cells Angina pectoris refers to chest pain that is brought about by myocardial ischemia. It is the result of cardiac muscle cells being deprived of oxygen due to the progressive symptoms of coronary artery disease. Artery blockage or closure leads to myocardial death. The destroyed part of the heart (death of heart tissue) is a myocardial infarction.
The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure? - an hourly urine output of 50 to 70 mL - a serum creatinine of 1.0 mg/dL - a urine specific gravity reading of 1.021 - a serum BUN of 70 mg/dL
a serum BUN of 70 mg/dL These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.
A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug? - beta-adrenergic blocker - diuretic - calcium-channel blocker - nitrate
calcium-channel blocker Calcium-channel blocking agents may be used to treat CAD as well, although research has shown that they may be less beneficial than beta-adrenergic blocking agents. Diltiazem (Cardizem) is an example of a calcium-channel blocker.
The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? - enhance myocardial oxygenation - decrease anxiety - administer sublingual nitroglycerin - educate the client about his symptoms
enhance myocardial oxygenation 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 isn't the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.
A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern? - blood pressure of 129/72 mm Hg - hemoglobin of 16 g/dL - hematocrit of 30% - heart rate of 87 bpm
hematocrit of 30% Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding. Blood pressure of 129/72 and heart rate of 87 bpm are normal. A hemoglobin count of 16 g/dL is also normal.
The nurse is reviewing the laboratory results for a client diagnosed with coronary artery disease (CAD). The client's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as... - low. - high. - critically high. - within normal limits.
high. Treatment of blood cholesterol to reduce cardiovascular risk in adults calls for a fasting lipid profile to demonstrate an LDL value below 100 mg/dL (or less than 70 mg/dL for very high-risk clients). An LDL level of 115 mg/dL is higher than the target for treatment
The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme? - cerebral bleeding - myocardial necrosis - skeletal muscle damage due to a recent fall - I.M. injection
myocardial necrosis An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injuries such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.
