220 Unit 1

A patient weighing 44 lb is prescribed a digoxin (Lanoxin) loading dose of 0.03 mg/kg to be administered in three divided doses. How much will the nurse administer in each dose? 0.2 mg 0.3 mg 0.6 mg 0.4 mg

0.2 mg (44 lb is converted to kilograms by dividing 44 by 2.2 kg = 20 kg. 0.03 mg/kg × 20 kg = 0.6 mg. 0.6 mg ÷ 3 doses = 0.2 mg/dose.)

A patient is being discharged to home on a single daily dose of a diuretic. The nurse instructs the patient to take the dose at which time so it will be least disruptive to the patient's daily routine? a. In the morning b. At noon c. With supper d. At bedtime

a. In the morning (It is better to take the diuretic medication early in the morning to prevent urination during the night. Taking the diuretic at the other times may cause nighttime urination and disrupt sleep.)

A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next? a. Administer the dose. b. Administer the dose, and notify the prescriber. c. Check the radial pulse for 1 full minute. d. Withhold the dose, and notify the prescriber.

d. Withhold the dose, and notify the prescriber. (Digoxin doses are held and the prescriber notified if the apical pulse is 60 beats/min or lower or is higher than 100 beats/min. The other options are incorrect.)

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? "I need to avoid eating hamburgers." "I must cut out bacon and canned foods." "I won't put the salt shaker on the table anymore." "I need to avoid lunchmeats but may cook my own turkey."

"I need to avoid eating hamburgers." (Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content.Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.)

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? Increase red meat in the diet. Consume melons and baked potatoes. Add several portions of dairy products each day. Try replacing your usual breakfast with oatmeal or Cream of Wheat.

Consume melons and baked potatoes. (Melons and baked potatoes are foods high in potassium.Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron. Oatmeal contains fiber but not potassium.)

When administering nitroprusside (Nipride) by continuous intravenous infusion, the nurse monitors for which symptom of drug toxicity? Wheezing Hypotension Fever Hyperglycemia

Hypotension (The main symptom of sodium nitroprusside overdose or toxicity is excessive hypotension.)

Enoxaparin sodium (Lovenox) is an anticoagulant used to prevent and treat deep vein thrombosis and pulmonary embolism. This medication is in which drug class? Oral anticoagulant Glycoprotein IIb/IIIa inhibitor Low-molecular-weight heparin Thrombolytic drug

Low-molecular-weight heparin (Enoxaparin is a low-molecular-weight heparin.)

What is a direct cause of peripheral arterial disease (PAD)? Diuretic use Thromboembolism Intermittent claudication Systemic atherosclerosis

Systemic atherosclerosis (PAD is a result of systemic atherosclerosis. It is a chronic condition in which partial or total arterial occlusion (blockage) decreases perfusion to the extremities. The tissues below the narrowed or obstructed arteries cannot live without an adequate oxygen and nutrient supply. Diuretics are used to treat hypertension. Thromboembolism may result from PAD. Intermittent claudication is a clinical symptom of PAD.)

When teaching a patient regarding the administration of digoxin (Lanoxin), the nurse instructs the patient not to take this medication with which food? Scrambled eggs French toast Wheat bran Bananas

Wheat bran (Encourage patients to avoid using antacids or eating ice cream, milk products, yogurt, cheese (dairy products), or bran for 2 hours before or 2 hours after taking medication to avoid interference with the drugs absorption.)

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

a. "Avoid using salt substitutes." (Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.)

A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

a. Advanced age b. Diabetes c. Ethnic background e. Smoking (Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.)

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia (Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.)

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

b. Hypertension c. Obesity d. Smoking e. Stress (Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.)

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

c. "It increases the force of the heart's contractions." (A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.)

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

d. "Do not take this medication within 1 hour of taking an antacid." (Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.)

When administering heparin subcutaneously, the nurse will follow which procedure? a. Aspirating the syringe before injecting the medication b. Massaging the site after injection c. Applying heat to the injection site d. Using a ½-⅝" 25-28 gauge needle

d. Using a ½-⅝" 25-28 gauge needle (A ½-⅝" 25-28 gauge needle is the correct needle to use for a subcutaneous heparin injection. The other options would encourage hematoma formation at the injection site.)

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? "My spouse will be the only person to change my dressing." "I can't believe that this has happened to me. I can't stand to look at it." "I do not want any visitors while I'm in the hospital." "It will take me some time to get used to this."

"It will take me some time to get used to this." (Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping.Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.)

Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? "I will be awake during this procedure." "I will have a balloon in my artery to widen it." "I must lie still after the procedure." "My angina will be gone for good."

"My angina will be gone for good." (In this situation, further teaching is needed when the client states that angina will be gone after the PTCA. The client's angina may not be eliminated. Reocclusion is possible after PTCA.The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.)

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? "This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack." "Angina is just a temporary interruption of blood flow to my heart." "I need to tell my wife I've had a heart attack." "Because this was temporary, I will not need to take any medications for my heart."

"This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack." (The statement by the client that unstable angina being a big warning and needing to alter his lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of unstable angina and/or MI.Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.)

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? "Elevate your legs above heart level to prevent swelling." "Inspect your legs daily for brownish discoloration around the ankles." "Walk to the point of leg pain, then rest, resuming when pain stops." "Apply a heating pad to the legs if they feel cold."

"Walk to the point of leg pain, then rest, resuming when pain stops." (The teaching point the nurse include for a client with PAD is walk to the point of leg pain, rest, and then resume when pain stops. Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous occlusive disease. Application of heat must be avoided in clients with PAD due to a lack of sensation and possible burns to the legs.)

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? "You are right. Work on your diet then." "You must find someplace to walk." "Walk around the edge of your apartment complex." "Where might you be able to walk?"

"Where might you be able to walk?" (In this situation, the best response by the nurse is to ask the client where he or she might be able to walk. This calls for cooperation and participation from the client. Increased activity is imperative for this client.Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.)

The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? Inferior wall Anterior wall Lateral wall Posterior wall

Anterior wall (The client with an anterior wall MI is most carefully observed for the development of left ventricular failure. Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of left ventricular contraction, leading to heart failure.The client with an inferior wall MI is most likely to develop right ventricular heart failure related to an occlusion of the right coronary artery. Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias or a posterior wall MI and sinus dysrhythmias.)

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? Temperature 98.2°F (36.8°C) Chest tube drainage 175 mL last hour Serum potassium 3.9 mEq/L (3.9 mmol/L) Incisional pain 6 on a scale of 0 to 10

Chest tube drainage 175 mL last hour (The nurse needs to report chest drainage over 150 mL/hr to the surgeon. Although some bleeding is expected after surgery, 175 mL per hour is excessive.Although hypothermia is a common problem after surgery, a temperature of 98.2°F (36.8°C) is a normal finding. Serum potassium of 3.9 mEq/L (3.9 mmol/L) is a normal finding. Incisional pain of 6 on a scale of 0-10 is expected immediately after major surgery; the nurse would administer prescribed analgesics.)

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? Select all that apply. Hypertension Tachycardia Bounding right pedal pulses Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg

Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg (Signs/symptoms of acute arterial occlusion of the right lower extremity include cold right foot, numbness and tingling of the right foot, and mottling and tingling of the right foot. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.)

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? Select all that apply. Bradycardia Cool, diaphoretic skin Crackles in the lung fields Respiratory rate of 12 breaths/min Anxiety and restlessness Temperature of 100.4°F (38.0°C)

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness (The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/minute is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.)

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? Urine output of 1500 mL on the preceding day Crackles in the lung fields Pedal edema Expectoration of yellow sputum

Crackles in the lung fields (Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields.A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.)

Potassium-sparing diuretics may cause which common adverse reactions? (Select all that apply.) Dizziness Hyperkalemia Headache Muscle weakness Mental confusion

Dizziness Hyperkalemia Headache (Hyperkalemia, dizziness, and headache are common adverse effects associated with potassium-sparing diuretics.)

The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? Reduce abdominal fat. Avoid stress. Do not smoke or chew tobacco. Avoid alcoholic beverages.

Do not smoke or chew tobacco. (The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.)

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? A 1-inch (2.5 cm) backup of blood in the IV tubing Facial drooping Partial thromboplastin time (PTT) 68 seconds Report of chest pressure during dye injection

Facial drooping (During and after thrombolytic administration, facial drooping may indicate intracranial bleeding, including changes in neurologic status.A 1-inch (2.5 cm) backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value which is 1½ to 2½ times the control. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.)

Which topics are included in patient teaching following a leg amputation? Select all that apply. How to wrap the limb Range-of-motion exercises How to turn independently if possible Exercises to prepare the limb for prosthesis Appropriate application of ice packs and heating pads How to inspect the area for signs of inflammation or skin breakdown

How to wrap the limb Range-of-motion exercises How to turn independently if possible Exercises to prepare the limb for prosthesis How to inspect the area for signs of inflammation or skin breakdown (The nurse should collaborate with physical and occupational therapists to begin exercises as soon as possible following amputation. Education topics include how to wrap the limb; range-of-motion exercises; instruction on how to turn independently in bed; exercises to prepare the limb for prosthesis; and inspection of the site for signs of inflammation or skin breakdown. Application of ice packs and heating pads are not appropriate education following an amputation.)

When assessing a patient taking triamterene (Dyrenium), the nurse would monitor for which possible adverse effect? Hyperkalemia Hypoglycemia Hypernatremia Hypokalemia

Hyperkalemia (Triamterene is a potassium-sparing diuretic, and therefore hyperkalemia is a possible adverse effect.)

Which laboratory test result is a common adverse effect of furosemide (Lasix)? Hypophosphatemia Hyperchloremia Hypokalemia Hypernatremia

Hypokalemia (Furosemide is a potent loop diuretic, and the most common adverse effect of loop diuretics is electrolyte imbalances. This results in major electrolyte losses of potassium and sodium and, to a lesser extent, calcium.)

Which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. Premenopausal Increasing age Family history Abdominal obesity Breast cancer

Increasing age Family history Abdominal obesity (Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. Also, a large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI.Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.)

A patient prescribed spironolactone (Aldactone) asks the nurse to assist with food choices that are low in potassium. The nurse would recommend which food choices? (Select all that apply.) Lean meat Winter squash Apples Bananas Pineapple

Lean meat Apples Pineapple (Spironolactone is a potassium-sparing diuretic that could potentially cause hyperkalemia. Bananas and winter (not summer) squash are high in potassium and should be avoided in patients taking spironolactone.)

Which are risk factors that are known to contribute to atherosclerosis-related diseases? Select all that apply. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL (4.14 mmol/L) Smoking Aspirin (acetylsalicylic acid [ASA]) consumption Type 2 diabetes Vegetarian diet

Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL (4.14 mmol/L) Smoking Type 2 diabetes (Risk factors that contribute to atherosclerosis-related diseases include LDL-C of 160 mg/dL (4.14 mmol/L), smoking, and type 2 diabetes. Having an LDL-C value of less than 100 mg/dL (2.59 mmol/L) is optimal. 100 to 129 mg/dL (2.59 to 3.34 mmol/L) is near or less than optimal. LDL-C 130 to 159 mg/dL (3.37 to 4.12 mmol/L) is borderline high. The client with a LDL-C of 160 mg/dL (4.14 mmol/L) is advised to modify diet and exercise. Smoking is a modifiable risk factor and needs to be avoided or terminated. Diabetes is a risk factor for atherosclerotic disease.ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. A diet high in whole grains, fruits, and vegetables is desirable to prevent atherosclerosis. Vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.)

A patient diagnosed with myocardial infarction has the following labs: potassium 3.5 mEq/L, calcium 8.5 mg/dL, magnesium 1.0 mEq/L, and pH 7.36. What value should be reported to the health care provider first? pH 7.36 Calcium 8.5 mg/dL Potassium 3.5 mEq/L Magnesium 1.0 mEq/L

Magnesium 1.0 mEq/L (The magnesium level of 1.0 mEq/L is low, which could lead to changes in normal conduction. Calcium (8.5 mg/dL), potassium (3.5 mEq/L), and pH (7.36) are normal.)

While observing a patient self-administer enoxaparin (Lovenox), the nurse identifies the need for further teaching when the patient performs which self-injection action? Massages the site after administration of the medication Does not aspirate before injecting the medication Administers the medication into subcutaneous (fatty) tissue Injects the medication greater than 2 inches away from the umbilicus

Massages the site after administration of the medication (It is not recommended to massage the area of injection of anticoagulants because of the increased risk of hematoma formation.)

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider immediately if which change occurs? Observation of a large amount of serosanguineous or bloody drainage Mild to moderate pain controlled with prescribed analgesics Absence of erythema and tenderness at the surgical site Ability to flex and extend the right knee

Observation of a large amount of serosanguineous or bloody drainage (A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention.Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.)

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? Administers oxygen therapy Obtains the client's description of the chest discomfort Provides pain relief medication Remains calm and stays with the client

Obtains the client's description of the chest discomfort (A description of the chest discomfort must be obtained first, before further action can be taken.Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first. Remaining calm and staying with the client are important but are not matters of highest priority.)

When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction (MI)? Select all that apply. Oxygen Morphine sulfate Nitroglycerin Naloxone Acetaminophen Verapamil (Calan, Isoptin)

Oxygen Morphine sulfate Nitroglycerin (Administering oxygen will increase available oxygen for the ischemic myocardium during the acute phase of an MI. Morphine is also needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain.Naloxone is a narcotic antagonist that is used for over dosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.)

Prompt pain management with myocardial infarction is essential for which reason? The discomfort will increase client anxiety and reduce coping. Pain relief improves oxygen supply and decreases oxygen demand. Relief of pain indicates that the MI is resolving. Pain medication would not be used until a definitive diagnosis has been established.

Pain relief improves oxygen supply and decreases oxygen demand. (The focus of pain relief is to improve oxygen supply and to reduce myocardial oxygen demand.Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain does not mean that the MI is resolving. Although it is used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.)

A patient who has severe peripheral vascular disease resulting in an above-the-knee amputation two months ago describes intense burning pain, numbness and tingling. The patient reports the symptoms worsen with exhaustion and stress. What is the patient most likely experiencing? Infection Neuroma Phantom limb pain Flexion contractures

Phantom limb pain (Phantom limb pain is often described as intense burning, crushing, or cramping. Patients with phantom limb pain experience numbness or tingling, and often report that the symptoms are worsened by temperature or barometric pressure changes, illness, fatigue, anxiety, or stress. Typical signs of infection include alteration in body temperature; redness, soreness, or warmth over the infected area; fatigue; rapid pulse; and increased respirations. A patient may or may not have pain with a neuroma. Flexion contractures of the hip or knee make it impossible for the patient to ambulate with a prosthetic device.)

Sensation that is felt in an amputated part immediately after surgery is known as which of the following? Neuroma Chronic limb pain Phantom limb pain Flexion contracture

Phantom limb pain (Sensation that is felt in the amputated part immediately after surgery is referred to as phantom limb pain. It is more common in patients who have had chronic limb pain prior to surgery. A neuroma is a sensitive tumor consisting of damaged nerve cells. Flexion contractures of the hip or knee are seen in patients with amputations of the lower extremity.)

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? Pulse 60 beats/min and regular Urinary frequency Incisional discomfort Respiratory rate 28 breaths/min

Respiratory rate 28 breaths/min (The activity should be terminated when the nurse notices the client's respiration rate of 28 breaths per minute. This indicates tachypnea and possibly tachycardia due to activity intolerance.Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.)

Which vascular assessment by the student nurse requires intervention by the supervising nurse? Measuring capillary refill in the fingertips Assessing pedal pulses by Doppler Measuring blood pressure in both arms Simultaneously palpating the bilateral carotids

Simultaneously palpating the bilateral carotids (The vascular assessment by the student that needs intervention by the supervisor nurse is simultaneously palpating the bilateral carotids. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. Many clients with vascular disease have poor blood flow. Pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in both arms.)

Which intervention does the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? Talking with an amputee close to the client's age who has a similar amputation Drawing a picture of how the client sees him- or herself Talking with a psychiatrist about the amputation Engaging in diversional activities to avoid focusing on the amputation

Talking with an amputee close to the client's age who has a similar amputation (Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation.Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist would not be necessary. Diversional activities do not help the client deal with loss of the limb.)

A patient with angina reports chest discomfort. Which principle related to angina pain is important for the nurse to remember? The administration of nitroglycerin (NTG) will improve oxygen supply. There will be an ST elevation noted on the electrocardiogram (ECG). The patient will have an increase in body temperature. Premature ventricular contractions (PVCs) accompany the pain.

The administration of nitroglycerin (NTG) will improve oxygen supply. (The pain of angina is typically relieved by nitroglycerin, which increases the oxygen supply to cardiac tissues. An ST elevation noted on the rhythm of an ECG signifies a myocardial infarction (MI); there are no rhythm changes with angina. An elevation in body temperature occurs for several days after a patient experiences an MI. PVCs occur within the first few hours after a patient experiences an MI.)

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? The client with acute coronary syndrome who has a 3-pound (1.4 kg) weight gain and dyspnea The client with percutaneous coronary angioplasty who has a dose of heparin scheduled The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

The client with acute coronary syndrome who has a 3-pound (1.4 kg) weight gain and dyspnea (The nurse needs to first assess the client with acute coronary syndrome with dyspnea and weight gain. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention.A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate.)

The nurse is providing education to a patient prescribed spironolactone (Aldactone) and furosemide (Lasix). What information does the nurseexplain to the patient? This combination promotes diuresis but decreases the risk of low levels of potassium. This combination maintains water balance to protect against dehydration and electrolyte imbalance. The lowest dose of two different types of diuretics are more effective than a large dose of one type. Using two drugs increases blood osmolality and the glomerular filtration rate.

This combination promotes diuresis but decreases the risk of low levels of potassium. (Spironolactone is a potassium-sparing diuretic; furosemide is a potassium-losing diuretic. Giving these together minimizes potassium loss.)

The patient presents to the emergency department with severe chest pain while at rest. The patient has changes on the electrocardiogram (ECG) but has negative troponin and creatine kinase levels. What diagnosis are these symptoms consistent with? Hypertension Unstable angina Myocardial infarction Peripheral vascular disease

Unstable angina (Unstable angina presents with chest pain unrelieved by rest, changes to the ECG, and no elevation of cardiac enzymes. Hypertension, myocardial infarction, and peripheral vascular disease are not consistent with the patient's tests or symptoms.)

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? Less than 30% of the daily caloric intake should be derived from proteins. Use canola oil rather than palm oil. Consume 10 mg of fiber daily. Work toward lowering your high-density lipoprotein (HDL) cholesterol levels.

Use canola oil rather than palm oil. (The nurse teaches the client who has had MI to use canola oil rather than palm oil. Palm oil is higher in saturated fats and needs to be avoided. Nontropical vegetable oils would be encouraged, e.g., canola.Less than 30% of daily calories need to come from fats. Clients would be encouraged to consume 30 g of dietary fiber daily. A higher HDL cholesterol level (good cholesterol) is more desirable. Clients need to strive to reduce low-density lipoprotein cholesterol (bad cholesterol) when elevated.)

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"

a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" e. "Are you able to accurately weigh yourself at home?" (To ensure safety upon discharge, the nurse should assess for structural barriers to functional ability, such as stairs. The nurse should also assess the client's available social support, which may include family, friends, and home health services. The client's ability to adhere to medication and treatments, including daily weights, should also be reviewed. The other questions do not address the client's safety upon discharge.)

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness."

a. "Continue to educate the client on possible healthy changes." (Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.)

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?"

a. "Could you walk further than that a few months ago?" (As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the client's disease is worsening. The other questions are useful, but not as important.)

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"

a. "Do you have any concerns about sexuality?" (Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.)

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."

a. "I can use a heating pad on my legs if it's set on low." (Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.)

When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? a. "Rotate application sites with each dose." b. "Use only the chest area for application sites." c. "Temporarily remove the patch if you go swimming." d. "Apply the patch to the same site each time."

a. "Rotate application sites with each dose." (Application sites for transdermal nitroglycerin patches need to be rotated. Apply the transdermal patch to any nonhairy area of the body; the old patch should first be removed. The patch may be worn while swimming, but if it does come off, it should be replaced after the old site is cleansed.)

A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "The device has been custom made specifically for you." b. "Your prosthetic is good for work but not for exercising." c. "A prosthetist will clean your inserts for you each month." d. "Make sure that you wear the correct liners with your prosthetic." e. "I have scheduled a follow-up appointment for you."

a. "The device has been custom made specifically for you." d. "Make sure that you wear the correct liners with your prosthetic." e. "I have scheduled a follow-up appointment for you." (A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the client's level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.)

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

a. Accompanied by shortness of breath b. Feelings of fear or anxiety d. No relief from taking nitroglycerin e. Pain occurs without known cause (The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.)

A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

a. Ask if the client eats grapefruit. (There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.)

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

a. Assess for any hemodynamic effects of the rhythm. (Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.)

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

a. Assess for symptoms of left-sided heart failure. (The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.)

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. d. Use an IV pump for the infusion. (Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.)

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

a. Assist the client to the chair for meals and to the bathroom. c. Ensure the client wears TED hose or sequential compression devices. e. Take and record a full set of vital signs per hospital protocol. (The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.)

The nurse is providing education about the use of sublingual nitroglycerin tablets. She asks the patient, "What would you do if you experienced chest pain while mowing your yard? You have your bottle of sublingual nitroglycerin with you." Which actions by the patient are appropriate in this situation? (Select all that apply.) a. Stop the activity, and lie down or sit down. b. Call 911 immediately. c. Call 911 if the pain is not relieved after taking one sublingual tablet. d. Call 911 if the pain is not relieved after taking three sublingual tablets in 15 minutes. e. Place a tablet under the tongue. f. Place a tablet in the space between the gum and cheek. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.

a. Stop the activity, and lie down or sit down. c. Call 911 if the pain is not relieved after taking one sublingual tablet. e. Place a tablet under the tongue. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. d. Confirm that an echocardiogram has been completed. (The Heart Failure Core Measure Set includes discharge instructions on diet, activity, medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is usually prescribed for clients who experience a myocardial infarction. Although the nurse may consult the social worker or case manager for additional resources, this is not part of the Core Measures.)

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? a. "Walk until you become short of breath, and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."

b. "Gather everything you need for a chore before you begin." (A client who has heart failure should be taught to conserve energy. Gathering all supplies needed for a chore at one time decreases the amount of energy needed. The client should not walk until becoming short of breath because he or she may not make it back home. Pushing a cart takes less energy than pulling or lifting. Although walking after dinner may help the client, the nurse should teach the client to complete activities when he or she has the most energy. This is usually in the morning.)

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."

b. "The best source is fish, but pills have benefits too." (Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.)

A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."

b. "The heparin keeps that artery from getting blocked again." (After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.)

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O₂ saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

b. Allow continued bathroom privileges. (This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.)

A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

b. Assist the client into a position of comfort in bed. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing. (Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.)

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

b. Baked chicken breast, broccoli, tomatoes (The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.)

A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom (Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.)

A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg (Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.)

A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety (The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.)

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

b. Distal pulse on affected extremity 2+/4+ (Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.)

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this client's plan of care? a. Place pillows between the client's knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

b. Encourage range-of-motion exercises. (Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.)

A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

b. Expired food in the refrigerator (Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.)

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

b. Give the client an aspirin. (The Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.)

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

c. "I must stop halfway up the stairs to catch my breath." (Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.)

A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

c. 1630 (4:30 PM) (The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).)

While assessing a patient who is taking a beta blocker for angina, the nurse knows to monitor for which adverse effect? a. Nervousness b. Hypertension c. Bradycardia d. Dry cough

c. Bradycardia (Adverse effects of beta blockers include bradycardia, hypotension, dizziness, lethargy, impotence, and several other effects, but not dry cough or nervousness.)

When a patient is receiving diuretic therapy, which of these assessment measures would best reflect the patient's fluid volume status? a. Blood pressure and pulse b. Serum potassium and sodium levels c. Intake, output, and daily weight d. Measurements of abdominal girth and calf circumference

c. Intake, output, and daily weight (Urinary intake and output and daily weights are the best reflections of a patient's fluid volume status.)

A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen

c. Intravenous calcitonin (The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.)

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

c. Maintain airway patency. (Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications.)

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

c. Poor peripheral pulses and cool skin (Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.)

The nurse notes in the patient's medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy? a. Stabilizing an existing thrombus b. Dissolving an existing thrombus c. Preventing thrombus formation d. Dilating the vessel around a clot

c. Preventing thrombus formation (Anticoagulants prevent thrombus formation but do not dissolve or stabilize an existing thrombus, nor do they dilate vessels around a clot.)

A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

c. Stop the infusion and call the provider. (A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.)

A patient has been instructed to take one enteric-coated low-dose aspirin a day as part of therapy to prevent strokes. The nurse will provide which instruction when providing patient teaching about this medication? a. Aspirin needs to be taken on an empty stomach to ensure maximal absorption. b. Low-dose aspirin therapy rarely causes problems with bleeding. c. Take the medication with 6 to 8 ounces of water and with food. d. Coated tablets may be crushed if necessary for easier swallowing.

c. Take the medication with 6 to 8 ounces of water and with food. (Enteric-coated aspirin is best taken with 6 to 8 ounces of water and with food to help decrease gastrointestinal upset. Enteric-coated tablets should not be crushed. Risk for bleeding increases with aspirin therapy, even at low doses.)

When reviewing the mechanisms of action of diuretics, the nurse knows that which statement is true about loop diuretics? a. They work by inhibiting aldosterone. b. They are very potent, having a diuretic effect that lasts at least 6 hours. c. They have a rapid onset of action and cause rapid diuresis. d. They are not effective when the creatinine clearance decreases below 25 mL/min.

c. They have a rapid onset of action and cause rapid diuresis. (The loop diuretics have a rapid onset of action; therefore, they are useful when rapid onset is desired. Their effect lasts for about 2 hours, and a distinct advantage they have over thiazide diuretics is that their diuretic action continues even when creatinine clearance decreases below 25 mL/min.)

A patient will be receiving a thrombolytic drug as part of the treatment for acute myocardial infarction. The nurse explains to the patient that this drug is used for which purpose? a. To relieve chest pain b. To prevent further clot formation c. To dissolve the clot in the coronary artery d. To control bleeding in the coronary vessels

c. To dissolve the clot in the coronary artery (Thrombolytic drugs lyse, or dissolve, thrombi. They are not used to prevent further clot formation or to control bleeding. As a result of dissolving of the thrombi, chest pain may be relieved, but that is not the primary purpose of thrombolytic therapy.)

When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? a. To prevent low blood pressure b. To relieve shortness of breath c. To prevent the occurrence of angina d. To keep the heart rate from rising too high during exercise

c. To prevent the occurrence of angina (Transdermal dosage formulations of nitroglycerin are used for the long-term prophylactic management (prevention) of angina pectoris. Transdermal nitroglycerin patches are not appropriate for the relief of shortness of breath, to prevent palpitations, or to control the heart rate during exercise.)

Furosemide (Lasix) is prescribed for a patient who is about to be discharged, and the nurse provides instructions to the patient about the medication. Which statement by the nurse is correct? a. "Take this medication in the evening." b. "Avoid foods high in potassium, such as bananas, oranges, fresh vegetables, and dates." c. "If you experience weight gain, such as 5 pounds or more per week, be sure to tell your physician during your next routine visit." d. "Be sure to change positions slowly and rise slowly after sitting or lying so as to prevent dizziness and possible fainting because of blood pressure changes."

d. "Be sure to change positions slowly and rise slowly after sitting or lying so as to prevent dizziness and possible fainting because of blood pressure changes." (Orthostatic hypotension is a possible problem with diuretic therapy. Foods high in potassium should be eaten more often, and the drug needs to be taken in the morning so that the diuretic effects do not interfere with sleep. A weight gain of 5 pounds or more per week must be reported immediately.)

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond? a. "The pain you are feeling does not actually exist." b. "This type of pain is common and will eventually go away." c. "Would you like to learn how to use imagery to minimize your pain?" d. "How would you describe the pain that you are feeling?"

d. "How would you describe the pain that you are feeling?" (The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse must assess the client's pain before determining the best action.)

A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? a. "Watch for unusual weight loss." b. "Monitor your pulse for increased heart rate." c. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."

d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia." (Beta blockers can cause both hypoglycemia and hyperglycemia. They may also cause weight gain if heart failure is developing, and decreased pulse rate. The use of hot tubs and saunas is not recommended because of the possibility of hypotensive episodes.)

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."

d. "My hands shake when I try to do things requiring coordination." (Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.)

A patient on diuretic therapy calls the clinic because he's had the flu, with "terrible vomiting and diarrhea," and he has not kept anything down for 2 days. He feels weak and extremely tired. Which statement by the nurse is correct? a. "It's important to try to stay on your prescribed medication. Try to take it with sips of water." b. "Stop taking the diuretic for a few days, and then restart it when you feel better." c. "You will need an increased dosage of the diuretic because of your illness. Let me speak to the physician." d. "Please come into the clinic for an evaluation to make sure there are no complications."

d. "Please come into the clinic for an evaluation to make sure there are no complications." (Vomiting and diarrhea cause fluid and electrolyte loss. The patient must not continue to take the diuretic until these problems have stopped. He needs to be checked for possible hypokalemia and dehydration. The other options are incorrect responses.)

A 79-year-old patient is taking a diuretic for treatment of hypertension. This patient is very independent and wants to continue to live at home. The nurse will know that which teaching point is important for this patient? a. He should take the diuretic with his evening meal. b. He should skip the diuretic dose if he plans to leave the house. c. If he feels dizzy while on this medication, he needs to stop taking it and take potassium supplements instead. d. He needs to take extra precautions when standing up because of possible orthostatic hypotension and resulting injury from falls.

d. He needs to take extra precautions when standing up because of possible orthostatic hypotension and resulting injury from falls. (Caution must be exercised in the administration of diuretics to the older adults because they are more sensitive to the therapeutic effects of these drugs and are more sensitive to the adverse effects of diuretics, such as dehydration, electrolyte loss, dizziness, and syncope. Taking the diuretic with the evening meal may disrupt sleep because of nocturia. Doses should never be skipped or stopped without checking with the prescriber.)

A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy? a. Dysrhythmias b. Nausea and vomiting c. Anaphylactic reactions d. Internal and superficial bleeding

d. Internal and superficial bleeding (Bleeding, both internal and superficial, as well as intracranial, is the most common undesirable effect of thrombolytic therapy. The other options list possible adverse effects of thrombolytic drugs, but they are not the most common effects.)

When assessing a patient who is receiving a loop diuretic, the nurse looks for the manifestations of potassium deficiency, which would include what symptoms? (Select all that apply.) a. Dyspnea b. Constipation c. Tinnitus d. Muscle weakness e. Anorexia f. Lethargy

d. Muscle weakness e. Anorexia f. Lethargy (Symptoms of hypokalemia include anorexia, nausea, lethargy, muscle weakness, mental confusion, and hypotension. The other symptoms are not associated with hypokalemia.)

What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? a. Omit a dose once a week. b. Leave the patch on for 2 days at a time. c. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.

d. Remove the patch at bedtime, and then apply a new one in the morning. (To prevent tolerance, remove the transdermal patch at night for 8 hours, and apply a new patch in the morning. Transdermal patches must never be cut or left on for 2 days, and doses must not be omitted.

The nurse will monitor a patient for signs and symptoms of hyperkalemia if the patient is taking which of these diuretics? a. Hydrochlorothiazide (HydroDIURIL) b. Furosemide (Lasix) c. Acetazolamide (Diamox) d. Spironolactone (Aldactone)

d. Spironolactone (Aldactone) (Spironolactone (Aldactone) is a potassium-sparing diuretic, and patients taking this drug must be monitored for signs of hyperkalemia. The other drugs do not cause hyperkalemia but instead cause hypokalemia.)

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.

d. Tell the client that anxiety is common and that you can help. (Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.)

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

d. Triglycerides: 198 mg/dL (Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.)

The patient asks the nurse, "How should sublingual nitroglycerin be stored when I travel?" What is the nurse's best response? "It's best to keep it in its original container away from heat and light." "You can put a few tablets in a resealable bag and carry it in your pocket." "You can protect it from heat by placing the bottle in an ice chest." "Keep it in the glove compartment of your car to prevent exposure to heat."

"It's best to keep it in its original container away from heat and light." (Although sublingual nitroglycerin needs to be kept in a cool, dry place, it should not be placed in an ice chest, where it could freeze. It should not be kept in the glove compartment of a car and needs to be kept away from heat, not in a clear plastic bag.)

When applying nitroglycerin (Nitro-Bid) ointment, the nurse should perform which action? Massage and then gently rub the ointment into the skin. Apply a thick layer of ointment on the nitroglycerin paper. Use the fingers to spread the ointment evenly over a 3-inch area. Apply the ointment to a nonhairy part of the upper torso.

Apply the ointment to a nonhairy part of the upper torso. (Use the proper dosing paper supplied by the drug company to apply a thin layer of ointment on clean, dry, hairless skin of the upper arms or body. Avoid areas below the knees and elbows. Wear gloves to avoid contact with the skin and subsequent absorption. Do not rub the ointment into the skin; cover the area with an occlusive dressing if not provided (e.g., plastic wrap).)

A patient prescribed digoxin (Lanoxin) 0.25 mg and furosemide (Lasix) 40 mg for the treatment of systolic heart failure states, "I am starting to see yellow halos around lights." Which action will the nurse take? Perform a visual acuity test on each eye. Assess for other symptoms of digoxin toxicity. Prepare to administer digoxin immune fab (Digifab). Document the finding and reassess in 1 hour.

Assess for other symptoms of digoxin toxicity. (Yellow-green halos around objects is a symptom of digoxin toxicity. Other signs and symptoms of digoxin toxicity include headache, dizziness, confusion, nausea, and blurred vision. Electrocardiogram findings show heart block, atrial tachycardia with block, or ventricular dysrhythmias.)

The home health nurse visits a client with heart failure who has gained 5 pounds (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Assess the client for peripheral edema. Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions.

Auscultate the client's posterior breath sounds. (The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.)

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. Blurred vision Tachycardia Fatigue Serum digoxin level of 1.5 ng/ml (1.92 nmol/L) Anorexia

Blurred vision Fatigue Anorexia (The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur.Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.5 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.)

Which assessment finding is an indication of left-sided heart failure? Nocturia Peripheral edema Swollen abdomen Crackles in the lung fields

Crackles in the lung fields (As the left ventricle fails, fluid that is not forwarded backs up into the left atrium and pulmonary veins. As pulmonary veins distend, fluid seeps into the alveoli, causing discrete "popping" sounds of crackles in the lung fields. Edema (peripheral and dependent) and ascites are symptomatic of right-sided heart failure. Nocturia results from dependent fluid being reabsorbed into the bloodstream at night when the patient is recumbent; the fluid circulates as blood volume passing through the kidneys, and awakening to void occurs.)

The nurse understands that a patient receiving nitroglycerin should be monitored for which common adverse effects associated with this medication? (Select all that apply.) Dizziness Blurred vision Hypotension Flushing Headache

Dizziness Hypotension Flushing Headache (The common adverse effects of nitroglycerin include flushing of the face, dizziness, fainting, headache, and hypotension.)

Which factor is the most common etiology of heart failure? Obesity Hypertension Hyperkinetic conditions Structural heart changes

Hypertension (Heart failure is caused by systemic hypertension in most cases. Hyperkinetic conditions are an uncommon cause of heart failure. Obesity by itself is not the most common etiology of heart failure, but it can be a contributing factor. Structural heart failure is the third most common cause of heart failure after systemic hypertension and myocardial infarction.)

Calcium channel blockers reduce myocardial oxygen demand by decreasing afterload. How would the nurse explain afterload to the patient? It is the total volume of blood in the heart. It is the pressure within the four chambers of the heart. It is the force against which the heart must pump. It is the contractility of the heart muscle.

It is the force against which the heart must pump. (Afterload is the force (systemic vascular resistance) against which the heart must exert itself when delivering blood to the body.)

Before administering isosorbide mononitrate (Imdur) sustained-release tablet to a patient, what is the priority nursing intervention? Remind the patient to take the tablet before meals. Emphasize that the patient should swallow the tablet whole. Obtain a blood pressure reading. Advise the patient that Tylenol is used to treat headache.

Obtain a blood pressure reading. (Mononitrate is a vasodilator and thus can cause hypotension. It is important to assess blood pressure before administering.)

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Monitor pulse oximetry and cardiac rate and rhythm. Reassure the client that his distress can be relieved with proper intervention. Place the client in high-Fowler's position with the legs down. Ask a family member to remain with the client.

Place the client in high-Fowler's position with the legs down. (The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler's position with the legs down. High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.)

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L (135 mmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L) Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) Serum magnesium level of 1.9 mEq/L (0.95 mmol/L)

Serum potassium level of 2.8 mEq/L (2.8 mmol/L) (The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.)

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min. The client's weight decreases by 2.5 kg.

The client's weight decreases by 2.5 kg. (The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 pounds (2.5 kg) in one day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.)

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The client ambulates around the nursing unit with a walker. The nurse monitors the client's pulse and blood pressure frequently. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when the client becomes tachycardic.

The nurse obtains a bedside commode before administering furosemide. (The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation.)

What are common symptoms of hypokalemia? Select all that apply. Weakness Cool extremities Dependent edema Depressed reflexes Irregular heart rate

Weakness Depressed reflexes Irregular heart rate (Hypokalemia refers to low levels of potassium in the body. Cellular functions of the body require potassium; therefore, low potassium levels may lead to weakness, depressed reflexes, and an irregular heart rate. Cool extremities and dependent edema are symptoms of hypernatremia.)

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 liters of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."

a. "I'll read the nutritional labels on food items for salt content." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake." (Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client should be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day.)

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

d. "Weigh yourself daily while wearing the same amount of clothing." (Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.)

Which instruction should be included in the discharge teaching for a patient with a transdermal nitroglycerin (Nitro-Dur) patch? "Make sure to rub a lotion or cream on the skin before putting on a new patch." "If you get chest pain, apply a second patch next to the first patch." "Apply the patch to a hairless, nonirritated area of the chest, upper arm, back or shoulder." "If you get a headache, remove the patch for 4 hours and then reapply."

"Apply the patch to a hairless, nonirritated area of the chest, upper arm, back or shoulder." (A nitroglycerin patch should be applied to a clean, residue-free, hairless, nonirritated area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and if headache occurs, the patient should not change the patch removal schedule to avoid these headaches. Sublingual nitroglycerin should be used to treat chest pain.)

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? "I will call the provider if I have a cough lasting 3 or more days." "I will report to the provider weight loss of 2 to 3 pounds (0.9 to 1.4 kg) in a day." "I will try walking for 1 hour each day." "I should expect occasional chest pain."

"I will call the provider if I have a cough lasting 3 or more days." (The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs.The client would call the provider for weight gain of 3 pounds (1.4 kg) in a week or 1-2 pounds (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 meters) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.)

The nurse is providing discharge teaching for a patient with a new prescription for nitroglycerin (Nitrostat) sublingual tablets. Which statement by the patient indicates an understanding of the nurse's discharge instructions about this medication? "I will need to refill my prescription when I feel burning under my tongue." "I can take some aspirin if I get a headache related to nitroglycerin." "I will keep my nitroglycerin tablets in their original glass container." "My nitroglycerin tablets are not affected by cold or heat."

"I will keep my nitroglycerin tablets in their original glass container." (The sublingual dosage form of nitroglycerin needs to be kept in its original amber-colored glass container with metal lid to avoid loss of potency from exposure to heat, light, moisture, and cotton filler. It should be replaced every 3 to 6 months in order to maintain potency. Potency of the sublingual nitroglycerin is noted if there is burning or stinging when the medication is placed under the tongue; if the medication does not burn, then the drug has lost its potency, and a new prescription must be obtained. Headaches associated with nitrates last approximately 20 minutes (with sublingual forms) and may be managed with acetaminophen.)

A patient who is taking nitroglycerin (Nitrostat) sublingual tablets is complaining of flushing and headaches. What is the nurse's best response? "Put a cold wet washcloth or use an icepack on your forehead and lie down in a quiet place." "These are the most common adverse effects of nitroglycerin. They should subside with continued use of nitroglycerin." "Stop taking the nitroglycerin because you are experiencing an allergic reaction to the medication." "Immediately notify your health care provider because these symptoms are not related to the sublingual nitroglycerin."

"These are the most common adverse effects of nitroglycerin. They should subside with continued use of nitroglycerin." (Headache, flushing of the face, dizziness, and fainting are the most common adverse effects of nitroglycerin and the headache generally subsides after the start of therapy.)

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) (The nurse would first assess the 46-year-old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.)

The patient presents to the emergency department with pedal edema, crackles on auscultation, and a report of a 10-pound weight gain in 1 week. The nurse suspects heart failure and knows which test will confirm her suspicion? Serum electrolytes Arterial blood gases B-type natriuretic peptide (BNP) Ventilation perfusion (V/Q) scan

B-type natriuretic peptide (BNP) (B-type natriuretic peptide (BNP) levels rise in response to stretching of the ventricles and best differentiates dyspnea of heart failure versus pulmonary dysfunction. Electrolytes may be altered in heart failure or its treatment, but they are not specific to diagnosing the problem. Blood gases may show hypoxemia in heart failure but are also altered in other disease states, making these readings nonspecific to heart failure. A lung scan or V/Q scan is used to diagnose a pulmonary embolism.)

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? Serum potassium level of 3.2 mEq/L (3.2 mmol/L) Ejection fraction of 60% B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) Chest x-ray report showing right middle lobe consolidation

B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) (A BNP of 760 pg/ml (760 ng/dL) is consistent with a diagnosis of heart failure. BNP is produced and released by the ventricles when the client has fluid overload as a result of HF. A normal BNP value is less than 0-99 picograms per milliliter (pg/mL) or 0-99 nanograms per liter (ng/L).Hypokalemia (serum potassium level of 3.2 mEq/L [3.2 mmol/L]) may occur in response to diuretic therapy for HF, but may also occur with other conditions. It is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.)

Which medication, when given in heart failure, may improve morbidity and mortality? Dobutamine (Dobutrex) Carvedilol (Coreg) Digoxin (Lanoxin) Bumetanide (Bumex)

Carvedilol (Coreg) (Carvedilol when given to clients in heart failure may improve morbidity and mortality. Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure. This category of pharmacologic agents improves morbidity, mortality, and quality of life.Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion, and does not improve morbidity and mortality.)

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Select all that apply. Chest discomfort or pain Tachycardia Expectorating thick, yellow sputum Sleeping on back without a pillow Fatigue

Chest discomfort or pain Tachycardia Fatigue (When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.)

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? Ejection fraction is 25%. Client states that she is able to sleep on one pillow. Client was hospitalized five times last year with pulmonary edema. Client reports that she experiences palpitations.

Client states that she is able to sleep on one pillow. (A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol.An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.)

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? Calls the family to lift the client's spirits Considers further assessment for depression Sedates the client to decrease myocardial oxygen demand Tells the client that things will get better

Considers further assessment for depression (The nurse's best response to the client when he/she says it isn't worth it anymore and I want it all to end is to consider further assessment for depression. This client is at risk for depression because of the diagnosis of heart failure, and further assessment must be done.Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.)

The patient has heart failure. Which signs or symptoms would prompt the nurse to suspect pulmonary edema? Select all that apply. Increased urination Decreased heart rate Crackles in the lung bases Difficulty in breathing at rest Disorientation regarding time and place

Crackles in the lung bases Difficulty in breathing at rest Disorientation regarding time and place (Pulmonary edema is a life-threatening event that can result from dysrhythmias, acute myocardial infarction, severe heart failure, and mitral valve disease. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs. The increased pressure causes fluid to leak across pulmonary capillaries and into the lung airways and tissues. Disorientation, dyspnea at rest, and crackles in the lung bases are the symptoms of pulmonary edema. Polyuria is not sign of pulmonary edema. Tachycardia, not bradycardia, occurs in pulmonary edema.)

What are common signs and symptoms of right-sided heart failure? Select all that apply. A hacking cough Dependent edema Increase in weight Nausea and vomiting Oliguria during the day

Dependent edema Increase in weight Nausea and vomiting (In right-sided heart failure, the right ventricle cannot completely empty. Increased volume and pressure develop in the venous system and peripheral edema results. Nausea, weight gain, and dependent edema are symptoms of right-sided heart failure. Nausea occurs due to direct consequence of liver engorgement resulting from fluid retention. Weight gain is observed in the patient due to retention of fluids. Dependent edema is observed, commonly in the ankles and legs and over the sacrum when the patient is restricted to bed rest. A hacking cough and oliguria during the day are symptoms of left-sided heart failure.)

The nurse understands a patient who is treated for hypertension may be switched to an angiotensin receptor blocker (ARB) because of which angiotensin-converting enzyme (ACE) inhibitor adverse effect? Dry, nonproductive cough Hypokalemia Fatigue Orthostatic hypotension

Dry, nonproductive cough (ACE inhibitors block the breakdown of bradykinins and may cause a dry, nonproductive cough. ARBs do not block this breakdown, thus minimizing this adverse effect. ACE inhibitors and ARBs are equally effective for the treatment of hypertension, but ARBs do not cause cough.)

What is the classification of carvedilol (Coreg)? Beta blocker ACE inhibitor Alpha₂ blocker Dual-action alpha₁ and beta receptor blocker

Dual-action alpha₁ and beta receptor blocker (Carvedilol blocks both the alpha₁ and beta receptors of the adrenergic nervous system.)

It is MOST important for the nurse to instruct a patient prescribed nitroglycerin to avoid which substance? Potassium-sparing diuretics Grapefruit juice Erectile dysfunction drugs Antacids

Erectile dysfunction drugs (Concurrent administration of nitrate drugs and erectile dysfunction drugs such as sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil (Levitra) can cause an additive hypotensive effect.)

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, with pink, frothy sputum, and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Crackles in all fields, S3 present, Oliguria, Ejection fraction 30%, BNP 560, Sodium 130 mEq/L (130 mmol/L) Diagnosis: heart failure Orders: Enalapril 10 mg orally daily, Heparin 5000 units subcutaneously every 12 hours, Furosemide 40 mg IV daily, Strict I & O What is the priority action? Enalapril Heparin Furosemide Intake and output (I & O)

Furosemide (While caring for a client with acute heart failure, the ED nurse Administers Furosemide first. The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion. A diuretic will promote fluid loss.Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis secondary to immobility, but will not reduce fluid excess. Although all clients with congestive heart failure need to have daily weights and I & O monitored, this is not a priority. Removing fluid volume and treating dyspnea are matters of priority.)

The nurse should question a prescription for a calcium channel blocker in a patient with which condition? Dysrhythmia Hypotension Angina pectoris Increased intracranial pressure

Hypotension (Calcium channel blockers cause smooth muscle vasodilation and thus a drop in blood pressure. They are contraindicated in the presence of hypotension.)

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? Ibuprofen (Motrin) Hydrochlorothiazide (HydroDIURIL) NPH insulin Levothyroxine (Synthroid)

Ibuprofen (Motrin) (The nurse questions an 82-year-old client with exacerbation of heart failure if the client is taking ibuprofen. Long-term use of nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF.A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism. It does not cause HF.)

Which parameter, determined through laboratory testing, is known as the "early warning detector" for heart failure? Hematocrit Microalbuminuria Electrocardiogram B-type natriuretic peptide

Microalbuminuria (Microalbuminuria is called the "early warning detector" because it is an early indicator of decreased compliance of the heart, presenting before the B-type natriuretic peptide (BNP) rises. Microalbumin levels in the urine indicate decreased compliance long before symptoms occur. The hematocrit test is used to identify heart failure resulting from anemia. An electrocardiogram shows ventricular hypertrophy, dysrhythmias, and any degree of myocardial ischemia, injury, or infarction; it is not helpful in determining the presence or extent of heart failure. B-type natriuretic peptide is used for diagnosing heart failure in patients with acute dyspnea.)

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? Determines the client's physical limitations Encourages alternate rest and activity periods Monitors and documents heart rate, rhythm, and pulses Positions the client to alleviate dyspnea

Positions the client to alleviate dyspnea (The ICU nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.)

Which medication should the nurse question if prescribed together with ACE inhibitors? Docusate sodium (Colace) Furosemide (Lasix) Potassium chloride (K-Dur) Morphine

Potassium chloride (K-Dur) (ACE inhibitors block the conversion of angiotensin I to angiotensin II, thus also blocking the stimulus for aldosterone production. Aldosterone is responsible for potassium excretion; thus, a decrease in aldosterone production can result in an increase in serum potassium.)

Which dosage form of nitroglycerin has the longest duration of action? Transdermal patch Sublingual tablet Intravenous (IV) infusion Immediate-release tablet

Transdermal patch (The transdermal patch has an 8- to 12-hour duration of action compared with 3 minutes to 6 hours for the other dosage forms of nitroglycerin.)

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) a. "Reposition the client every 2 hours." b. "Teach the client to perform deep-breathing exercises." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning." e. "Place the client on oxygen if the client becomes short of breath."

a. "Reposition the client every 2 hours." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning." (The UAP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The UAP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess the need for and provide oxygen therapy.)

A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How should the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

a. "Weight is the best indication that you are gaining or losing fluid." (Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.)

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." How should the nurse respond? a. "Would you like to talk more about this?" b. "You are lucky to have such a devoted daughter." c. "It is normal to feel as though you are a burden." d. "Would you like to meet with the chaplain?"

a. "Would you like to talk more about this?" (Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client's concerns and do not allow the nurse to obtain more information to provide client-centered care.)

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

a. A 36-year-old woman with aortic stenosis (Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.)

Which drug classes are considered first-line treatment for heart failure? (Select all that apply.) a. Angiotensin-converting enzyme (ACE) inhibitors b. Angiotensin II receptor blockers (ARBs) c. Digoxin (cardiac glycoside) d. Beta blockers e. Nesiritide (Natrecor), the B-type natriuretic peptide

a. Angiotensin-converting enzyme (ACE) inhibitors b. Angiotensin II receptor blockers (ARBs) d. Beta blockers (ACE inhibitors, ARBs, and beta blockers are now considered the first-line treatments for heart failure. Digoxin is used when the first-line treatments are not successful; nesiritide is considered a last-resort treatment.)

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the client's respiratory status. b. Draw blood to assess the client's serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications.

a. Assess the client's respiratory status. (Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.)

A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? a. Blood pressure of 88/62 mm Hg b. Apical pulse rate of 110 beats/min c. History of renal disease d. History of a myocardial infarction 2 years ago

a. Blood pressure of 88/62 mm Hg (Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease. The other options are incorrect.)

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L e. Proteinuria f. Microalbuminuria (A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is on the high side of normal and the serum creatinine level is normal.)

When counseling a male patient about the possible adverse effects of antihypertensive drugs, the nurse will discuss which potential problem? a. Impotence b. Bradycardia c. Increased libido d. Weight gain

a. Impotence (Sexual dysfunction is a common complication of antihypertensive medications and may be manifested in men as decreased libido or impotence. The other options are incorrect.)

In assessing a patient before administration of a cardiac glycoside, the nurse knows that which lab result can increase the toxicity of the drug? a. Potassium level 2.8 mEq/L b. Potassium level 4.9 mEq/L c. Sodium level 140 mEq/L d. Calcium level 10 mg/dL

a. Potassium level 2.8 mEq/L (Hypokalemia increases the chance of digitalis toxicity. The other levels listed are incorrect.)

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night

a. Pulmonary crackles b. Confusion, restlessness e. Cough that worsens at night (Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.)

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

b. "Are you able to walk upstairs without fatigue?" (Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.)

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

b. "My shoes fit really tight lately." (Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.)

A patient who has been taking antihypertensive drugs for a few months complains of having a persistent dry cough. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs? a. Beta blockers b. Angiotensin-converting enzyme (ACE) inhibitors c. Angiotensin II receptor blockers (ARBs) d. Calcium channel blockers

b. Angiotensin-converting enzyme (ACE) inhibitors (ACE inhibitors cause a characteristic dry, nonproductive cough that reverses when therapy is stopped. The other drug classes do not cause this cough.)

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

b. Instruct the client to ask for assistance when rising from bed. (Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.)

A patient has a digoxin level of 1.1 ng/mL. Which interpretation by the nurse is correct? a. It is below the therapeutic level. b. It is within the therapeutic range. c. It is above the therapeutic level. d. It is at a toxic level.

b. It is within the therapeutic range. (The normal therapeutic drug level of digoxin is between 0.5 and 2 ng/mL. The other options are incorrect.)

The nurse is creating a plan of care for a patient with a new diagnosis of hypertension. Which is a potential nursing diagnosis for the patient taking antihypertensive medications? a. Diarrhea b. Sexual dysfunction c. Urge urinary incontinence d. Impaired memory

b. Sexual dysfunction (Sexual dysfunction is a potential nursing diagnosis related to possible adverse effects of antihypertensive drug therapy. The other nursing diagnoses are not appropriate.)

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How should the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." (Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question.)

A patient is in the intensive care unit and receiving an infusion of milrinone (Primacor) for severe heart failure. The prescriber has written an order for an intravenous dose of furosemide (Lasix). How will the nurse give this drug? a. Infuse the drug into the same intravenous line as the milrinone. b. Stop the milrinone, flush the line, and then administer the furosemide. c. Administer the furosemide in a separate intravenous line. d. Notify the prescriber that the furosemide cannot be given at this time.

c. Administer the furosemide in a separate intravenous line. (Furosemide must not be injected into an intravenous line with milrinone because it will precipitate immediately. The infusion must not be stopped because of the patient's condition. A separate line will be needed. The other options are incorrect.)

A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? a. Take up to 5 doses at 15-minute intervals for an angina attack. b. If the tablet does not dissolve quickly, chew the tablet for maximal effect. c. If the chest pain is not relieved after one tablet, call 911 immediately. d. Wait 1 minute between doses of sublingual tablets, up to 3 doses.

c. If the chest pain is not relieved after one tablet, call 911 immediately. (According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient may take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved.)

The nurse is reviewing the orders for a patient and notes a new order for an angiotensin-converting enzyme (ACE) inhibitor. The nurse checks the current medication orders, knowing that this drug class may have a serious interaction with what other drug class? a. Calcium channel blockers b. Diuretics c. Nonsteroidal anti-inflammatory drugs d. Nitrates

c. Nonsteroidal anti-inflammatory drugs (Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can reduce the antihypertensive effect of ACE inhibitors. In addition, the use of NSAIDs and ACE inhibitors may also predispose patients to the development of acute renal failure.)

When the nurse is administering topical nitroglycerin ointment, which technique is correct? a. Apply the ointment on the skin on the forearm. b. Apply the ointment only in the case of a mild angina episode. c. Remove the old ointment before new ointment is applied. d. Massage the ointment gently into the skin, and then cover the area with plastic wrap.

c. Remove the old ointment before new ointment is applied. (The old ointment should be removed before a new dose is applied. The ointment should be applied to clean, dry, hairless skin of the upper arms or body, not below the elbows or below the knees. The ointment is not massaged or spread on the skin, and it is not indicated for the treatment of acute angina.)

A patient has been taking digoxin at home but took an accidental overdose and has developed toxicity. The patient has been admitted to the telemetry unit, where the physician has ordered digoxin immune Fab (Digifab). The patient asks the nurse why the medication is ordered. What is the nurse's best response? a. "It will increase your heart rate." b. "This drug helps to lower your potassium levels." c. "It helps to convert the irregular heart rhythm to a more normal rhythm." d. "This drug is an antidote to digoxin and will help to lower the blood levels."

d. "This drug is an antidote to digoxin and will help to lower the blood levels." (Digoxin immune Fab (Digifab) is the antidote for a severe digoxin overdose. It is given intravenously. The other options are incorrect.)

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

d. "Would you like information about advance directives?" (The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of pushing the client's issues off on a chaplain or psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.)

A calcium channel blocker (CCB) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. Which instruction is correct? a. Chew the tablet for faster release of the medication. b. To increase the effect of the drug, take it with grapefruit juice. c. If the adverse effects of chest pain, fainting, or dyspnea occur, discontinue the medication immediately. d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur.

d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur. (Constipation is a common effect of CCBs, and a high-fiber diet and plenty of fluids will help to prevent it. Grapefruit juice decreases the metabolism of CCBs. Extended-release tablets must never be chewed or crushed. These medications should never be discontinued abruptly because of the risk for rebound hypertension.)

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

d. Administer PRN acetaminophen. (The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.)

The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? a. The solution will be slightly colored green or blue. b. The intravenous form is given by bolus injection. c. It can be given in infusions with other medications. d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.

d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used. (The non-PVC infusion kits are used to avoid absorption and/or uptake of the nitrate by the intravenous tubing and bag and/or decomposition of the nitrate. The medication is given by infusion via an infusion pump and not with other medications. It is not given by bolus injection. If the parenteral solution is discolored blue or green, it should be discarded.)

A patient asks the nurse about using potassium supplements while taking spironolactone (Aldactone). What is the nurse's best response? "I would recommend that you take two multivitamins every day." "This diuretic is potassium sparing, so there is no need for extra potassium." "I will call your health care provider and discuss your concern." "You will need to take potassium supplements for the medication to be effective."

"This diuretic is potassium sparing, so there is no need for extra potassium." (Spironolactone is a potassium-sparing diuretic, and thus the patient does not need potassium supplementation. Intake of excess potassium may lead to hyperkalemia.)

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? "This way you will not need to have a leg incision." "The surgeon prefers this approach because it is easier." "These arteries remain open longer." "The surgeon has chosen this approach because of your age."

"These arteries remain open longer." (The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts.Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.)

Which statement by the patient demonstrates a need for further education regarding nitroglycerin(Nitrostat) sublingual tablets? "I should keep my nitroglycerin in a cool, dry place." "I should change positions slowly to avoid getting dizzy from the drug's effect on my blood pressure." "If I get a headache, I should keep taking my nitroglycerin and use Tylenol to relieve my headache." "I can take up to four tablets at 5-minute intervals for chest pain."

"I can take up to four tablets at 5-minute intervals for chest pain." (Patients are taught to take up to three sublingual tablets 5 minutes apart. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after one dose, the patient (or family member) must call 911 immediately. The patient can take one more tablet while awaiting emergency care and a third tablet 5 minutes later, but no more than three tablets total. Patients should always sit or lie down before taking this medication.)

The patient states to the nurse, "My friend said nitroglycerin relieves angina pain by reducing preload. What is preload?" Which statement by the nurse explains preload to this patient? "It is dilation of arteries and veins throughout the body." "It is the oxygen demand of the heart." "It is the pressure against which the heart must pump." "It is the blood return to the heart."

"It is the blood return to the heart." (Preload is determined by the amount of blood in the ventricle just before contraction.)

When preparing to administer intravenous furosemide (Lasix) to a patient with renal dysfunction, the nurse will administer the medication no faster than which rate? 2 mg/min 4 mg/min 6 mg/min 8 mg/min

4 mg/min (Furosemide controlled infusion rate should not exceed at a rate of 4 mg/min in patients with renal failure.)

To prevent the development of tolerance to nitroglycerin (Nitro-Bid) transdermal patch, the nurse instructs the patient to perform which action? Use the nitroglycerin patch for acute episodes of angina only. Apply the nitroglycerin patch in the morning and remove it at night for 8 hours. Switch to sublingual nitroglycerin when the systolic blood pressure is greater than 140 mm Hg. Apply a new nitroglycerin patch every other day.

Apply the nitroglycerin patch in the morning and remove it at night for 8 hours. (To avoid development of tolerance to transdermal nitroglycerin patches, maintain an 8-hour nitrate-free period each day. A common regimen with transdermal patches is to remove them at night for 8 hours and apply a new patch in the morning.)

The nurse would assess which laboratory value to determine the effectiveness of intravenous heparin (Hemochron)? Complete blood count Activated partial thromboplastin time (aPTT) Blood urea nitrogen Prothrombin time (PT)

Activated partial thromboplastin time (aPTT) (Heparin dosing is based on aPTT results. The PT is reflective of warfarin's anticoagulant effect.)

The patient's serum digoxin level is 0.4 ng/mL. How does the nurse interpret this laboratory value result for digoxin? Normal therapeutic level Below the therapeutic level A toxic serum blood level Above the therapeutic level

Below the therapeutic level (Therapeutic serum digoxin levels are 0.5 to 2 ng/mL.)

When caring for a patient with angina pectoris, the nurse would question a prescription for a noncardioselective beta blocker in a patient with which preexisting condition? Atrial fibrillation Bronchial asthma Myocardial infarction Hypertension

Bronchial asthma (Noncardioselective beta blockers should be used with caution in patients with bronchial asthma, because any level of blockade of beta₂-receptors can promote bronchoconstriction.)

Which electrolyte imbalances at the cellular level cause changes in the normal conduction and contractile function of the myocardium? Select all that apply. Sodium Calcium Potassium Magnesium Phosphorus

Calcium Potassium Magnesium (Electrolyte imbalances that occur at the cellular level causing changes in the normal conduction and contractile function of the myocardium are calcium, potassium, and magnesium. The main function of sodium includes regulation of fluid balance and acid-base balance in the body. The main function of phosphorus is growth and repair of the body cells and tissue.)

A patient diagnosed with my myocardial infarction has the following labs: potassium 3.5 mEq/L, calcium 7.5 mg/dL, magnesium 1.8 mEq/L, and pH 7.43. What value should be reported to the health care provider first? pH 7.43 Calcium 7.5 mg/dL Potassium 3.5 mEq/L Magnesium 1.8 mEq/L

Calcium 7.5 mg/dL (Calcium of 7.5 mg/dL is low and can result in changes to normal conduction. The pH (7.43), magnesium (1.8 mEq/L), and potassium (3.5 mEq/L) levels are normal.)

For a patient receiving IV nitroglycerin (Tridil), what are the priority nursing interventions? (Select all that apply.) Check the heart rate. Monitor blood pressure. Measure intake and output. Assess for worsening chest pain. Auscultate lung sounds.

Check the heart rate. Monitor blood pressure. Assess for worsening chest pain. (IV nitroglycerin can cause sudden and severe hypotension, worsening of chest pain, and significant changes in heart rate (less than 60 beats/min or greater than 100 beats/min).)

Which medication is an antiplatelet drug? Clopidogrel (Plavix) Alteplase (Activase) Enoxaparin (Lovenox) Heparin (Hemochron)

Clopidogrel (Plavix) (Clopidogrel (Plavix) is an antiplatelet drug. Enoxaparin and heparin are anticoagulants. Alteplase is a thrombolytic drug.)

The nurse is preparing to administer digoxin (Lanoxin) 0.25mg intravenous push to a patient. Which is an expected patient outcome related to the administration of digoxin? Low serum potassium Reduction in urine output Increase in blood pressure Decrease in the heart rate

Decrease in the heart rate (Digoxin has a negative chronotropic effect (decreased heart rate).)

A patient receiving IV nitroglycerin at 20 mcg/min complains of dizziness. Nursing assessment reveals a blood pressure of 85/40 mm Hg, heart rate of 110 beats/min, and respiratory rate of 16 breaths/min. What is the nurse's best action? Recheck the patient's vital signs in 1 hour. Assess the patient's lung sounds. Increase the IV nitroglycerin by 10 mcg/min. Decrease the IV nitroglycerin by 10 mcg/min.

Decrease the IV nitroglycerin by 10 mcg/min. (Nitroglycerin, as a vasodilator, causes a decrease in blood pressure. Because it is short-acting, decreasing the infusion rate will allow the blood pressure to rise. The patient should be monitored every 10 minutes while changing the rate of the IV nitroglycerin infusion.)

In a patient with compartment syndrome, what is the physiologic change that causes pallor? Increased tissue pressure Decreased oxygen to tissues Pressure on the nerve endings Increased capillary permeability

Decreased oxygen to tissues (Pallor results from decreased oxygen to tissues. Increased tissue pressure, pressure on the nerve endings results in pain, and increased capillary permeability cause edema, tingling, and numbness.)

When teaching a patient about a new prescription for carvedilol (Coreg), the nurse explains that this medication reduces blood pressure by which action? (Select all that apply.) Decreases heart rate Promotes excretion of sodium Relaxes muscle tone Peripheral vasodilation Increases urine output

Decreases heart rate Peripheral vasodilation (Carvedilol (Coreg) has the dual antihypertensive effects of reduction in heart rate (beta₁ receptor blockade) and vasodilation (alpha₁ receptor blockade).)

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? Select all that apply. Sharp, inspiratory chest pain Dyspnea Dizziness Extreme fatigue Anorexia

Dyspnea Dizziness Extreme fatigue (Many women who experience an MI present with dyspnea, light-headedness and dizziness, and fatigue.Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.)

To treat a patient with pulmonary edema, the nurse prepares to administer which diuretic to this patient? Amiloride (Midamor) Furosemide (Lasix) Spironolactone (Aldactone) Triamterene (Dyrenium)

Furosemide (Lasix) (Furosemide is a potent, rapid-acting diuretic that would be the drug of choice to treat pulmonary edema. The other medications are not potent enough to cause the diuresis necessary to treat this condition.)

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8°F (37.7°C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action does the nurse take? Give the digoxin; reassess the heart rate in 30 minutes. Give the digoxin; document assessment findings in the medical record. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement.

Hold the digoxin, and obtain a prescription for a potassium supplement. (The nurse needs to hold the digoxin and get a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.)

The use of which drug may pose a risk for the development of heart failure, especially in older adults? Insulin Digoxin Ibuprofen Potassium chloride

Ibuprofen (Long-term use of NSAIDs (ibuprofen, naproxen) may cause fluid and sodium retention. Insulin controls blood glucose levels, which should help prevent heart disease and heart failure. Digoxin is a medication used in the treatment of heart failure to increase stroke volume and heart rate. Potassium chloride is used as a supplement to prevent or treat electrolyte imbalance; this often results from diuretics used when treating heart failure.

What statements about amputation are correct? Select all that apply. Traumatic amputations are caused by peripheral vascular diseases. Lisfranc and Chopart amputations are types of midfoot amputations. In a Syme amputation, most of the foot is removed but the ankle remains. Lower extremity amputations are less common in black and Hispanic populations. Lower extremity amputations are more common than upper extremity amputations.

Lisfranc and Chopart amputations are types of midfoot amputations. In a Syme amputation, most of the foot is removed but the ankle remains. Lower extremity amputations are more common than upper extremity amputations. (Lower extremity amputations are performed more frequently than upper extremity amputations. In the Syme amputation, most of the foot is removed but the ankle remains. Lisfranc and Chopart amputations are types of midfoot amputations. Traumatic amputations usually result from accidents and are often upper extremity amputations. Lower extremity amputations are more common in black and Hispanic populations due to the high incidence of diabetes and arteriosclerosis.)

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action would be performed first? Assess coping skills. Assess for postoperative pain at the client's incision site. Monitor the heart rate for dysrhythmias. Monitor mental status.

Monitor the heart rate for dysrhythmias. (The nurse would monitor the client's heart rate for dysrhythmias. Dysrhythmias are the leading cause of prehospital death.Assessing mental status, coping skills, or postoperative pain is not the priority for this client.)

When teaching a patient about symptoms of hypokalemia, the nurse will instruct the patient to notify the health care provider if which symptom occurs? Diaphoresis Constipation Blurred vision Muscle weakness

Muscle weakness (Muscle weakness is a common symptom of hypokalemia. The other answers are incorrect.)

What finding is consistent with myocardial infarction in women? Negative troponin levels Non-ST elevation on an ECG Oxygen saturation less than 80% Elevated erythrocyte sedimentation rate

Non-ST elevation on an ECG (Women commonly do not have ST elevation on an electrocardiogram (ECG). Troponin levels would be elevated. Oxygen saturation and erythrocyte sedimentation rate are not diagnostic for myocardial infarction.)

For a patient receiving a positive inotropic drug, which nursing assessments should be performed? (Select all that apply.) Obtain daily weights. Check apical pulse. Auscultate lung sounds. Review red blood cell count. Monitor serum electrolytes.

Obtain daily weights. Check apical pulse. Auscultate lung sounds. Monitor serum electrolytes. (Lung sounds and daily weights are appropriate assessments related to the treatment of heart failure with inotropic drugs. The apical pulse and serum electrolytes are important assessments related to potential adverse reactions (bradycardia, toxicity with hypokalemia).)

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? Ankle-brachial index Dye allergy Pedal pulses Gag reflex

Pedal pulses (After a client with PAD has had a PTA, it is essential for the nurse to assess for pedal pulses. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring distal pulses to ensure adequate perfusion. Pulse checks must be assessed post procedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).Ankle-brachial index is a diagnostic study used to detect the presence of PAD. This is not necessary after PTA, which is an intervention to treat PAD. It is imperative to assess for dye allergy before performing PTA. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy). The femoral artery is generally the access site for PTA.)

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)? Partial thromboplastin time (PTT) 60 seconds Platelets 32,000/mm³ (32 × 10⁹/L) White blood cells 11,000/mm³ (11 × 10⁹/L) Hemoglobin 12.2 g/dL (122 mmol/L)

Platelets 32,000/mm³ (32 × 109/L) (When caring for a client receiving UFH, the nurse notifies the PCP of a platelet level of 32,000/³ (32 × 10⁹/L). UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm³ (100 to 120 × 10⁹/L). Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm³ (150 × 10⁹/L).A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.)

ACE inhibitors and ARBs both work to decrease blood pressure by which action? Enhance sodium and water resorption Increase the breakdown of bradykinin Prevent the formation of angiotensin II Prevent aldosterone secretion

Prevent aldosterone secretion (Whereas ACE inhibitors block the formation of angiotensin II, ARBs allow the formation of angiotensin II but block its effect at the receptors. Without the receptors stimulated (because of either drug), aldosterone secretion is inhibited, preventing the reabsorption of sodium and water.)

Before emergency surgery, the nurse would anticipate administering which medication to a patient receiving heparin? Vitamin K (Phytonadione) Protamine (Protamine sulfate) Phenytoin (Dilantin) Vitamin E

Protamine (Protamine sulfate) (Protamine sulfate binds with heparin in the bloodstream to inactivate it and thus reverse its effect.)

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? Reproducible leg pain with exercise Unilateral swelling of affected leg Decreased pain when legs are elevated Pulse oximetry reading of 90%

Reproducible leg pain with exercise (The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.)

The nurse is teaching treatment of acute chest pain for a patient prescribed nitroglycerin (Nitrostat) sublingual tablets. Which instructions should the nurse include? Keep the tablets locked in a safe place until you need them. Chew or swallow the tablet for the quickest effect. Take five tablets every 3 minutes for chest pain. Sit or lie down before taking medication.

Sit or lie down before taking medication. (Nitroglycerin is a vasodilator and can cause orthostatic hypotension, resulting in dizziness. It should be kept in a readily accessible location for immediate use should chest pain occur. Three tablets may be taken 5 minutes apart. It should be placed under the tongue and allowed to dissolve.)

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? Substernal chest discomfort occurring at rest Chest pain brought on by exertion or stress Substernal chest discomfort relieved by nitroglycerin or rest Substernal chest pressure relieved only by opioids

Substernal chest pressure relieved only by opioids (Substernal chest pressure relieved only by opioids is typically indicative of MI.Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.)

The nurse is assigned to all of these clients. Which client would be assessed first? The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago (The client who would be assessed first is the client who had a PTA of the right femoral artery 30 minutes ago. This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment and can be assessed after the PTA client is seen.)

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The risk for hypotension The potential for bradycardia Liver function tests

The risk for hypotension (At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.)

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase Homocysteine and C-reactive protein Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol Troponin

Troponin (Positive findings for troponin is the most specific cardiac marker used to determine whether an MI has occurred.Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.)

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? Auscultation of crackles Pedal edema Weight loss of 6 pounds (2.7 kg) since the last visit Reports sucking on ice chips all day for dry mouth

Weight loss of 6 pounds (2.7 kg) since the last visit (The clinic nurse recognizes that the client has been compliant with fluid restrictions when the client has a weight loss of 6 pounds (2.7 kg) since the last visit. Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions. Alternative methods of treating dry mouth need to be explored.)