4510-Cardiac EAQ

Which nursing intervention is specific to clients in active labor who present with a history of cardiac disease?

Auscultating the lungs for crackles every 30 minutes Rationale: Clients with cardiac problems are prone to heart failure during active labor; crackles indicate the presence of pulmonary edema. Encouraging frequent voiding and checking the blood pressure hourly is done for all clients who are in labor. Helping turn the client from side to side at 15-minute intervals is not necessary; although clients who are in labor are maintained on the side to facilitate venous return, the sides do not have to be alternated every 15 minutes.

Which medication prescribed for a client with an acute episode of heart failure would the nurse question?

Beta-blocker Rationale: Beta blockers reduce cardiac output and are contraindicated for clients with acute heart failure, although they are frequently used to prevent progression of chronic heart failure.

Which landmark is correct for the nurse to use when auscultating the mitral valve?

Left fifth intercostal space, midclavicular line

The nurse is preparing to assess the heart of a client during a routine health checkup. Which positioning of the client would be appropriate to assess the murmurs of the heart?

Left lateral recumbent position Rationale: The client should lie in the lateral recumbent position so that the nurse can effectively detect heart murmurs (as shown in Figure 2). The supine position provides easy access to the pulse sites (shown in Figure 1). The client should be placed in the dorsal recumbent position (Figure 3) for abdominal assessment. Sims position (Figure 4) is used so that the nurse can assess the rectum and vagina.

Which activity would the nurse teach clients to avoid after having implantation of a permanent cardiac pacemaker?

Touring a power plant Rationale: Large electrical fields can change pacemaker settings and should be avoided. These clients should avoid magnetic resonance imaging (MRI), not a CT scan. Modern microwaves are shielded and do not cause pacemaker problems. Water, regardless of whether it is fresh or saltwater, will not affect a pacemaker.

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct.

Unusual fatigue Dependent edema Nocturnal dyspnea Rationale: Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure.

When assessing a client who has aortic stenosis and is scheduled for aortic valve replacement, which finding by the nurse is most important to communicate to the health care provider?

multiple dental caries Rationale: Multiple dental caries increase the risk for endocarditis in clients with valvular disease and caries should be treated before surgery. A loud systolic murmur is typical for aortic stenosis. Heartburn will be treated with medications such as histamine blockers or protein pump inhibitors, but is not a reason to postpone surgery. Paroxysmal nocturnal dyspnea is a common symptom of severe aortic stenosis.

A 50-year-old client who has aortic stenosis and is scheduled for a valve replacement tells the nurse, "I gave my spouse all my financial records in case I don't make it." Which response by the nurse is best?

"Are you concerned that you may die during surgery?" Rationale: Asking if the client is concerned about dying is reflective and encourages further communication. A statement that the surgeon is experienced may be true, but is not specific to the client's statement and cuts off further communication. Telling the client that other people generally do well is nonspecific and provides false reassurance that is unlikely to decrease anxiety. Asking about whether the client would like sleep medication evades the client's concerns and cuts off more communication about the client's concerns.

When the nurse is obtaining the health history for a client with mitral valve stenosis, which question will be most relevant to ask?

"Did you ever have strep throat during childhood?" Rationale: Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve.

When caring for an older client who has had multiple recent hospital admissions for heart failure, which action would the nurse take first?

Ask the client about medication use and activity level at home. Rationale: Further assessment of the client's home situation and possible reasons for frequent readmissions are needed before other actions can be taken.

After donning gloves, which action would the nurse take first after discovering a large amount of blood under the buttocks of a client who had a cardiac catheterization through the femoral artery?

Assess the catheterization site. Rationale: Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined, the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.

Which catecholamine receptor is responsible for increased heart rate?

Beta-1 Receptor Rationale: Beta-1 receptors are responsible for increased heart rate. Beta-2 receptors, alpha-1 receptors, and alpha-2 receptors are not present in the heart; therefore, they are not responsible for increasing the heart rate. Beta receptors are present in such organs as blood vessels, kidneys, bronchioles, and bladder. Alpha receptors are present in such organs as eyes, skin, and liver.

The nurse is assessing four different clients. Which findings show that the client is at risk for heart disease? Client 1: Red color assessed. Location assessed- face, area of trauma, sacrum, shoulders Client 2: Bluish color assessed. Location assessed- nail beds, lips, mouth, skin. Client 3: Pallor color assessed. Location assessed- Face, conjunctiva, nail beds, palms of hands. Client 4: Yellow orange color assessed. Location assessed- sclera, mucous membranes, skin.

Client 2 Rationale: Client 2 is at risk for heart disease because the nail beds, lips, mouth, and skin show cyanosis, or a bluish color. This may be due to an increased amount of deoxygenated hemoglobin, which may be due to heart or lung disease.

When caring for a client with heart failure, which type of lung sounds would the nurse expect to hear?

Crackles Rationale: Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are typically heard with airway narrowing caused by asthma. Rhonchi are heard when airways are obstructed with thick secretions caused by problems such as pneumonia.

A child being treated with cardiac medications developed vomiting, bradycardia, anorexia, and dysrhythmias. The nurse understands which medication toxicity is responsible for these symptoms?

Digoxin Rationale: Digoxin helps improve pumping efficacy of the heart, but an overdose can cause toxicity leading to nausea, vomiting, bradycardia, anorexia, and dysrhythmias.

Cardiac catheterization in a child with a ventricular septal defect (VSD) serves which purpose? Correct 1 Identifies the specific location of the defect

Identifies the specific location of the defect Rationale: Cardiac catheterization visualizes the exact location of the ventricular septal defect; also, it measures pulmonary pressures. A murmur can be heard with a stethoscope placed at the left lower sternal border. Cardiomegaly and ventricular hypertrophy are both demonstrated on electrocardiography and echocardiography.

Which would the nurse consider the major characteristic of a cardiac malformation associated with left-to-right shunting?

Increased blood flow to the lungs Rationale: With a left-to-right shunt, blood flows through a defect in the ventricular wall of the heart and is shunted from the higher pressure left side to the lower pressure right side. The increased blood flow from the right ventricle results in an increased blood flow to the lungs. Polycythemia and an increased hematocrit are not common in children with a left-to-right shunt. Severe growth delay is not common in children with a left-to-right shunt. Clubbing is a more common finding in children with a right-to-left shunt.

Which nursing intervention is the priority when the nurse notices that the client has a blood pressure of 90/70 mm Hg and a heart rate of 50 beats per minute while the nurse is performing nasotracheal suctioning?

Stop the suctioning procedure immediately. Rationale: Nasotracheal suctioning can result in vagal stimulation and bronchospasm. Vagal stimulation can result in hypotension, bradycardia, heart block, ventricular tachycardia, or other dysrhythmias and require immediate intervention. A blood pressure of 90/70 mm Hg and heart rate of 50 breaths per minute indicate hypotension and bradycardia so the nurse would immediately stop the suctioning procedure. The nurse can report to the primary health care provider, but only after stopping the suctioning. The nurse can administer intravenous fluids to the client, but only after ensuring the safety of the client. The nurse can administer 100% oxygen to the client, but only after stopping suctioning.

Which topics will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? Select all that apply. One, some, or all responses may be correct.

Symptoms of infection Use of pain medications Purpose of anticoagulant medications

A child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5 ½ NS at 4 mL/h, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left side of the chest dressing. Which is the priority nursing intervention?

Testing the level of consciousness Rationale: Assessing the level of consciousness provides the nurse with information about how awake the client is and therefore how able to clear the throat and protect the airway. The airway takes priority over listening to the lungs (checking for breathing: ABCs—airway-breathing-circulation), measuring drainage, or determining the suction pressure of the nasogastric tube.