Adaptive quizzing Cardiovascular
A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? "I am unable to run a mile now." "I wake up at night short of breath." "My shoes seem larger lately." "My wife says I snore very loudly."
"I wake up at night short of breath." Rationale Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile, snoring loudly, and shoes seeming larger are not related to heart failure.
A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. What is the nurse's best response? "Hot drinks such as coffee are not good for your heart." "Coffee is not permitted on the diet that was prescribed for you." "You cannot have coffee. I can bring you a cup of tea if you like." "Coffee has caffeine, which can affect your heart. It should be avoided."
"Coffee has caffeine, which can affect your heart. It should be avoided." Rationale Caffeine is a stimulant that causes vasoconstriction and is contraindicated for a client with a dysrhythmia. Although "Hot drinks such as coffee are not good for your heart" is a true statement, it does not provide information as to why it is not good for the heart. Adherence to a medical regimen increases when the client understands the rationale for recommendations. Tea contains caffeine and should be avoided by a client with a dysrhythmia.
Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will turn off clients' IVs that have infiltrated." "I will take clients' vital signs after their procedures are over." "I will use unit written materials to teach clients before surgery." "I will help by giving medications to clients who are slow in taking pills."
"I will take clients' vital signs after their procedures are over." Rationale Monitoring vital signs after procedures is within the scope of a UAP's role. Registered professional nurses or licensed practical nurses, not UAPs, should perform turning off clients' IVs that have infiltrated. Using unit written materials to teach clients before surgery should be performed by registered professional nurses or licensed practical nurses, not UAPs. Helping by giving medications to clients who are slow in taking pills should be performed by registered professional nurses or licensed practical nurses, not UAPs.
A client with hypertension is to follow a 2-gram sodium diet. Which client statement provides evidence that the nurse's dietary instructions are understood? "My fluid intake should be restricted." "I should limit the number of daily food servings." "Salt should not be used during cooking but can be used at the table." "Labels on prepackaged food products should be evaluated before purchase."
"Labels on prepackaged food products should be evaluated before purchase." Rationale Prepackaged foods generally are high in sodium, and labels should be read before purchase to ensure that wise choices are made. Fluids are not restricted on a 2-gram sodium diet; if hypertension is severe, fluid restriction may be an additional precaution. A 2-gram sodium diet restricts the types, not the amounts or frequency, of food to be consumed. With a 2-gram sodium diet, salt should not be added to food during cooking or at the table.
A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" The most appropriate response by the nurse is: "Let me ask your primary health care provider for you." "I can understand why you are worried." "Tell me about your concerns right now." "It depends on whether the tumor has spread."
"Tell me about your concerns right now." Rationale The response "Tell me about your concerns right now" encourages the client to review facts and provides an opportunity to talk about feelings. The response "Let me ask your primary health care provider for you" suggests the nurse does not want to discuss the subject; it abdicates the nurse's responsibility to explore the issue with the client. Although it is an empathic answer, the response "I can understand why you are worried" does not encourage the client to explore feelings; it may increase anxiety. Although the statement "It depends on whether the tumor has spread" is true, the response does not encourage the client to examine feelings.
Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client? 1 to 3 minutes 4 to 5 seconds 30 to 45 seconds 20 to 45 minutes
1 to 3 minutes Rationale The onset of action of sublingual nitroglycerin tablets is rapid (1 to 3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.
The spouse of a client who had emergency coronary artery bypass surgery asks why there is a dressing on the client's left leg. What does the nurse explain? This is the access site for the heart-lung machine A filter is inserted in the leg to prevent embolization A vein in the leg was used to bypass the coronary artery The arteries in the extremities are examined during surgery
A vein in the leg was used to bypass the coronary artery Rationale The response that a vein in the leg was used to bypass the coronary artery provides information and reduces anxiety; the nurse understands that the greater saphenous vein of the leg is used to bypass the diseased coronary artery because one surgical team obtains the vein while another team performs the chest surgery; this shortens the surgical time and lessens the risks of surgery. The internal mammary arteries are the grafts of choice but the surgery is usually longer because of the necessity of dissecting the arteries from the chest wall. In addition, the internal mammary arteries may have been used in a previous bypass surgery. Cardiopulmonary bypass (extracorporeal circulation) is accomplished by placement of a cannula in the right atrium, vena cava, or femoral vein to withdraw blood from the body; blood is returned to the body via a cannula in the aorta or the femoral artery. Off-pump surgery is used for minimally invasive surgical techniques. A filter is not inserted in the leg to prevent embolization during a coronary artery bypass graft (CABG). The arteries in the extremities are not examined during a CABG.
A client asks a nurse why captopril (Capoten) was prescribed. What specific drug classification should the nurse include in the explanation to the client? Diuretic Sedative Hypnotic Antihypertensive
Antihypertensive Rationale Captopril is an antihypertensive; it inhibits conversion of angiotensin I to angiotensin II. Diuretics promote fluid excretion. Sedatives reduce muscle tension and anxiety. Hypnotics promote sleep.
The nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram. Which clinical finding is most significant when assessing the left extremity before the arteriogram? Mottling of the leg Coolness of the foot Absence of the pedal pulse Thickening of the toenails on the foot
Absence of the pedal pulse Rationale Absence of the left pedal pulse indicates inadequate circulatory status of the left lower extremity. Mottling of the left leg may indicate impaired circulation, but observation of both extremities for comparison is necessary. Coolness of the left foot is a less significant indication of arterial occlusive disease than the absence of a pulse. Thickening of the toenails on the left foot is not as significant as the pulse; this can occur because of inadequate circulation, aging, or fungal infection.
Where should the nurse expect the first heart sound (S 1) to be the loudest when auscultating a client's heart? Base of the heart Apex of the heart Left lateral border Right lateral border
Apex of the heart Rationale The first heart sound is produced by closure of the mitral and tricuspid valves; it is best heard at the apex of the heart. The base of the heart is where the second heart sound (S 2) is best heard; S 2 is produced by closure of the aortic and pulmonic valves. Left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. Right lateral border covers a large area; the only auscultatory area near it is the aortic area.
A nurse is providing discharge instructions about digoxin. Which response should a nurse include as a reason for a client to withhold the digoxin? Chest pain Blurred vision Persistent hiccups Increased urinary output
Blurred vision Rationale Visual disturbances, such as blurred or yellow vision, may be evidence of digoxin toxicity. Chest pain is not a toxic effect of digoxin. Persistent hiccups are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin toxicity; it may be a sign of a therapeutic response to the drug and an improved cardiac output.
Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? Call the primary healthcare provider. Check the client's pedal pulses. Take the client's blood pressure. Recognize the response is expected.
Check the client's pedal pulses. Rationale These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.
A child with leukemia who is undergoing chemotherapy is susceptible to rectal ulcerations. What should the nurse recommend to the parents that will lessen the severity of this problem? Encourage lying on the abdomen when in bed. Have the child wear cotton underpants at night. Apply rectal ointment liberally four times a day. Clean the child's perianal area after each bowel movement.
Clean the child's perianal area after each bowel movement. Rationale Meticulous toilet hygiene is essential to prevent infection and promote comfort. Changing positions in bed is preferable. Underpants keep the area moist and promote bacterial growth; it is preferable to leave the area exposed to air, even if it remains under bed linens. Ointments tend to occlude and trap organisms, thus promoting infection.
When assessing a client with heart failure, the nurse asks when the client most notices an increase in symptoms. Which activity should the nurse expect will cause the client the greatest distress? Getting up from bed in the morning Walking to visit the next-door neighbor Climbing a flight of stairs to the bedroom Leaving the table immediately after a meal
Climbing a flight of stairs to the bedroom Rationale Stair climbing increases oxygen consumption and therefore increases the workload of the heart; this results in dyspnea and fatigue. Getting up from bed in the morning may cause orthostatic hypotension, not increase oxygen demands on the heart. The oxygen demands of the body are not significantly increased when sitting up. Walking short distances on level surfaces will not place as much strain on the cardiovascular system as does climbing stairs against gravity. Although moving from a sitting to a standing position during digestion increases the demand on the heart, it is not as demanding or sustained an activity as is climbing stairs.
A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities? Restrict fluids. Elevate the legs. Apply elastic bandages. Do range-of-motion exercises.
Elevate the legs. Rationale Elevation of extremities promotes venous and lymphatic drainage by gravity. Restricting fluids and applying elastic bandages are dependent functions of the nurse. Doing range-of-motion exercises may have little effect on edema.
A client with angina pectoris is scheduled for a stress echocardiogram. What does the nurse explain the echocardiogram is? Tool used solely to determine the cause of chest pain Noninvasive approach to assess cardiovascular status Modality of minimal value in planning treatment for angina Test that is invasive that measures the body's reaction to progressive increases in exertion
Noninvasive approach to assess cardiovascular status Rationale A stress echocardiogram is noninvasive and uses echoes from pulsed high-frequency sound waves to locate and study the movements and dimensions of cardiac structures; it assesses myocardial disease, valve function, congenital heart defects, blood flow abnormalities, and systemic and pulmonic hypertension. A stress echocardiogram assesses structural defects as well as blood flow abnormalities. A stress echocardiogram is valuable in diagnosing and indicating treatment for a variety of conditions involving the heart's structure and function. A stress echocardiogram is not an invasive examination.
The nurse is providing post-procedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. What action should the nurse take? Monitor vital signs more frequently Notify the primary health care provider immediately Apply a warm moist compress to the incision site Increase the intravenous fluid rate by 20 mL/hr
Notify the primary health care provider immediately Rationale The health care provider must be notified immediately so that anticoagulation therapy can be instituted. Although monitoring vital signs is appropriate, it is an insufficient intervention; the health care provider must be notified so that anticoagulants can be prescribed. Applying a warm, moist compress to the incision site is inappropriate because it may promote bleeding; if phlebitis occurs, warm, moist compresses may be applied with a health care provider's prescription. Increasing the intravenous fluid rate by 20 mL hourly will not resolve embolus.
A nurse is caring for a child with newly diagnosed acute lymphoblastic leukemia. What clinical findings does the nurse anticipate when assessing the child? Select all that apply. Pallor Fatigue Jaundice Multiple bruises Generalized edema
Pallor Fatigue Multiple bruises Rationale Pallor is the result of anemia associated with leukemia. Fatigue is the result of anemia associated with leukemia. Multiple bruises are the result of thrombocytopenia associated with leukemia. Jaundice usually indicates liver damage or excessive hemolysis and is not an early sign of leukemia. Edema is not a manifestation of the disease because the pathophysiology does not involve transport of fluids.
Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test? Complete blood count Serum potassium level X-ray film of long bones Blood cultures times three
Serum potassium level Rationale Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. Complete blood count, x-ray film of long bones, and blood cultures times three will have no significance in the diagnosis of a potassium deficit.
The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" What does the nurse explain is the primary purpose of early ambulation? To promote healing of the incision To lower the incidence of urinary tract infections To use energy to help the client sleep better at night To keep blood from pooling in the legs to prevent clots
To keep blood from pooling in the legs to prevent clots Rationale The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.
A male client with aortic stenosis is scheduled for a valve replacement in two days. He tells the nurse, "I told my wife all she needs to know if I don't make it." What response is most therapeutic? "Men your age do very well." "You are worried about dying." "I know you are concerned, but your surgeon is excellent." "I'll get you a sleeping pill tonight because I know you will need it."
"You are worried about dying." Rationale "You are worried about dying" is a reflective statement that conveys acceptance and encourages further communication. The response "Men your age do very well" is false reassurance that does not lessen anxiety. The response "I know you are concerned, but your surgeon is excellent" is false reassurance and cuts off communication; this statement does not encourage the client to discuss feelings. The reliance on a pill to help the client in this instance evades the problem and cuts off further communication.
A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? Arteriolar constriction occurs. The cardiac workload decreases. Contractility of the heart decreases. The parasympathetic nervous system is triggered.
Arteriolar constriction occurs. Rationale The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.
A primary health care provider prescribes atenolol (Tenormin) 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to include in the discharge teaching plan for this client? Drink alcoholic beverages in moderation. Avoid abruptly discontinuing the medication. Increase the medication if chest pain develops. Report a pulse rate less than seventy beats per minute.
Avoid abruptly discontinuing the medication. Rationale Clients should never increase medications without a health care provider's direction. Alcohol is contraindicated for clients taking atenolol because it can cause additive hypotension. An abrupt discontinuation of atenolol may cause an acute myocardial infarction. The pulse rate can go much lower as long as the client feels well and is not dizzy.
Metoprolol (Toprol-XL) is prescribed for a client with hypertension. For which side effect should the nurse monitor the client? Hirsutism Bradycardia Restlessness Hypertension
Bradycardia Rationale Beta blockers block stimulation of beta 1 (myocardial) adrenergic receptors, which decreases the heart rate and blood pressure. The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest. Excessive growth of hair or presence of hair in unusual places does not occur with this medication; however, absence or loss of hair (alopecia) may occur. A side effect of this medication is fatigue, not restlessness. This medication may produce hypotension, not hypertension.
A client comes to the emergency department complaining of weakness and dizziness. The blood pressure is 90/60, pulse is 92 and weak, and body weight reflects a 3-pound loss in two days. The weather has been hot. What does the nurse conclude is the biggest concern for this client? Deficient fluid volume Impaired skin integrity Inadequate nutritional intake Decreased participation in activities
Deficient Fluid Volume Rationale The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration in the older adult, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.
A client is scheduled to be transferred from the coronary care unit to a progressive care unit. The client asks a nurse, "Are you sure I'm ready for this move?" What does the nurse conclude the client most likely is experiencing? Fear Depression Dependency Ambivalence
Fear Rationale Fear of another myocardial infarct or sudden death is common when the client's environment is to be changed to one that appears less vigilant. Depression is exhibited by withdrawal, crying, anorexia, and apathy and usually becomes more evident after discharge from the hospital. Dependency usually is exhibited by an unwillingness to increase exercise or perform tasks. Ambivalence is exhibited by contrasting emotions; the client's statement does not demonstrate contrasting emotions.
The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response is based on which principle of bed rest? It prevents the further aggregation of platelets It enhances the peripheral circulation in the deep vessels It decreases the potential for further dislodgment of emboli It maximizes the amount of blood available to damaged tissues
It decreases the potential for further dislodgment of emboli Rationale Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation. Bed rest supports venous stasis rather than the circulation of blood to damaged tissues.
A nurse has administered sublingual nitroglycerine. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerin? Relief of anginal pain Improved cardiac output Decreased blood pressure Dilation of superficial blood vessels
Relief of anginal pain Rationale Cardiac nitrates relax smooth muscles of the coronary arteries; they dilate and deliver more blood to heart muscle, relieving ischemic pain. Although cardiac output may improve because of improved oxygenation of the myocardium, improved cardiac output is not a basis for evaluating the drug's effectiveness. Although dilation of blood vessels and a subsequent drop in blood pressure may occur, decreased blood pressure is not the basis for evaluating the drug's effectiveness. Although superficial vessels dilate, lowering the blood pressure and creating a flushed appearance, dilation of superficial blood vessels is not the basis for evaluating the drug's effectiveness.
A nurse is preparing to teach a client to apply a nitroglycerin patch (Nitro-Dur) as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? Apply the patch on a distal extremity Remove a previous patch before applying the next one Massage the area gently after applying the patch to the skin Apply a warm compress to the site before attaching the patch
Remove a previous patch before applying the next one Rationale Removing the previous patch before applying the next patch ensures that the client receives just the prescribed dose. Ideally, a patch should be removed after 12 to 14 hours to avoid the development of tolerance. The patch should be rotated among hair-free and scar-free sites; acceptable sites include chest, upper abdomen, proximal anterior thigh, or upper arm. The patch should be gently pressed against the skin to ensure adherence; it should not be massaged. Appling a warm compress to the site before attaching the patch is unnecessary and can result in an excessive absorption of the medication.
The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? Refer the client to a nutritionist after providing health teaching about a low-sodium diet. Place the client in a recumbent position and call the paramedics for transport to the hospital. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.
Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible. Rationale According to the United States Department of Health and Human Services (Canada: Canadian Heart and Lung Association), both of these readings indicate hypertension and thus require further evaluation by a healthcare provider; having a baseline for both arms can assist the healthcare provider with the medical diagnosis. Teaching about a low-sodium diet is an inadequate intervention. An appointment with a healthcare provider, not a nutritionist, should be scheduled as soon as possible. There are insufficient data to support this emergency intervention (calling the paramedics). The client's elevated blood pressure needs to be evaluated by a healthcare provider and then medical therapy implemented. Although emotional stress can precipitate hypertension, physical causes should be ruled out first.
A client is taking administering warfarin (Coumadin). The nurse recalls that the antidote for this medication is what? Vitamin K Fibrinogen Prothrombin Protamine sulfate
Vitamin K Rationale Warfarin sodium inhibits vitamin K; therefore, vitamin K is the antidote for warfarin sodium. Fibrinogen and prothrombin are blood-clotting factors, not the antidotes for warfarin sodium. Protamine sulfate is the antidote for heparin, not warfarin sodium.
