Adult 3 Exam 1

An adult client is admitted to the ED with chest pain. The client states that he had unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following?

Morphine, oxygen, and bed rest

Nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure?

My shoes fit really tight lately

A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take first?

Assess the patient's respiratory status

A nurse assesses a patient who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? SATA

-Expanding groin hematoma -Rhythm changes on the cardiac monitor -Serum potassium on 2.9 mEq/L (2.9 mmol/L)

After teaching a patient with congestive heart failure (CHF), the nurse assesses the patient's understanding. Which patient statements indicate a correct understanding of the teaching related to nutritional intake? SATA

-I'll read the nutritional labels on food items for salt content -Substituting fresh vegetables for canned ones will lower my salt intake -I will eat oatmeal for breakfast instead of ham and eggs

A nurse assesses a patient who is diagnosed with infective endocarditis. Which assessment findings would the nurse expect? SATA

-Osler's nodes -Cardiac murmur -Night sweats

A nurse teaches a patient with a new permanent pacemaker. Which instructions would the nurse include in this patients teaching? SATA

-Report any pulse rates lower than your pacemaker settings -Until your incision is healed, do not submerge your pacemaker. Only take showers. -Do not lift you arm above the level of your shoulder

A nurse reviews a patient's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? SATA

-Total cholesterol: 280 mg/dL (7.3 mmol/L) -Triglycerides: 200 mg/dL (2.3 mmol/L) -Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

A nurse is assessing patients on a medical-surgical unit. Which patient would the nurse identify as being at greatest risk for a atrial fibrillation?

A 50-year-old who is post coronary artery bypass graft surgery

An emergency department nurse triages patients who present with chest discomfort. Which patient would the nurse plan to assess first?

A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication?

Cardiac tamponade

The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe?

Cardiopulmonary bypass

A nurse assesses a patient who is scheduled for a cardiac catheterization. Which assessment would the nurse complete prior to this procedure?

Allergies to iodine-based agents

A client with a history of rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which of the following drugs?

Amoxicillin

The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he doesn't have pain. What would be the nurse's best response?

An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks

A nurse cares for a patient who is on a cardiac monitor. The monitor displayed they rhythm shown below:

Assess airway, breathing, and circulation

A nurse assesses an older adult patient who has multiple chronic diseases. The patient's heart rate is 48 beats/min. What action would the nurse take?

Assess the patient's medications

A nurse assesses a patient 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take?

Assess the color and temperature of the left leg

A nurse cares for a patient with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the patient's electrocardiogram. What action would the nurse take next?

Assess vital signs and level of consciousness

A client with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the client to exhibit what heart rhythm?

Atrial fibrillation

A nurse cares for a patient who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate?

Avoid straining while having a bowel movement

The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments?

Balancing myocardial oxygen supply with demand

A client presents to the ED reporting severe sub sternal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infraction (MI). What nursing assessment activity is a priority on admission to the CCU?

Begin ECG monitoring

A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributed to what cause?

Coronary arteriosclerosis

A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following?

Dental procedures

A nurse assesses a patient with pericarditis. Which assessment finding would the nurse expect to find?

Friction rub at the left lower sternal boarder

A brain (B-type) natriuretic peptide (BMP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis?

Heart failure

An emergency room nurse obtains the health history of a patient. Which statement by the patient would alert the nurse to the occurrence of heart failure?

I get short of breath when I climb the stairs

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

I must stop halfway up the stairs to catch my breath

A nurse assesses a patient who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?

Location A

The nurse is caring for a client who is scheduled to undergo mechanical valve replacement. Client education should include which of the following?

Long-term anticoagulant therapy

The nurse is caring for a client with a history of endocarditis. What topic should the nurse prioritize during health promotion education?

Oral hygiene

The nurse asks a patient who has experiences ventricular dysrhythmias about substance abuse. The patient asks, "Why do you want to know if I use cocaine?" What is the nurse's best response?

Patients who use cocaine are at risk for fatal dysrhythmias

A nurse is caring for a patient with acute pericarditis who reports sub sternal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?

Sit the patient up with a pillow to lean forward on.

A community health nurse is presenting an educational even and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease?

Recognizing and promptly treating streptococcal infections

The cardiac care nurse is reviewing the conduction system of the heart. The nurse that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence?

SA node to AV node to bundle of His to Purkinje fibers

A nurse administers prescribed adenosine (Adenocard) to a patient. Which response would the nurse assess for as the expected therapeutic response?

Short period of asystole

A nurse assesses a patient who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?

Slurred speech and confusion

The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response?

Stop the test and monitor the client closely

The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs?

The client experiences chest pain, palpitations, or dyspnea

The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment.

This is an accurate indicator of myocardial injury

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects?

Throbbing headache or dizziness

A client is undergoing diagnostic testing for mitral stenosis. What statement by the client during the nurse's interview is most suggestive of this valvular disorder?

Whenever I do any form of exercise I get terribly short of breath

A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test?

blood cultures

The public health nurse is participating in the health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:

diet therapy and smoking cessation

A nurse teaches a patient who has a history of heart failure. Which statement would the nurse include in this patient's discharge teaching?

weigh yourself daily while wearing the same amount of clothes