Adult exam 1
A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education?
"My family is bringing me a cup of coffee to drink before the test."
The nurse is caring for a client experiencing an acute MI (STEMI). The nurse anticipates the physician will prescribe alteplase. Before administering this medication, which question is most important for the nurse to ask the client?
"What time did your chest pain start today?"
A client has just arrived in the ER with a possible myocardial infarction (MI). The electrocardiogram (ECG) should be obtained within which time frame of arrival to the ER?
10 minutes
Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. With regards to partial thromboplastin time (PTT), when should the nurse plan to remove the femoral sheath?
50 seconds or less.
A nurse is discussing with a nursing student how to accurately measure blood pressure. What statement by the student indicates an understanding of the education?
A cuff that is too small will give a false high blood pressure.
A client with newly diagnosed hypertension asks what to do to decrease the risk for related cardiovascular problems. Which risk factor is not modifiable by the client?
Age
Which method to induce hemostasis after sheath removal after percutaneous transluminal coronary angioplasty (PTCA) is most effective?
Application of a vascular closure device such as Angio-Seal or VasoSeal
The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?
Arterial blood gases
A client has undergone cardiac catheterization and will be discharged today. What information should the nurse emphasize during discharge teaching?
Avoid heavy lifting for the next 24 hours.
Which is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP)
A client is admitted for treatment of Prinzmetal angina. When developing this client's care plan, the nurse should keep in mind that this type of angina is a result of what trigger?
Coronary artery spasm.
The nurse is developing a teaching plan for the client to address modifiable risk factors for coronary artery disease (CAD), the nurse will include which factor(s)? Select all that apply.
Elevated blood pressure Alcohol use Obesity Physical inactivity
Which medication is categorized as a loop diuretic?
Furosemide
Following the morning assessment of an older adult patient, the nurse has documented, "Edema 3+ present to ankles and feet; dorsalis pedis and posterior tibial pulses palpable bilaterally." The nurse should recognize that this patient may be exhibiting symptoms of:
Heart failure
The nurse identifies which symptom as a characteristic of right-sided heart failure?
Jugular vein distention (JVD)
An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. Changes in which leads of a 12-lead ECG indicate damage to the left ventricular septal region?
Leads V3 and V4
During a shift assessment, the nurse is assessing the patient's point of maximum impulse (PMI). Where will the nurse best palpate and auscultate the PMI?
Left midclavicular line of the chest wall at the fifth intercostal space
After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is:
Loud and may be associated with a thrill sound similar to (a purring cat).
The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?
Obtain an oxygen saturation level.
A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged uncontrolled hypertension is at risk for developing what health problem?
Renal failure
Which finding indicates that hypertension is progressing to target organ damage?
Retinal blood vessel damage
Which term describes high blood pressure from an identified cause, such as renal disease?
Secondary hypertension
Which is a potassium-sparing diuretic used in the treatment of heart failure?
Spironolactone
The nurse is providing care for a hemodynamically unstable patient in a critical care setting. The nurse has read in the patient's chart that his most recent echocardiogram prior to admission indicated a low stroke volume, which the nurse recognizes as being a function of preload, afterload, and contractility. Which of the following statements best describes afterload?
The amount of resistance to the ejection of blood from the ventricle
A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient?
The patient had a vagal response.
The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?
The thin fibrous sac encasing the heart
The nurse is caring for a client recovering from an acute myocardial infarction (MI). Which outcome indicates that care provided to maintain adequate tissue perfusion has been effective? Select all that apply.
Urine output 60 mL/hr Awake, alert, and oriented Blood pressure 118/60 mm Hg Normal sinus rhythm at 72 beats per minute
The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply.
adequate cough and gag reflexes acceptable arterial blood gas values breathing without assistance of the ventilator
An client who has been diagnosed with arteriosclerosis is confused by what this means. The nurse explains that arteriosclerosis is:
an expected part of the aging process.
The nurse is caring for a client with a blood pressure of 210/100 mm Hg in the emergency room. What is the most appropriate route of administration for antihypertensive agents?
continuous IV infusion
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?
contractility
A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing
decompensated heart failure with pulmonary edema.
During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse:
deficit.
Frequently, what is the earliest symptom of left-sided heart failure?
dyspnea on exertion
It is appropriate for the nurse to recommend smoking cessation for clients with hypertension because nicotine
increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.
When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating
orthopnea.
The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with
percutaneous coronary intervention (PCI).
A patient is being treated for hypertensive emergency. When treating this patient, the priority goal is to lower the mean blood pressure (BP) by up to which percentage in the first hour?
25%
A client is brought to the emergency department with reports of a bad headache and an increase in blood pressure. The blood pressure reading obtained by the nurse is 260/180 mm Hg. What is the therapeutic goal for reduction of the mean blood pressure?
Reduce the blood pressure by 20% to 25% within the first hour of treatment.
