Cardiac

STEMI

ST elevation on EKG - indicates MI

Unmodifiable risk factors CAD

age, gender, race, family hx

Antidysrhytmics and MI

amioderone, lidocaine

Atherosclerosis

an accumulation of lipid-containing plaque in the arteries

Interventions for Angina

assess pain (1-10), administer O2, vital signs, administer nitrates, obtain 12 lead EKG

Medications for sinus tachycardia

beta blockers - block beta receptors in heart and decrease heart rate - decrease force of contraction and decrease AV conduction

Troponin level

blood test used to diagnose MI - level rises within 3 hours and remains elevated 7 - 10 days

Creatine kinase level

blood test used to diagnose MI - level rises within 6 hours after onset of chest pain and peaks within 18 hours

Treatment for sinus tachycardia

carotid massage ice

Aortic stenosis - signs and symptoms

dyspnea on exertion, angina, syncope

Symptoms of CAD occur when...

the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs, causing ischemia

Small box on EKG =

0.04 seconds

Big box on EKG =

0.20 seconds

Normal Digoxin level

0.5 - 2

Risk factors for MI

Aterosclerosis, CAD, elevated cholesterol, smoking, hypertension, obesity, physical inactivity, impaired glucose tolerance, stress

Diagnostic tests for CAD/Angina

EKG (shows ischemia), cardiac catheterization (most definitive), blood lipid level, cardiac enzymes, stress test, holter monitor, echocardiogram, TEE, MUGA (ejection fraction)

PVCs are treated with

IV Lidocaine

Endocarditis - treatment

IV antibiotics (maybe at home, PIC), rest, ROM, valve repair, anticoagulants

3 Grades of Myocardial Insult

Ischemia - not enough O2 Injury - enzymes released Infarction - permanent irreversible damage

Pain management for MI

Morphine - increases oxygen to myocardium - 2-5mg IV push - decreases preload

Chemo receptors

Nerve endings located in the aortic arch and carotid bodies that are stimulated by hypoxemia and that subsequently transmit impulses to the CNS.

Signs & Symptoms CAD

Possibly normal findings during asymptomatic periods, chest pain, palpitations, dyspnea, syncope, cough, hemoptysis, excessive fatigue

Myocardial Infarction

Results from sustained cardiac ischemia causing cellular death (after 20 min) and necrosis of myocardium - scar tissue replaces necrotic tissue after 6 weeks

Conduction system of heart

SA node --> AV node --> Bundle of His --> Purkinje fibers

Baroreceptors

Specialized nerve endings located in the walls of the aortic arch and carotid sinuses. They are affected by changes in blood pressure. Increases in BP stimulate baroreceptors and heart rate and BP decrease. Decrease in BP leads to less stimulation of baroreceptors, vasoconstriction occurs and heart rate increases.

Afterload

The force against which the heart has to pump to eject blood from the left ventricle.

Arterial pressure

The pressure of the blood against the arterial walls.

pace maker - sensing

ability to recognize spontaneous atrial or ventricular activity

When assessing a client with left-sided heart failure, the nurse expects to note: a. ascites. b. jugular vein distention. c. air hunger. d. pitting edema of the legs.

c. air hunger. With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.

Digoxin - how does it work?

slows heart rate by increasing block at AV node and increases force of myocardial contraction

Unstable angina

unpredictable - increases in occurrence, duration, and severity over time - may not be relieved with nitroglycerine and may require hospitalization

A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is appropriate at this time? a. Deficient knowledge (disease process) related to interventions used to treat acute illness b. Impaired physical mobility related to complete bed rest c. Social isolation related to restricted visiting hours in the ICU d. Ineffective tissue perfusion (cardiopulmonary) related to arrhythmia

d. Ineffective tissue perfusion (cardiopulmonary) related to arrhythmia The client suffered a lethal arrhythmia, requiring immediate resuscitation. This arrhythmia was caused by ineffective perfusion to the heart. Therefore, the client should have the nursing diagnosis Ineffective tissue perfusion (cardiopulmonary). Client teaching should be limited to clear, concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the knowledge deficit would continue despite attempts at teaching. Impaired physical mobility and Social isolation are necessitated by the client's critical condition; therefore, they are considered therapeutic, not problems warranting nursing diagnoses.

Which of the following terms is used to describe the amount of stretch on the myocardium at the end of diastole? a. Afterload b. Cardiac index c. Cardiac output d. Preload

4. Preload is the amount of stretch of the cardiac muscle fibers at the end of diastole. The volume of blood in the ventricle at the end of diastole determines the preload. Afterload is the force against which the ventricle must expel blood. Cardiac index is the individualized measurement of cardiac output, based on the client's body surface area. Cardiac output is the amount of blood the heart is expelling per minute.

Clinical presentation of MI

Chest pain not relieved by nitroglycerine Pallor Diaphoresis Nausea and vomiting Dyspnea Impending doom Altered LOC

Causes of PVCs

Digoxin toxicity, hypoxia, hypokalemia, fever, acidosis, exercise

Drugs used to teat valve disease

Digoxin, coumadin, amioderone, antibiotics

Contractility

The inherent ability of the myocardium to alter contractile force and velocity. Decreased contractility ---> decreased stroke volume ---> decreased cardiac output

When the appropriate complex follows the pacing spike, it is said to be a. captured. b. nonsynchronous. c. inhibited. d. triggered.

a. captured.

During CPR for ventricular fibrillation, which drug would an RN most like prepare first? a. Atropine sulfate b. Epinephrine c. Furosemide (Lasix) d. Lidocaine

b. Epinephrine - first line drug used during CPR to stimulate cardiac activity Atropine sulfate is used for bradycardia and first-degree AV blocks. Furosemide is a diuretic. Lidocaine is used for ventricular arrhythmias, specifically PVCs.

When a client is started on oral or I.V. diltiazem (Cardizem), the nurse should monitor for which potential complication? a. Flushing b. Heart failure c. Renal failure d. Hypertension

b. Heart failure The chief adverse effects of diltiazem are hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels. Other reactions that have been reported include flushing, nocturia, and polyuria, but not renal failure. Although flushing may occur, it's an adverse reaction, not a potential complication. Heart failure is a life-threatening reaction.

Which of the following ECG waveforms characterizes conduction of an electrical impulse through the left ventricle? a. P wave b. QRS complex c. PR interval d. QT interval

b. QRS complex

Vasoactive drugs, which cause the arteries and veins to dilate thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as a. furosemide (Lasix) b. sodium nitoprusside (Nipride) c. dopamine (Inotropin) d. norepinephrine (Levophed)

b. sodium nitoprusside (Nipride)

Which of the following blood tests is most indicative of cardiac damage? a. Lactate dehydrogenase b. Complete blood count (CBC) c. Troponin I d. Creatine kinase (CK)

c. Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin levels aren't detectable in people without cardiac injury.

A client is admitted for treatment of Prinzmetal's angina. When developing the care plan, the nurse keeps in mind that this type of angina is triggered by: a. activities that increase myocardial oxygen demand. b. an unpredictable amount of activity. c. coronary artery spasm. d. the same type of activity that caused previous angina episodes.

c. coronary artery spasm. Prinzmetal's angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; however, anginal pain is increasingly severe.

Angina

chest pain resulting from myocardial ischemia caused by inadequate myocardial blood/O2 supply - demand exceeds supply - conversion from aerobic to anaerobic respiration causes lactic acid build up which causes pain

How to calculate heart rate from EKG

count the number of R waves in a six second strip and multiply by 10

S2

created by closure of aortic and pulmonic valves

S1

created by the closure of the mitral and tricuspid valves - indicates beginning of ventricular systole

The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: a. Aorta b. Right atrium c. Superior vena cava d. Pulmonary circulation

d. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure.

Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is: a. narrowing complex. b. widening complex. c. amplitude increase. d. amplitude decrease.

d. amplitude decrease. Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing and widening complexes as well as an amplitude increase aren't what is expected on the ECG of an individual with cardiac tamponade.

Janeway lesions

nontender hemorrhagic lesions - fingers, toes, nose, earlobes - associated with endocarditis

PR interval

normal is .12 - .20 seconds - represents

Stable angina

occurs with activities involving exertion or emotional stress - stable pattern of onset, duration, and intensity

Sinus bradycardia

rate < 60 BPM regular rhythm P wave before each QRS PR interval .12 to .20 QRS < .12

Lidocaine (cardiac)

ventricular arrhythmias, specifically PVCs

Which of the following is a modifiable risk factor for coronary artery disease ( CAD)? a. Race b. Diabetes mellitus c. Gender d. Increasing age

b. Diabetes mellitus

In order to be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction? a. 6 to 12 months b. 9 days c. 60 minutes d. 30 minutes

c. 60 minutes

Myocardial injury is indicated on EKG by...

elevation or depression of ST segment, T wave inversion, or deep Q waves

Pericardial sac

encases the heart and protects from trauma and infection 2 layers - parietal (outer, tough/fibrous) and visceral (inner, thin)

Mitral stenosis can lead to...

eventually increased pressure in left atrium causes dilation and eventual CHF - also causes Afib

Normal sinus rhythm

heart rate 60 - 100 BPM regular rhythm P wave before each QRS PR interval .12 to .20 QRS < .12

Ventricular tachycardia

heart rate > 100 bpm regular rhythm no p wave QRS > .12

QRS complex

represents ventricular depolarization/contraction - normal is < .12 seconds

Three layers of the heart

Epicardium - outermost layer Myocardium - middle layer - muscle of heart Endocardium - innermost layer - lines inner chambers of heart and valves

Treatment for A-Fib and A-Flutter

Digoxin, coumadin/pradaxa, calcium channel blockers/beta blockers, antiarrhythmics/amioderone

Conductivity

The ability of the heart muscle fibers to propagate electrical impulses along and across cell membranes.

PTCA/Angioplasty

Treatment for CAD - compresses plaque against walls and dilates vessel

Endocarditis - diagnostic tests

WBC/sed rate (elevated), blood cultures (+), TEE

Pericarditis - diagnostic tests

WBC/sed rate, blood culture, EKG, edho, BP, temp

Prinzmetal's angina

results from coronary artery spasm - may occur at rest - changes in ST segment on EKG - treat with calcium channel blockers

Regurgitant valve

a valve that cannot close completely - sometimes called insufficient

Stenotic valve

a valve that cannot open fully

The staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process? a. "I will have the transplant coordinator speak with you to answer your questions." b. "There is never contact between the donor's family and the recipient." c. "The recipient is allowed to ask questions about the donor and have them answered." d. "It is important that the recipient know where to send Thank-You cards."

a. "I will have the transplant coordinator speak with you to answer your questions." The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.

Before discharge, which instruction should the nurse give to a client receiving flecainide (Tambocor) to reduce the risk of heart failure? a. "Limit your fluid intake." b. "Take a diuretic before going to bed." c. "Limit your potassium intake." d. "Have your serum electrolyte levels measured weekly."

a. "Limit your fluid intake." The nurse should tell the client receiving flecainide to limit fluid intake. The client shouldn't take a diuretic unless prescribed by the physician; if prescribed, the diuretic should be taken early in the day to prevent nocturia. Sodium (not potassium) should be limited because excessive sodium intake causes water retention. The client's electrolyte levels don't need to be measured weekly

The nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he complains of dizziness. Which medication would be used to treat his bradycardia? a. Atropine b. Dobutamine (Dobutrex) c. Amiodarone (Cordarone) d. Lidocaine (Xylocaine)

a. Atropine I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.

Which sign or symptom suggest that a client's abdominal aortic aneurysm is extending? a. Increased abdominal and back pain b. Decreased pulse rate and blood pressure c. Retrosternal back pain radiating to the left arm d. Elevated blood pressure and rapid respirations

a. Increased abdominal and back pain Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

The nurse is evaluating a client who had a myocardial infarction (MI) 7 days ago. Which outcome indicates that the client is responding favorably to therapy? a. The client demonstrates the ability to tolerate increasing activity without chest pain. b. The client exhibits a heart rate above 100 beats/minute. c. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking. d. The client states that sublingual nitroglycerin usually relieves chest pain.

a. The client demonstrates the ability to tolerate increasing activity without chest pain. The ability to tolerate increasing activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.

After receiving shift report, the registered nurse in the cardiac step-down unit, must prioritize her client care assignment. She has an ancillary staff member available to help her care for her clients. Which of these clients should the registered nurse assess first? a. The client with heart failure who is having some difficulty breathing. b. The anxious client who was diagnosed with an acute myocardial infarction (MI) two days ago and who was transferred from the coronary care unit today. c. The demanding client who underwent coronary bypass surgery three days ago. d. The client admitted during the previous shift with new-onset controlled atrial fibrillation who has her call light on.

a. The client with heart failure who is having some difficulty breathing. The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. She can also attend to the demanding client who underwent coronary bypass surgery three days ago. Although anxiety can be detrimental to a client with an MI, anxiety doesn't take precedence over another client's breathing difficulty.

A client with chest pain doesn't respond to nitroglycerin. On admission to the emergency department, the health care team obtains an electrocardiogram and begins infusing I.V. morphine. The physician also considers administering alteplase (Activase). This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? a. Within 12 hours b. Within 24 hours c. Within 24 to 48 hours d. Within 5 to 7 days

a. Within 12 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 12 hours after onset of chest pain or other signs or symptoms of MI. Within the first 24 hours after an MI, sudden death is most likely to occur. I.V. heparin therapy begins after administration of a thrombolytic agent and usually continues for 5 to 7 days.

After a myocardial infarction, a client develops a complication requiring a continuous infusion of lidocaine. To monitor the effectiveness of this infusion, the nurse should focus primarily on: a. electrocardiogram (ECG). b. urine output. c. creatine kinase (CK) and troponin levels. d. blood pressure and heart rate.

a. electrocardiogram (ECG). Lidocaine is an antiarrhythmic given to treat cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is the reduction or disappearance of ventricular arrhythmias as seen on the ECG. Urine output is an indicator of pump effectiveness. CK and troponin levels monitor myocardial damage. Blood pressure and heart rate are too nonspecific to be indicators of lidocaine's effectiveness.

A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth (P.O.) daily, and furosemide (Lasix), 20 mg P.O. twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digitalis toxicity. Digitalis toxicity also may cause: a. visual disturbances. b. taste and smell alterations. c. dry mouth and urine retention. d. nocturia and sleep disturbances.

a. visual disturbances. Digitalis toxicity may cause visual disturbances (such as flickering light flashes, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (abnormal heart rate and arrhythmias). Taste and smell alterations aren't associated with digitalis toxicity. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.

Patients with metal valve replacements require what type of therapy?

anticoagulant - lifetime

Atrial fibrillation

atria quiver at a rate of 300 - 600 BPM - irregular ventricular response - risk of mural thrombi

Multifocal PVCs

runs of PVCs - danger of decreased cardiac output - risk of V-tach or V-fib

The nurse on the telemetry unit is faced with various situations. Which situation takes priority? a. A client's cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions. b. A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. c. A client is requesting help to go to the bathroom. d. The cardiologist is asking the nurse to make rounds with him to his clients.

b. A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. The client whose cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation takes priority. This cardiac rhythm change may cause clots to shower from the atria placing the client at risk for a stroke. The client whose cardiac monitor reveals sinus tachycardia with isolated premature ventricular contractions isn't experiencing a life-threatening situation; therefore, he doesn't take priority. The nurse can ask her ancillary staff member to assist the client to the bathroom. Making rounds with the physician can wait until the nurse addresses the needs of the client in atrial fibrillation.

The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect? a. Pulmonary embolism b. Heart failure c. Cardiac tamponade d. Tension pneumothorax

b. Heart failure A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.

A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position? a. Semi-Fowler's b. Leaning forward while sitting c. Supine d. Prone

b. Leaning forward while sitting When the client leans forward, the heart pulls away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis.

A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs? a. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to lower the secretion of aldosterone and antidiuretic hormone. b. Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. c. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to raise aldosterone secretion. d. Low blood pressure triggers the baroreceptors to decrease sympathetic nervous system stimulation.

b. Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing a faster heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone and antidiuretic hormone, in turn causing sodium and water retention and arterial vasoconstriction.

For a patient who has undergone peripheral arteriography, how should the nurse assess the adequacy of peripheral circulation? a. By checking for cardiac dysrhythmias b. By observing the client for bleeding c. By checking peripheral pulses d. By hemodynamic monitoring

c. By checking peripheral pulses

The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? a. Croup b. Rheumatic fever c. Severe staphylococcal infection d. Medullary sponge kidney

b. Rheumatic fever Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn't damage heart structures.

Atrial flutter

saw tooth shaped flutter waves on EKG - artrial rate 250 - 300 - AV node selectively conducts impulse to ventricles - ventricular rate can be regular or variable

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because: a. the client is experiencing heart failure. b. the client is going into cardiogenic shock. c. the client shows signs of aneurysm rupture. d. the client is in the early stage of right-sided heart failure.

b. the client is going into cardiogenic shock. This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as lactic acid accumulates from poor blood flow, preventing waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

CK-MB

blood test used to diagnose MI - peak elevation occurs 18 hours after onset of chest pain - level returns to normal 48 - 72 hours later

An 84-year-old male is returning from the operating room (OR) after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? a. Jugular vein distention b. Right upper quadrant pain c. Bibasilar fine crackles d. Dependent edema

c. Bibasilar fine crackles Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

Which of the following nursing interventions is required to prepare a patient with cardiac dysrhythmia for an elective electrical cardioversion? a. Monitor blood pressure every 4 hours b. Administer digitalis and diuretics 24 hours before cardioversion c. Instruct the patient to restrict food and oral intake d. Facilitate CPR until the patient is prepared for cardioversion

c. Instruct the patient to restrict food and oral intake

The nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize? a. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses. b. Store the drug in a cool, well-lit place. c. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. d. Restrict alcohol intake to two drinks per day.

c. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

Which of the following nursing interventions must a nurse perform when administering prescribed vasopressors to a patient with a cardiac dysrhythmia? a. Keep the patient flat for one hour after administration b. Administer every five minutes during cardiac resuscitation c. Monitor vital signs and cardiac rhythm d. Document heart rate before and after administration

c. Monitor vital signs and cardiac rhythm The nurse should monitor the patient's vital signs and cardiac rhythm for effectiveness of the medication and for side effects and should always have emergency life support equipment available when caring for an acutely ill patient. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria.

Which complication of cardiac surgery occurs when there is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles? a. hypothermia b. hypertension c. cardiac tamponade d. fluid overload

c. cardiac tamponade

The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should: a. administer oxygen. b. have the client take deep breaths and cough. c. place the client in high Fowler's position. d. perform chest physiotherapy.

c. place the client in high Fowler's position. The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

Signs and symptoms of angina

chest pain/pressure, pain may radiate, pain relieved by nitroglycerin and rest, dyspnea, pallor/diaphoresis, indigestion, "impending doom"

EKG and MI

shows either ST elevation, T wave inversion, or non-ST elevation - sometimes there is an abnormal q wave - ST and T waves return to normal within hours to days post MI - abnormal q waves are usually permanent

A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do? a. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. b. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician. c. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. d. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

d. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen increases the myocardial oxygen supply. Cardiac monitoring helps detect life-threatening arrhythmias. Ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team before completing the initial assessment is premature.

Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? a. Refrain from sexual activity for one month. b. Cleanse the site with disinfectants and dress the wound appropriately. c. Normal activities of daily living can be resumed the first day post op. d. Cleanse the site with soap and water and remove any dressing.

d. Cleanse the site with soap and water and remove any dressing.

white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis? a. Race b. Age c. History of diabetes mellitus d. History of aortic valve replacement

d. History of aortic valve replacement A heart valve prosthesis, such as an aortic valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? a. Cyanosis of the lips b. Bilateral crackles c. Productive cough d. Leg edema

d. Leg edema Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, neck vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.

A client with a history of I.V. drug abuse is admitted to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has: a. retrosternal pain that worsens during supine positioning. b. pulsus paradoxus. c. a scratchy pericardial friction rub. d. Osler's nodes and splinter hemorrhages.

d. Osler's nodes and splinter hemorrhages. Infective endocarditis occurs when an infectious agent enters the bloodstream, such as from I.V. drug abuse or during an invasive procedure or dental work. Typical assessment findings in clients with this disease include Osler's nodes (red, painful nodules on the fingers and toes), splinter hemorrhages, fever, diaphoresis, joint pain, weakness, abdominal pain, a new or altered heart murmur, and Janeway's lesions (small, hemorrhagic areas on the fingers, toes, ears, and nose). The other options are common findings in clients with pericarditis, not infective endocarditis.

A client is admitted to the acute care facility for treatment of heart failure. The nurse expects the physician to prescribe which drug? a. prednisone (Orasone) b. hydroxychloroquine sulfate (Plaquenil Sulfate) c. lidocaine (Xylocaine) d. furosemide (Lasix)

d. furosemide (Lasix) To maintain fluid balance — crucial for a client with heart failure — the physician typically prescribes a diuretic, such as furosemide; vasodilating agents; and drugs that increase contractility, such as digitalis glycosides. Prednisone, a corticosteroid, and hydroxychloroquine, an antimalarial agent, aren't indicated for heart failure. Lidocaine would be used only if the client also had ventricular ectopy.

Calcium channel blockers (CAD/Angina)

dilate coronary arteries and reduce vasospasm

How is 3rd degree heart block treated?

pace maker

P wave

represents atrial depolarization/contraction

Atropine sulfate

used for bradycardia and first-degree AV blocks

Causes for sinus bradycardia

vagal stimulation digitalis toxicity (>2.4) Increased ICP MI trained athletes severe pain beta blockers hypothermia

Premature ventricular contraction

wide and distorted QRS complex on EKG - irritable focus in ventricle - result of increased automaticity of ventricular muscle cells - warning sign for sick heart

Atherosclerosis impedes coronary blood flow by which of the following mechanisms? a. Plaques obstruct the vein b. Plaques obstruct the artery c. Blood clots form outside the vessel wall d. Hardened vessels dilate to allow blood to flow through

b. Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Atherosclerosis is a direct result of plaque formation in the artery. Hardened vessels can't dilate properly and, therefore, constrict blood flow.

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: a. Normal sinus rhythm b. Sinus bradycardia c. Sick sinus syndrome d. First-degree heart block.

a. Normal sinus rhythm measurements are normal, measuring 0.12 to 0.20 seconds and < .12 seconds, respectively.

A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the following conditions? a. Hypovolemic shock b. Cardiac tamponade c. Wound dehiscence d. Atelectasis

b. All of the client's symptoms are found in both cardiac tamponade and hypovolemic shock except the increase in urinary output.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. a. The RR intervals are relatively consistent b. One P wave precedes each QRS complex c. Four to eight complexes occur in a 6-second strip d. The ST segment is higher than the PR interval e. The QRS complex ranges from 0.12 to 0.2 seconds

a and b. (a) The consistency of the RR interval indicates a regular rhythm. (b) A normal P wave before each complex indicates the impulse originated in the SA node. (c) The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. (d) Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. (e) The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 seconds.

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Check all that apply. a. Tachycardia b. Hypertension c. Increased CVP d. Increased urine output e. Jugular vein distention

a, c, e. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid thready pulse. Tamponade causes hypotension and a narrowed pulse pressure. As the tamponade increases, pressure on the heart interferes with the ejection of blood from the left ventricle, resulting in an increased pressure in the right side of the heart and the systemic circulation. As the heart because more inefficient, there is a decrease in kidney perfusion and therefore urine output. The increased venous pressure caused JVD.

When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply. a. Reflects electrical impulse beginning at the SA node. b. Indicated electrical impulse beginning at the AV node. c. Reflects atrial muscle depolarization. d. Identifies ventricular muscle depolarization. e. Has duration of normally 0.11 seconds or less.

a, c, e. In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

Which of the following instructions should be included in the discharge teaching for a patient discharged with a transdermal nitroglycerin patch? a. "Apply the patch to a nonhairy, nonfatty area of the upper torso or arms." b. "Apply the patch to the same site each day to maintain consistent drug absorption." c. "If you get a headache, remove the patch for 4 hours and then reapply." d. "If you get chest pain, apply a second patch right next to the first patch."

a. A nitroglycerin patch should be applied to a nonhairy, nonfatty area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and the drug should be continued if headache occurs because tolerance will develop. Sublingual nitroglycerin should be used to treat chest pain.

A 53-year-old client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? a. Medicate the client and document his comment. b. Medicate the client and notify the physician about the comment. c. Explain that cardiac catheterization doesn't involve open heart surgery, and then medicate the client. d. Withhold the medication and notify the physician immediately.

d. Withhold the medication and notify the physician immediately. The nurse should withhold the medication and notify the physician that the client doesn't understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client doesn't understand, he can't give a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse can't just medicate the client and document her finding; she must notify the physician.

Heart murmur

reflects turbulent blood flow through valve - valve can be normal or abnormal

Aortic insuffciency/regurgitation

related to Marfan's syndrome and bacterial endocarditis - backflow of blood from aorta to left ventricle during diastole leads to dilation of ventricle - usually asymptomatic for many years

Mitral insufficiency/regurgitation

related to RHD - backflow of blood into left atrium during systole because valve does not fully close

Aortic stenosis

related to RHD - tissue thickens and narrows opening - left ventricular obstruction during systole leads to hypertrophy of ventricle

Mitral stenosis

related to RHD - tissue thickens and narrows the valve opening - valve cannot open fully - prevents blood flow from left atrium to left ventricle

Mitral valve prolapse

related to endocarditis and RHD - present in healthy individuals - can lead to mitral valve insufficiency - 5 times risk of bacterial endocarditis

T wave

represents ventricular repolarization/relaxation - should appear upright

Treatment for sinus bradycardia

Atropine, transcutaneous or transvenous pacer

Pericarditis - treatment

Analgesics, antibiotics if bacterial, steroids, high fowler's leaning forward, monitor for signs of cardiac tamponade

A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? a. Blood pressure and peripheral perfusion b. Sensation of palpitations c. Causative factors such as caffeine d. Precipitating factors such as infection

a. Blood pressure and peripheral perfusion Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.

A client is experiencing tachycardia. The nurse's understanding of the physiological basis for this symptom is explained by which of the following statements? a. The demand for oxygen is decreased because of pleural involvement b. The inflammatory process causes the body to demand more oxygen to meet its needs. c. The heart has to pump faster to meet the demand for oxygen when there is lowered arterial oxygen tension. d. Respirations are labored.

c. The arterial oxygen supply is lowered and the demand for oxygen is increased, which results in the heart's having to beat faster to meet the body's needs for oxygen.

A client enters the ER complaining of chest pressure and severe epigastric distress. His VS are 158/90, 94, 24, and 99*F. The doctor orders cardiac enzymes. If the client were diagnosed with an MI, the nurse would expect which cardiac enzyme to rise within the next 3 to 8 hours? a. Creatine kinase (CK or CPK) b. Lactic dehydrogenase (LDH) c. LDH-1 d. LDH-2

a. Creatine kinase (CK, formally known as CPK) rises in 3-8 hours if an MI is present. When the myocardium is damaged, CPK leaks out of the cell membranes and into the blood stream. Lactic dehydrogenase rises in 24-48 hours, and LDH-1 and LDH-2 rises in 8-24 hours.

Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: a. A manual toothbrush b. An electric toothbrush c. An irrigation device d. Dental floss

a. Daily dental care and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the blood stream, increasing the risk of endocarditis.

ST depression

indicated ventricles are having difficulty returning to resting state

Pericarditis

inflammation of pericardium - inflammation causes layers to rub and can result in accumulation of fluid in sac

In presenting a workshop on parameters of cardiac function, which conditions should the nurse list as those most likely to lead to a decrease in preload? a. Hemorrhage, sepsis, and anaphylaxis b. Myocardial infarction, fluid overload, and diuresis c. Fluid overload, sepsis, and vasodilation d. Third spacing, heart failure, and diuresis

a. Hemorrhage, sepsis, and anaphylaxis Preload is the volume in the left ventricle at the end of diastole. It's also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload would increase with fluid overload and heart failure.

A client is admitted to an emergency department with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows at 11am, P: 92 beats/min, RR: 24 breaths/min, BP: 140/88 mm Hg; 11:15am P: 96 beats/min, RR: 26 breaths/min, BP: 128/82 mm Hg, 11:30am P: 104 beats/min, RR: 28 breaths/min, BP: 104/68 mm Hg, 11:45am P: 118 beats/min, RR: 32, breaths/min, BP: 88/58 mm Hg. The nurse should alert the physician because these changes are most consistent with which of the following complications? a. Cardiogenic shock b. Cardiac tamponade c. Pulmonary embolism d. Dissecting thoracic aortic anyeurysm

a. Cardiogenic shock Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypertension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneyurysms usually are accompanied by back pain.

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: a. Hypotension and dizziness b. Nausea and vomiting c. Hypertension and headache d. Flat neck veins

a. Hypotension and dizziness The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

Endocarditis

inflammation of the inner lining of the heart and valves - occurs primarily in IV drug users, valve replacements disease, and invasive procedures (portal of entry) - eroded areas in endocardium attract sediment which attracts bacteria - lesions grow and destroy endocardium and valves -eventually leads to obstruction of blood flow through valves

Balloon valvuloplasty

invasive non surgical procedure - catheter is placed in femoral vein to valve and balloon is inflated to enlarge orifice - monitor for bleeding from insertion site - monitor for signs of emboli - monitor cardiac rhythm, heart sounds, and cardiac output

First degree heart block

PR interval > .20 seconds - conduction is delayed at AV node - related to digoxin or vagal stimulation

Thrombolytic therapy for MI

Streptokinase - TPA - may be prescribed within first 6 hours

Automaticity

The ability of cardiac cells to initiate impulse spontaneously and repetitively without external neurohormonal control.

After open-heart surgery a client develops a temperature of 102*F. The nurse notifies the physician, because elevated temperatures: a. Increase the cardiac output b. May indicate cerebral edema c. May be a forerunner of hemorrhage d. Are related to diaphoresis and possible chilling

a. Temperatures of 102*F or greater lead to an increased metabolism and cardiac workload.

Splinter hemmorhages

longitudinal black lines in nail beds - associated with endocarditis

Collateral circulation

more than one artery supplying a muscle with blood, develops when chronic ischemia occurs to meet the metabolic demands; therefore an occlusion of a coronary artery in a younger individual is more likely to be lethal than in an older individual

Cardiac output

Total volume of blood pumped through the heart in 1 minute. Stroke volume x heart rate.

A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. The specific type of MI the client had is most probably: a. anterior. b. posterior. c. lateral. d. inferior.

a. anterior. An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. The other types of MI aren't usually associated with heart failure.

Which of the following terms describes the force against which the ventricle must expel blood? a. Afterload b. Cardiac output c. Overload d. Preload

a. Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled from the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole.

A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest x-ray, an ECG, and 2mg of morphine given intravenously. The nurse should first: a. Administer the morphine. b. Obtain a 12-lead ECG. c. Obtain the lab work. d. Order the chest x-ray.

a. Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse's priority action would be to relieve the crushing chest pain.

The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: a. Headache b. High blood pressure c. Shortness of breath d. Stomach cramps

a. Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or **** down to avoid fainting. Nitro does not cause shortness of breath or stomach cramps.

A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time? a. Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction b. Anxiety related to an actual threat to health status, invasive procedures, and pain c. Disabled family coping related to knowledge deficit and a temporary change in family dynamics d. Hypothermia related to exposure to cold temperatures and a long cardiopulmonary bypass time

a. Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction For a client recovering from CABG surgery, Decreased cardiac output is the most important nursing diagnosis because myocardial function may be depressed from anesthetics or a long cardiopulmonary bypass time, leading to decreased cardiac output. Other possible causes of decreased cardiac output in this client include fluid volume deficit and impaired electrical conduction. The other options may be relevant but take lower priority at this time because maintaining cardiac output is essential to sustaining the client's life.

A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common symptom that typically resolves spontaneously? a. Depression b. Ankle edema c. Memory lapses d. Dizziness

a. Depression For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves on its own and doesn't require medical intervention; however, family members should be aware that symptoms don't always resolve on their own. They should also be instructed about worsening symptoms of depression and when to seek care. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure; because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition after CABG surgery that warrants immediate physician notification.

A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? a. Review the intake and output records for the last 2 days. b. Change the time of diuretic administration from morning to evening. c. Request a sodium restriction of 1 g/day from the physician. d. Order daily weights starting the following morning.

a. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

Which signs and symptoms are present with a diagnosis of pericarditis? a. Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) b. Low urine output secondary to left ventricular dysfunction c. Lethargy, anorexia, and heart failure d. Pitting edema, chest discomfort, and nonspecific ST-segment elevation

a. Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. All other symptoms may result from acute renal failure.

Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses the client's past compliance with medical regimens. Lack of compliance with which of the following regimens would pose the greatest health hazard to this client? a. Medication therapy b. Diet modification c. Activity restrictions d. Dental care

a. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Post-op, all clients with mechanical valves and some with bioprostheses are maintained indefinitely on anticoagulation therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence from rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, GI, or GU surgery.

When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride: a. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. b. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. c. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. d. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.

a. Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction.

Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn't understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is: a. "Cardiac rehabilitation is not a cure but can help restore you to many of your former activities." b. "Here we teach you to gradually change your lifestyle to accommodate your heart disease." c. "You are probably right but we can gradually increase your activities so that you can live a more active life." d. "Do you feel that you will have to make some changes in your life now?"

a. Such a response does not have false hope to the client but is positive and realistic. The answer tells the client what cardiac rehabilitation is and does not dwell upon his negativity about it.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: a. Check the client status and lead placement. b. Press the recorder button on the electrocardiogram console. c. Call the physician. d. Call a code blue.

a. Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. a. The RR intervals are relatively consistent b. One P wave precedes each QRS complex c. Four to eight complexes occur in a 6 second strip d. The ST segment is higher than the PR interval e. The QRS complex ranges from 0.12 to 0.20 second.

a. The RR intervals are relatively consistent b. One P wave precedes each QRS complex The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? a. A change in the pattern of her pain b. Pain during sex c. Pain during an argument with her husband d. Pain during or after an activity such as lawnmowing

a. The client should report a change in the pattern of chest pain. It may indicate increasing severity of CAD.

When the patient diagnosed with angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it take less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina? a. Unstable b. Intractable c. Refractory d. Variant

a. Unstable

A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: a. Vagus nerve to slow the heart rate b. Vagus nerve to increase the heart rate; overdriving the rhythm. c. Diaphragmic nerve to slow the heart rate d. Diaphragmic nerve to overdrive the rhythm

a. Vagus nerve to slow the heart rate Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm.

A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. When exploring the chief complaint, the nurse should find out if the client has any other common cardiovascular symptoms, such as: a. shortness of breath. b. insomnia. c. irritability. d. lower substernal abdominal pain.

a. shortness of breath. Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, dyspnea, palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.

Amioderone

antidysrhytmic

Before discharge, which instruction should the nurse give to a client receiving digoxin (Lanoxin)? a. "Take an extra dose of digoxin if you miss one dose." b. "Call the physician if your heart rate is above 90 beats/minute." c. "Call the physician if your pulse drops below 80 beats/minute." d. "Take digoxin with meals."

b. "Call the physician if your heart rate is above 90 beats/minute." The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digitalis toxicity. To prevent toxicity, the client should be instructed never to take an extra dose of digoxin if a dose is missed. The nurse should show the client how to take her pulse and to call the physician if her pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. Digoxin shouldn't be administered with meals because this slows the absorption rate.

The home care nurse is visiting a left-handed client who has an automated implantable cardioverter-defibrillator implanted in his left chest. The client tells the nurse how excited he is because he's planning to go rifle hunting with his grandson. How should the nurse respond? a. "Be sure to enjoy your time with your grandson." b. "You cannot shoot a rifle left-handed because the rifle's recoil will traumatize the AICD site." c. "Being that close to a rifle might make your AICD fire." d. "You will need to take an extra dose of your antiarrhythmic before you shoot."

b. "You cannot shoot a rifle left-handed because the rifle's recoil will traumatize the AICD site." The recoil from the rifle can damage the AICD so the client should be warned against shooting a rifle with his left hand. Close proximity to a rifle won't cause the AICD to fire inadvertently. The client shouldn't take an extra dose of his antiarrhythmic.

A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse's next action would be to: a. Call for the doctor. b. Start an intravenous line. c. Obtain a portable chest radiograph. d. Draw blood for laboratory studies.

b. Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood are important but secondary to starting the intravenous line.

When do coronary arteries primarily receive blood flow? a. During inspiration b. During diastolic c. During expiration d. During systole

b. Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns are irrelevant to blood flow.

The nurse is preparing a client for cardiac catheterization. The nurse knows that she must provide which nursing intervention when the client returns to his room after the procedure? a. Withhold analgesics for at least 6 hours after the procedure. b. Assess the puncture site frequently for hematoma formation or bleeding. c. Inform the client that he may experience numbness or pain in his leg. d. Restrict fluids for 6 hours after the procedure.

b. Assess the puncture site frequently for hematoma formation or bleeding. Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as prescribed and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client's system.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: a. Sinus tachycardia b. Atrial fibrillation c. Ventricular tachycardia d. Ventricular fibrillation

b. Atrial fibrillation Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

The physician refers the client with unstable angina for a cardiac catherization. The nurse explains to the client that this procedure is being used in this specific case to: a. Open and dilate the blocked coronary arteries b. Assess the extent of arterial blockage c. Bypass obstructed vessels d. Assess the functional adequacy of the valves and heart muscle.

b. Cardiac catherization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catherization results.

When ventricular fibrillation occurs in a CCU, the first person reaching the client should: a. Administer oxygen b. Defibrillate the client c. Initiate CPR d. Administer sodium bicarbonate intravenously

b. Defibrillate the client Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU.

After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine (Dobutrex), 5 mcg/kg/minute I.V. Which classification best describes dobutamine? a. Indirect-acting dual-active agent b. Direct-acting beta-active agent c. Indirect-acting beta-active agent d. Direct-acting alpha-active agent

b. Direct-acting beta-active agent Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent. Adrenergic agents are classified according to their method of action and the type of receptor they act on. Direct-acting agents act directly on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual-acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors.

A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The complication the nurse will constantly observe for is: a. Presence of heart murmur b. Systemic emboli c. Fever d. Congestive heart failure

b. Emboli are the major problem; those arising in the right heart chambers will terminate in the lungs and left chamber emboli may travel anywhere in the arteries. Heart murmurs, fever, and night sweats may be present, but do not indicate a problem with emboli. CHF may be a result, but this is not as dangerous an outcome as emboli.

A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that aren't followed by a beat. Which condition should the nurse suspect? a. Failure to pace b. Failure to capture c. Failure to sense d. Asystole

b. Failure to capture Extra pacemaker spikes that aren't followed by a beat may indicate failure to capture, in which the pacemaker fires but the heart doesn't conduct the beat. In failure to pace, the pacemaker doesn't fire when it should, causing hypotension and other signs of low cardiac output, accompanied by bradycardia or a heart rate slower than the pacemaker's preset rate. In failure to sense, the pacemaker can't sense the client's intrinsic heartbeat; on the rhythm strip, spikes may fall on T waves, or they may fall regularly but at points where they shouldn't appear. Asystole is characterized by an absent heart rate or rhythm as reflected by a flat line on the rhythm strip.

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? a. Breathe deeply, regularly, and easily. b. Inhale deeply and cough forcefully every 1 to 3 seconds. c. Lie down flat in bed d. Remove any metal jewelry

b. Inhale deeply and cough forcefully every 1 to 3 seconds. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: a. Ventricular tachycardia b. Ventricular fibrillation c. Atrial fibrillation d. Asystole

b. Ventricular fibrillation Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: a. Increase the IV infusion rate b. Notify the physician promptly c. Increase the oxygen concentration d. Administer a prescribed analgesic

b. Notify the physician promptly PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? a. Strict bed rest for 24 hours after transfer. b. Bathroom privileges and self-care activities. c. Unsupervised hallway ambulation with distances under 200 feet. d. Ad lib activities because the client is monitored.

b. On transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation for brief distances are encouraged, with distances gradually increased (50, 100, 200 feet).

A client with end-stage heart failure is preparing for discharge. The client and his caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave him feeling isolated. Which suggestion by the home care nurse best addresses this concern? a. Place a chair in the bedroom so guests can visit with the client. b. Set up the hospital bed in the family room so the client can be part of household activities. c. Set up the hospital bed in the bedroom so the client can rest in a quiet environment. d. Set up the hospital bed in the bedroom so the client can be assessed in a quiet environment.

b. Set up the hospital bed in the family room so the client can be part of household activities. The client should be kept actively involved in the household to prevent feelings of isolation. This can be accomplished by setting up the hospital bed in the family room. Placing a chair in the bedroom allows the client periods of isolation when visitors aren't present. It's important for the client to have periods of rest; however, that can be accomplished without keeping the client isolated in a bedroom. The needs of the client should be considered before the needs of the nurse who assesses the client during an occasional visit.

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: a. Premature ventricular contractions b. Ventricular tachycardia c. Ventricular fibrillation d. Sinus tachycardia

b. Ventricular tachycardia Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

The nurse just received shift report for a group of clients on the telemetry unit. Which client should the nurse assess first. a. The client with a history of atrial fibrillation b. The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block c. The client with a history of heart failure who has bibasilar crackles and pitting edema in both feet d. The client with a demand pacemaker whose monitor shows normal sinus rhythm at a rate of 90 beats/minute

b. The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client with a history of atrial fibrillation whose monitor reveals atrial fibrillation doesn't need to be assessed first. Because his rhythm is chronic, he has most likely been given an anticoagulant and isn't at immediate risk from this rhythm. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first isn't necessary. The client's demand pacemaker fires only when the client's intrinsic heart rate falls below the pacemaker's set rate. In option 4, the pacemaker isn't firing because it most likely has been set at a slower rate than the client's intrinsic heart rate of 90 beats/minute.

The nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first? a. The client admitted with unstable angina who wants to be discharged. b. The client who suffered an acute myocardial infarction (MI) who is complaining of constipation. c. The client who had a pacemaker inserted yesterday and who is complaining of incisional pain. d. The client who has his call light on.

b. The client who suffered an acute myocardial infarction (MI) who is complaining of constipation. The client who suffered an acute MI who is complaining of constipation should be addressed first. If the client strains at stool after an MI, the vagal response may be stimulated causing bradycardia thereby provoking arrhythmias. The nurse should delegate answering the call light to the ancillary personnel. She can also delegate some of the discharge preparation, such as packing the client's belongings. After addressing the MI client with constipation, the nurse should promptly address the pain relief needs of the client who had a pacemaker inserted the previous day.

Before using a defibrillator to terminate ventricular fibrillation, the nurse should check the synchronizer switch. Why is this so important? a. The delivered shock must be synchronized with the client's QRS complex. b. The defibrillator won't deliver a shock if the synchronizer switch is turned on. c. The defibrillator won't deliver a shock if the synchronizer switch is turned off. d. The shock must be synchronized with the client's T wave.

b. The defibrillator won't deliver a shock if the synchronizer switch is turned on. The defibrillator won't deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on. The synchronizer switch should be turned on when attempting to terminate arrhythmias that contain QRS complexes, such as rapid atrial fibrillation that is resistant to pharmacologic measures.

When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to: a. Help keep him well hydrated. b. Dissolve clots he may have. c. Prevent kidney failure. d. Treat potential cardiac arrhythmias.

b. Thrombolytic drugs are administered within the first 6 hours after onset of a MI to lyse clots and reduce the extent of myocardial damage.

A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? a. Frequent movement of the client b. Tightly secured cable connections c. Leads applied over hairy areas d. Leads applied to the limbs

b. Tightly secured cable connections Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.

Coronary Artery Disease (definition)

narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis causing decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply leading to hypertension, angina, dysrhythmias, MI, heart failure, and death

A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin: a. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this to exert an anticoagulant effect. b. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect. c. Stimulates production of the body's own thrombolytic substances, but it takes 2-4 days for this to begin. d. Has the same mechanism of action as Heparin, and the crossover time is needed for the serum level of warfarin to be therapeutic.

b. Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited.

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of: a. right-sided heart failure. b. acute pulmonary edema. c. pneumonia. d. cardiogenic shock.

b. acute pulmonary edema. Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.

A client with substernal chest pain that radiates to the jaw is admitted to the coronary care unit. The client subsequently develops hypotension and suffers cardiac arrest. Which calcium preparation is injected into the ventricle during cardiac arrest? a. calcium carbonate (BioCal) b. calcium chloride c. calcium glubionate (Neo-Calglucon) d. calcium lactate

b. calcium chloride Calcium chloride is the only calcium preparation that should be injected into the ventricle during cardiac arrest, if appropriate.

A client with chest pain receives nitroglycerin on the way to the acute care facility. Based on an electrocardiogram obtained on admission, the physician suspects a myocardial infarction (MI) and prescribes I.V. morphine to relieve continuing pain. A primary goal of nursing care for this client is to recognize life-threatening complications of an MI. The major cause of death after an MI is: a. cardiogenic shock. b. cardiac arrhythmia. c. heart failure. d. pulmonary embolism.

b. cardiac arrhythmia. Cardiac arrhythmias cause roughly 40% to 50% of deaths after MI. Heart failure, in contrast, accounts for 33% and cardiogenic shock for 9% of post-MI deaths. Pulmonary embolism, another potential complication of an MI, is less common.

A client is recovering from surgical repair of a dissecting aortic aneurysm. The nurse should evaluate the client for signs of bleeding or recurring dissection. These signs include: a. hematuria and decreased urine output. b. hypotension and tachycardia. c. increased urine output and bradycardia. d. hypotension and bradycardia.

b. hypotension and tachycardia. When caring for a client recovering from surgical repair of a dissecting aortic aneurysm, the nurse must monitor for hypotension with reflex tachycardia, decreased urine output, and unequal or absent peripheral pulses — all potential signs of bleeding or recurring dissection. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

pace maker - capture

pacemaker provides adequate stimulus to produce ventricular contraction

Considering a client's atrial fibrillation, the nurse must administer digoxin (Lanoxin) with caution because it: a. affects the sympathetic division of the autonomic nervous system, decreasing vagal tone. b. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. c. can induce hypertensive crisis by constricting arteries. d. can trigger proarrhythmia by increasing stroke volume.

b. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, thus increasing the potential for new arrhythmias to develop. Digoxin doesn't constrict arteries. Although it can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).

Surgical treatments for valve disease

balloon valvuloplasty, aortic valve replacement, mitral valve replacement

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, the nurse should include which expected outcome? a. "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours." b. "Client will verbalize the intention to avoid exercise." c. "Client will verbalize the intention to stop smoking." d. "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol."

c. "Client will verbalize the intention to stop smoking." The client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 10 to 15 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).

After cardiac surgery, a client's blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following? a. 46 mm Hg b. 80 mm Hg c. 95 mm Hg d. 90 mm Hg

c. 95 mm Hg

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: a. The presence of occasional coupled beats b. Long pauses in an otherwise regular rhythm c. A continuous and totally unpredictable irregularity d. Slow but strong and regular beats

c. A continuous and totally unpredictable irregularity In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? a. Immediately defibrillate b. Prepare for pacemaker insertion c. Administer amiodarone (Cordarone) intravenously d. Administer epinephrine (Adrenaline) intravenously

c. Administer amiodarone (Cordarone) intravenously First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated.

During a cardiac catherization blood samples from the right atrium, right ventricle, and pulmonary artery are analyzed for their oxygen content. Normally: a. All contain less CO2 than does pulmonary vein blood b. All contain more oxygen than does pulmonary vein blood c. The samples of blood all contain about the same amount of oxygen d. Pulmonary artery blood contains more oxygen than the other samples

c. Blood samples from the right atrium, right ventricle, and pulmonary artery would all be about the same with regard to oxygen concentration. Such blood contains slightly less oxygen than does systemic arterial blood.

A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? a. "Have you ever had this pain before?" b. "Can you describe the pain to me?" c. "Does the pain get worse when you breathe in?" d. "Can you rate the pain on a scale of 1-10, with 10 being the worst?"

c. Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

A client is admitted to the emergency department after complaining of acute chest pain radiating down his left arm. Which laboratory studies would be indicated? a. Hemoglobin and hematocrit b. Serum glucose c. Creatinine phosphokinase (CPK) d. Troponin T and troponin I e. Myoglobin f. Blood urea nitrogen (BUN)

c. Creatinine phosphokinase (CPK) d. Troponin T and troponin I e. Myoglobin Levels of CPK, troponin T, and troponin I elevate because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage. Hemoglobin, hematocrit, serum glucose, and BUN levels don't provide information related to myocardial ischemia.

The nurse is awaiting the arrival of a client from the emergency department. The client has a left ventricular myocardial infarction and is being admitted. In caring for this client, the nurse should be alert for which signs and symptoms of left-sided heart failure? a. Jugular vein distention b. Hepatomegaly c. Dyspnea d. Crackles e. Tachycardia f. Right upper quadrant pain

c. Dyspnea d. Crackles e. Tachycardia Signs and symptoms of left-sided heart failure include dyspnea, orthopnea, and paroxysmal nocturnal dyspnea; fatigue; nonproductive cough and crackles; hemoptysis; point of maximal impulse displaced toward the left anterior axillary line; tachycardia and S3 and S4 heart sounds; and cool, pale skin. Jugular vein distention, hepatomegaly, and right upper quadrant pain are all signs of right-sided heart failure.

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic indicates myocardial ischemia? a. Prolonged PR interval b. Absent Q wave c. Elevated ST segment d. Widened QRS complex

c. Elevated ST segment Ischemic myocardial tissue changes cause elevation of the ST segment, a peaked or inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? a. Hypocalcemia b. Hypermagnesemia c. Hypokalemia d. Hypernatremia

c. Furosemide is a potassium-depleting diuretic than can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia.

The physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test is used to determine a client's response to oral anticoagulant drugs? a. Bleeding time b. Platelet count c. Prothrombin time (PT) d. Partial thromboplastin time (PTT)

c. Prothrombin time (PT) PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample after calcium ions and tissue thromboplastin are added and compares this time with the fibrin clotting time in a control sample. Anticoagulant dosages should be adjusted, as needed, to maintain PT at 1.5 to 2.5 times the control value. PTT determines the effectiveness of heparin therapy and helps evaluate bleeding tendencies. Roughly 99% of bleeding disorders are diagnosed from PT and PTT values. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reveals the number of circulating platelets in venous or arterial blood.

A client with mitral stenosis is scheduled for mitral valve replacement. Which condition may arise as a complication of mitral stenosis? a. Left-sided heart failure b. Myocardial ischemia c. Pulmonary hypertension d. Left ventricular hypertrophy

c. Pulmonary hypertension Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. This may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include mural thrombi, pulmonary hemorrhage, and embolism to vital organs. Myocardial ischemia may occur in a client with coronary artery disease. Left ventricular hypertrophy is a potential complication of aortic stenosis.

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? a. Take one tablet every 2 to 5 minutes until the pain stops. b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. c. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persists after three tablets. d. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician.

c. The correct protocol for nitroglycerin used involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of 3 tablets. Sublingual nitroglycerin appears in the blood stream within 2 to 3 minutes and is metabolized within about 10 minutes.

A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary artery pressure monitoring, including pulmonary capillary wedge pressures. The purpose of this is to help assess the: a. Degree of coronary artery stenosis b. Peripheral arterial pressure c. Pressure from fluid within the left ventricle d. Oxygen and carbon dioxide concentration is the blood

c. The pulmonary artery pressures are used to assess the heart's ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricle end-diastolic pressure and guides the physician in determining fluid management for the client. The degree of coronary artery stenosis is assessed during a cardiac catherization. The peripheral arterial pressure is assessed with an arterial line.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is: a. The same as the client's own baseline level b. Lower than the needed therapeutic level c. Within the therapeutic range d. Higher than the therapeutic range

c. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within therapeutic range.

In order to prevent the development of tolerance, the nurse instructs the patient to: a. Apply the nitroglycerin patch every other day b. Switch to sublingual nitroglycerin when the patient's systolic blood pressure elevates to >140 mm Hg c. Apply the nitroglycerin patch for 14 hours each and remove for 10 hours at night d. Use the nitroglycerin patch for acute episodes of angina only

c. Tolerance can be prevented by maintaining an 8- to 12-hour nitrate-free period each day.

Which of the following is also termed preinfarction angina? a. Stable angina b. Variant angina c. Unstable angina d. Silent ischemia

c. Unstable angina

A client with severe angina and ST-segment elevation on the electrocardiogram is being seen in the emergency department. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a: a. creatine kinase level. b. hemoglobin (Hb) level. c. troponin level. d. liver panel.

c. troponin level. Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction (MI). It's the best serum indicator of MI and is more indicative of cardiac damage than creatine kinase. Hb values and liver panel components aren't as useful in the diagnosis of MI as a troponin level.

Aspirin and MI

chew 325mg - antiplatelet

Pericarditis - signs and symptoms

pain radiating to neck or back, increased pain on inspiration, increased pain when supine and decrease when leaning forward - friction rub on auscultation near lower left sternal border, elevated WBC and sed rate, fever, + blood culture, STEMI or inverted T wave, echo showing pericardial effusion, narrow pulse pressure

Cardiac tamponade

pericardial effusion - compresses heart restricting ventricular filling - cardiav output drops

A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the prescribed cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction? a. "Client performs relaxation exercises three times per day to reduce stress." b. "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." c. "Client verbalizes an understanding of the need to seek emergency help if the heart rate increases markedly while at rest." d. "Client walks 4 miles in 1 hour every day."

d. "Client walks 4 miles in 1 hour every day." Four weeks after an MI, a client's walking program should aim for a goal of 2 miles in less than 1 hour. Walking 4 miles in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. The other options indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower the risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.

The monitor technician on the telemetry unit asks the charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin (Coumadin). Which response by the charge nurse is best? a. "It's just a coincidence; most clients with atrial fibrillation don't receive warfarin." b. "Warfarin controls heart rate in the client with atrial fibrillation." c. "Warfarin prevents atrial fibrillation from progressing to a lethal arrhythmia." d. "Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

d. "Warfarin prevents clot formation in the atria of clients with atrial fibrillation." Blood pools in the atria of clients with atrial fibrillation. As the blood pools, clots form. These clots can be forced from the atria as the heart beats, placing the client at risk for stroke. Warfarin is prescribed in most clients with atrial fibrillation to prevent clot formation and decrease the risk of stroke, not to control heart rate. Digoxin is typically prescribed to control heart rate in atrial fibrillation. Atrial fibrillation doesn't typically progress to a lethal arrhythmia such as ventricular fibrillation.

How long after oral administration can the nurse expect to see digoxin's (Lanoxin) peak effect? a. 2 to 5 minutes b. 10 to 20 minutes c. 30 minutes to 2 hours d. 2 to 6 hours

d. 2 to 6 hours The peak effect of digoxin occurs 2 to 6 hours after an oral dose and 1 to 4 hours after an I.V. dose. Digoxin's onset of action ranges from 30 minutes to 2 hours after an oral dose and from 5 to 30 minutes after an I.V. dose.

A paradoxical pulse occurs in a client who had a coronary artery bypass graft (CABG) surgery 2 days ago. Which of the following surgical complications should the nurse suspect? a. Left-sided heart failure b. Aortic regurgitation c. Complete heart block d. Pericardial tamponade

d. A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (pulse amplitude alternation from beat to beat, with a regular rhythm). Aortic regurgitation may cause bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).

Cardiac tamponade - treatment

pericardiocentesis - pericardial window for recurrent effusion

Sinus tachycardia

rate > 100 BPM regular rhythm P wave before each QRS PR interval .12 to .20 QRS < .12 usually related to SNS stimulation

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? a. Seating the client with arm bared, supported, and at heart level. b. Measuring the blood pressure after the client has been seated quietly for 5 minutes. c. Using a cuff with a rubber bladder that encircles at least 80% of the limb. d. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

d. BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygnomanometer should be calibrated every 6 months to ensure accuracy.

The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? a. Cancer b. Hypertension c. Liver disease d. Myocardial infarction

d. Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about one hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction (Remember, less than 90 mg/L is normal).

The nurse records a client's history and discovers several risk factors for coronary artery disease. Which cardiac risk factors are considered controllable? a. Diabetes, hypercholesterolemia, and heredity b. Diabetes, age, and gender c. Age, gender, and heredity d. Diabetes, hypercholesterolemia, and hypertension

d. Diabetes, hypercholesterolemia, and hypertension Controllable risk factors include hypertension, hypercholesterolemia, obesity, lack of exercise, smoking, diabetes, stress, alcohol abuse, and use of contraceptives. Uncontrollable risk factors for coronary artery disease include gender, age, and heredity.

Oselr's nodes

reddish tender lesions on pads of fingers, hands, and toes - associated with endocarditis

Beta blockers (CAD/Angina)

reduces BP - prevents adrenaline from causing tachycardia and vasoconstriction - desired heart rate 50-60 to enhane cardiac output

The adaptations of a client with complete heart block would most likely include: a. Nausea and vertigo b. Flushing and slurred speech c. Cephalalgia and blurred vision d. Syncope and low ventricular rate

d. Syncope and low ventricular rate In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result there is decreased cerebral circulation, causing syncope.

Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? a. Cardiac catherization b. Cardiac enzymes c. Echocardiogram d. Electrocardiogram (ECG)

d. The ECG is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. Cardiac enzymes are used to diagnose MI but can't determine the location. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catherization is an invasive study for determining coronary artery disease and may also indicate the location of myocardial damage, but the study may not be performed immediately.

When assessing an ECG, the nurse knows that the P-R interval represents the time it takes for the: a. Impulse to begin atrial contraction b. Impulse to transverse the atria to the AV node c. SA node to discharge the impulse to begin atrial depolarization d. Impulse to travel to the ventricles

d. The P-R interval is measured on the ECG strip from the beginning of the P wave to the beginning of the QRS complex. It is the time it takes for the impulse to travel to the ventricle.

IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? a. Vitamin K b. Aminocaporic acid c. Potassium chloride d. Protamine sulfate

d. The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin.

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: a. Stroke volume b. Cardiac output c. Venous pressure d. Left ventricular functioning

d. The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.

When preparing a client for discharge after surgery for a CABG, the nurse should teach the client that there will be: a. No further drainage from the incisions after hospitalizations b. A mild fever and extreme fatigue for several weeks after surgery c. Little incisional pain and tenderness after 3 to 4 weeks after surgery d. Some increase in edema in the leg used for the donor graft when activity increases

d. The client is up more at home, so dependent edema usually increases. Serosanguinous drainage may persist after discharge.

A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe: a. Sagging ST segments b. Absence of P wave configurations c. Inverted T waves following each QRS complex d. Widening of QRS complexes to 0.12 second or greater.

d. Widening of QRS complexes to 0.12 second or greater. Bundle branch block interferes with the conduction of impulses from the AV node to the ventricle supplied by the affected bundle. Conduction through the ventricles is delayed, as evidenced by a widened QRS complex.

A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents: a. atrial repolarization. b. ventricular repolarization. c. atrial depolarization. d. ventricular depolarization.

d. ventricular depolarization. The QRS complex on the ECG strip represents ventricular depolarization. Atrial repolarization usually occurs at the same time as ventricular depolarization and can't be distinguished on the ECG. The T wave represents ventricular repolarization. The P wave represents atrial depolarization.

Nitrates (CAD/Angina)

dilate coronary arteries - decrease preload and afterload - side effects: headache, hypotension, flushing 1 sublingual q5min as needed - max 3 doses

Mitral valve insufficiency can lead to...

dilation and hypertrophy of left atrium and left ventricle - can cause Afib and CHF

Mitral valve insufficiency - signs and symptoms

dyspnea on exertion, orthopnea

Aortic insufficiency - signs and symptoms

dyspnea on exertion, orthopnea, palpitations, angina

Mitral stenosis - signs and symptoms

dyspnea on exertion, orthopnea, paroxsymal nocturnal dyspnea, pulmonary edema/hemoptysis, JVD, peripheral edema, right ventricular failure and associated signs and symptoms

Modifiable risk factors CAD

elevated lipid levels, hypertension, smoking, sedentary lifestyle, obesity, stress, diabetes, increased homocysteine levels

Mitral valve prolapse - signs and symptoms

fatigue, atypical chest pain, palpitations, dizziness, tachycardia

Causes for sinus tachycardia

fever acute blood loss anemia shock exercise CHF pain anxiety drugs

Endocarditis - signs and symptoms

fever, anorexia, weight loss, fatigue, embolic complications, petechiae, splinter hemmorhages, Osler's nodes, Janeway lesions

Nitrates and MI

given IV dilates coronary arteries decreases SVR/afterload decreases preload

Signs of Digoxin toxicity

green/yellow vision, bradycardia, nausea

Which of the following types of pain is most characteristic of angina? a. Knifelike b. Sharp c. Shooting d. Tightness

d. The pain of angina usually ranges from a vague feeling of tightness to heavy, intense pain. Pain impulses originate in the most visceral muscles and may move to such areas as the chest, neck, and arms.

Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? a. Exertional dyspnea b. Confusion c. Elevated creatine phosphokinase concentration d. Chest pain

a. Weight gain, due to fluid retention and worsening heart failure, causes exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward into pulmonary veins, capillaries, and arterioles and eventually to the right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow.

The nurse is caring for a cardiac client who requires various cardiac medications. When the nurse helps the client out of bed for breakfast, the client becomes dizzy and asks to lie down. The nurse helps the client lie down, puts up the side rails, and obtains the client's blood pressure, which is 84/50 mm Hg. It's time for the nurse to administer the client's medications: nitroglycerin, metoprolol (Lopressor), and furosemide (Lasix). Which action is best taken by the nurse? a. Withhold the medications and notify the physician. b. Administer the medications immediately. c. Encourage the client to sit up and eat breakfast. d. Administer the nitroglycerin and metoprolol and withhold the furosemide.

a. Withhold the medications and notify the physician. The nurse should withhold the three medications and notify the physician. Each of these medications has the potential to lower the client's blood pressure. Administering them together when the client is already hypotensive may severely lower the client's blood pressure. The client may continue to experience dizziness when sitting up so breakfast should be held until his blood pressure stabilizes.

A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? a. Intake and output b. Baseline peripheral pulse rates c. Height and weight d. Allergy to iodine or shellfish

d. This procedure requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure.

An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician prescribes a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client's well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine if the client has other major risk factors for CAD, the nurse should assess for: a. a history of diabetes mellitus. b. elevated high-density lipoprotein (HDL) levels. c. a history of ischemic heart disease. d. alcoholism.

a. a history of diabetes mellitus. Diabetes mellitus, smoking, and hypertension are other major risk factors for CAD. Elevated HDL levels aren't a risk factor for CAD; in fact, increased HDL levels seem to protect against CAD. Ischemic heart disease is another term for CAD, not a risk factor. Alcoholism hasn't been identified as a major risk factor for CAD.

A client is in hemorrhagic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: a. blood pressure. b. hemoglobin level. c. temperature. d. heart rate.

a. blood pressure. With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route is the nurse most likely to administer? a. 0.6 mg I.M. b. 1 mg I.V. c. 2 mg I.M. d. 2 mg I.V.

b. 1 mg I.V. To reverse arrhythmias, bradycardia, or sinus arrest, the usual adult dosage of atropine is 0.4 to 1 mg I.V. every 2 hours as needed. The drug isn't administered I.M. for the treatment of bradycardia.

Following a percutaneous transluminal coronary angioplasty (PTCA), 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. The nurse should plan to remove the femoral sheath when the partial thromboplastin time (PTT) is: a. 25 seconds or less. b. 50 seconds or less. c. 75 seconds or less. d. 100 seconds or less.

b. 50 seconds or less. Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 40 seconds or less before the sheath is removed. Removing the sheath prematurely can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.

A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is prescribed. Morphine is given because it: a. eliminates pain, reduces cardiac workload, and increases myocardial contractility. b. lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. c. raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain. d. increases venous return, lowers resistance, and reduces cardiac workload.

b. lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. When given to treat acute MI, morphine sulfate eliminates pain, reduces venous return to the heart, reduces vascular resistance, reduces myocardial workload, and reduces the oxygen demand of the heart. Morphine sulfate doesn't increase myocardial contractility, raise blood pressure, or increase venous return.

A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? a. Monitoring vital signs b. Completing a physical assessment c. Maintaining cardiac monitoring d. Maintaining at least one IV access site

c. Even though initial tests seem to be within normal range, it takes at least 3 hours for the cardiac enzyme studies to register. In the meantime, the client needs to be watched for bradycardia, heart block, ventricular irritability, and other arrhythmias. Other activities can be accomplished around the MI monitoring.

A hospitalized client experiences digoxin- (Lanoxin-) induced premature ventricular contractions (PVCs). Which type of effect do such contractions represent? a. Toxic b. Secondary c. Iatrogenic d. Idiosyncratic

c. Iatrogenic Digoxin-induced PVCs are iatrogenic because the drug is mimicking a cardiac disorder. Because the client is experiencing an apparent pathological disorder, this effect isn't considered toxic, secondary, or idiosyncratic.

The nurse would obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia? a. Calcium and magnesium b. Potassium and calcium c. Magnesium and potassium d. Potassium and sodium

c. Magnesium and potassium Hypomagnesemia as well as hypokalemia and hyperkalemia are common causes of ventricular tachycardia. Calcium imbalances cause changes in the QT interval and ST segment. Alterations in sodium level don't cause rhythm disturbances.

A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have any symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the nice lady, the nurse would most likely learn that the client's childhood health history included: a. Chicken pox b. poliomyelitis c. Rheumatic fever d. meningitis

c. Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis.

During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she is visiting an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? a. Visit her friend earlier in the day. b. Rest for at least an hour before climbing the stairs. c. Take a nitroglycerin tablet before climbing the stairs. d. Lie down once she reaches the friend's apartment.

c. Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug's principle effects are produced by: a. Antispasmotic effect on the pericardium b. Causing an increased mycocardial oxygen demand c. Vasodilation of peripheral vasculature d. Improved conductivity in the myocardium

c. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.