Cardiac portion test 1
The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best response?
"An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks."
The nurse is caring for a patient admitted with angina who is scheduled for cardiac catheterization. The patient is anxious and asks the reason for this test. What is the best response?
"Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are."
A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should the nurse provide to this patient?
"Diuril can cause low blood pressure and dizziness, especially when you get up suddenly."
The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise?
"Eventually aim to work up to 30 minutes of exercise each day."
A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurse's nutritional teaching plan has been effective?
"I will have a baked potato with broiled chicken for dinner."
The nurse is conducting patient teaching about cholesterol levels. When discussing the patient's elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what?
"Increased LDL and decreased HDL increase my risk of coronary artery disease."
A patient is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this procedure will affect her busy work schedule. What guidance should the nurse provide to the patient?
"Patients usually remain at the hospital for 24 to 48 hours."
A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor asks the student about the relationships between BP and age. What would be the best answer by the student?
"Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure."
The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient states that she is nervous about "things going wrong" during the procedure. What is the nurse's best response?
"The whole team will be monitoring you very closely for the entire procedure.
A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response?
"To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia.The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation
A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse's interview is most suggestive of this valvular disorder?
"Whenever I do any form of exercise I get terribly short of breath."
A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the nurse perform?Inform the patient that she will remain on bed rest following the procedure
.During the recovery period, the patient must maintain bed rest with the head of the bed elevated to 45 degrees. patient must be NPO 6 hours preprocedure
The patient has a homocysteine level ordered. What aspects of this test should inform the nurse's care?
A 12-hour fast is necessary before drawing the blood sample.Genetic factors can elevate homocysteine levels. A diet low in folic acid elevates homocysteine levels.
While auscultating a patient's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in what patient?
A 20-year-old patient
An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A high-protein diet that is rich in vitamins
A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers.
The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?
A heart rate of 54 bpm Cardiac output is computed by multiplying the stroke volume by the heart rate.
The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms?Confusion and bradycardia
A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia.
A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient
A sheath will be placed over the insertion site after the procedure is finished.
While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding?Implement interventions relevant to arterial narrowing.
ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries.
The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply.
Abrupt closure of the coronary artery Bleeding at the insertion site Retroperitoneal bleeding Arterial occlusion
The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF.
According to national standards, the nurse should anticipate the administration of what medication? Epinephrine 1 mg IV push
A patient with pericarditis has just been admitted to the CCU. The nurse planning the patient's care should prioritize what nursing diagnosis?
Acute pain related to pericarditis
The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patient's care plan?
Administer supplementary oxygen, as needed.
A lipid profile has been ordered for a patient who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results?
After a 12-hour fast
The nurse has entered a patient's room and found the patient unresponsive and not breathing. What is the nurse's next appropriate action?Activate the Emergency Response System (ERS).
After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
A patient with a diagnosis of HF is started on a beta-blocker. What is the nurse's priority role during gradual increases in the patient's dose?Educating the patient that symptom relief may not occur for several weeks
An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks.
The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.
Ans: Facilitate the presence of friends and family whenever possible, Provide supplemental oxygen, as needed, Provide validation of the patient's expressions of anxiety
Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient have with mitral valve prolapse?
Anxiety Fatigue Palpitations A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety.
nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. nurse is aware that afterload influences a patient's stroke volume. nurse recognizes that afterload is increased when there is what?
Arterial vasoconstriction
A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day?
Assess pulse of affected extremity every 15 minutes at first.
The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurse's most recent assessment reveals that CVP is 7 mm Hg. What is the nurse's most appropriate action
Assess the patient for fluid overload and inform the physician.
The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patient's medical history, what is a potential primary cause of the patient's heart failure?
Atherosclerosis of the coronary arteries is the primary cause of HF.
During a patient's care conference, the team is discussing whether the patient is a candidate for cardiac conduction surgery. What would be the most important criterion for a patient to have this surgery?
Atrial and ventricular tachycardias not responsive to other treatments
A patient with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the patient to exhibit what heart rhythm?
Atrial fibrillation In patients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation.
A patient with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the patient's symptoms, the nurse should teach the patient to do which of the following?
Avoid activities that cause an increased heart rate.
The nurse is planning discharge teaching for a patient with a newly inserted permanent pacemaker. What is the priority teaching point for this patient?
Avoid exposure to high-voltage electrical generators
The critical care nurse is caring for a patient who is receiving cyclosporine postoperative heart transplant. The patient asks the nurse to remind him what this medication is for. How should the nurse best respond?
Azathioprine minimizes rejection of the transplant.
The nurse is participating in the care conference for a patient with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments?
Balancing myocardial oxygen supply with demand
public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD.
Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following? Diet therapy and smoking cessation
The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action?Stay with the patient.
Because the patient has an unstable condition, the nurse must remain with the patient.
A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this patient?
Bleeding at the implantation site
A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The physician's choice of antibiotics would be primarily based on what diagnostic test?
Blood cultures
A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?
Blood pressure Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia increased potassium in the blood, and alterations in renal function.
An older adult patient has been diagnosed with aortic regurgitation. What change in blood flow should the nurse expect to see on this patient's echocardiogram?
Blood to flow back from the aorta to the left ventricle
A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurse's most appropriate action?
Call for help and apply pressure to the access site.
The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the step-down unit should prioritize what assessment?
Cardiac monitoring
Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication?
Cardiac tamponade An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade.
The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?patient admitted following an MI
Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic.
The nurse is caring for an acutely ill patient who has central venous pressure monitoring in place. What intervention should be included in the care plan of a patient with CVP in place?
Change the site dressing whenever it becomes visibly soiled.
The nurse is caring for a patient who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output?
Changes in level of consciousness Blood pressure tends to decrease with lowered cardiac output
A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patient's daily medication administration record, the nurse should anticipate administering what drug?
Clopidogrel
The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs?
Combination of hydralazine and isosorbide dinitrate A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors.
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action?
Contact the patient's physician and suggest assessment of fluid balance and renal function.
A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause?
Coronary arteriosclerosis
A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention?
Defibrillation
The cardiac nurse is caring for a patient who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding?
Decreased ejection fraction
The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify?
Decreased peripheral resistance Decreased blood volume Decreased strength and rate of myocardial contractions
A patient who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following?
Dental procedures
New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to explain depolarization. What would be the best answer by the preceptor?
Depolarization is the electrical stimulation of the heart muscles."
A patient is scheduled for catheter ablation therapy. When describing this procedure to the patient's family, the nurse should address what aspect of the treatment?
Destruction of specific cardiac cells
nurse is teaching a patient about risk factors for hypertension. nurse explainrisk factors for primary hypertension?Obesity, stress, high intake of sodium or saturated fat, family history are all risk factors for primary
Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, renal disease, and coarctation of the aorta are causes of secondary hypertension.
A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the patient's care?
Diagnose the dysrhythmia.
The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM?
Dilated ventricles without hypertrophy of the ventricles
The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patient's psychosocial needs?
Directly address the patient's anxieties and fears.
When assessing venous disease in a patient's lower extremities, the nurse knows that what test will most likely be ordered?
Duplex ultrasonography may be used to determine the level and extent of venous disease as well as its chronicity.
A critical care nurse is caring for a patient with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill patients?
Left ventricular preload
CPR has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following?Perform at least 100 chest compressions per minute.
During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitator's goal;
A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? Systole
During a shift assessment, the nurse is identifying the client's point of maximum impulse . Where will the nurse best palpate the PMI? Left midclavicular line of the chest at the fifth intercostal space
nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS?
Dyspnea,Unusual fatigue,Syncope
The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document?
ECG to compare time of onset of VT and onset of device's shock
The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal?
Less than 120/80 mm Hg
The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the adequacy of the patient's blood flow. On what physiological variables does adequate blood flow depend?
Efficiency of heart as a pump, Adequacy of circulating blood volume, Patency and responsiveness of the blood vessels
How should the nurse best position a patient who has leg ulcers that are venous in origin?
Elevate the patient's lower extremities.
The patient has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should know that complications following this procedure include what?
Emboli Mitral valve damage Ventricular dysrhythmia
The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?
Ensure no one is touching the patient at the time shock is delivered.
A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities?
Ensure that the patient's heels are protected and supported.
A patient has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the patient for this test, what action should the nurse perform?
Establish peripheral IV access.
nurse is relating the deficits in a patient's synchronization of the atrial and ventricular events to his diagnosis. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization?
Excitability Automaticity Conductivity
When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena?
Exercise increases the heart's oxygen demands.
A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state?
Exercise on a regular basis.
The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurse's best response?
Explore the factors underlying the patient's anxiety
An adult patient with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?
Fewer QRS complexes than P waves
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply.
Fluid status, Cardiac rhythm, Action of medications
A patient who has recently recovered from a systemic viral infection is undergoing diagnostic testing for myocarditis. Which of the nurse's assessment findings is most consistent with myocarditis?
Flulike symptoms
A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA.
For what complication should the nurse most closely monitor the patient?Bleeding at insertion site
The nurse is auscultating the breath sounds of a patient with pericarditis. What finding is most consistent with this diagnosis?
Friction rub A pericardial friction rub is diagnostic of pericarditis
An ECG has been ordered for a newly admitted patient. What should the nurse do prior to electrode placement?
Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.
triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?
Gently shake and shout, "Are you OK?"Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?
Greater saphenous vein
The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patient's risk for heart failure (HF)? The patient's age is greater than 65.
HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physician's office.
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patient's sensorium and LOC. Why is the assessment of the patient's sensorium and LOC important in patients with HF?
HF ultimately affects oxygen transportation to the brain. As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain.
A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult patient who has been experienced vital fatigue and shortness of breath. test will allow the care team to investigate the possibility of what diagnosis?
Heart failure The level of BNP in the blood increases as the ventricular walls expand from increased pressure
When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize?
Heart rate and rhythm
A patient has been living with dilated cardiomyopathy for several years but has experienced worsening symptoms despite aggressive medical management. The nurse should anticipate what potential treatment?
Heart transplantation
A patient with hypertrophic cardiomyopathy (HCM) has been admitted to the medical unit. During the nurse's admission interview, the patient states that she takes over-the-counter "water pills" on a regular basis.
How should the nurse best respond to the fact that the patient has been taking diuretics?Inform the care provider because diuretics are contraindicated.
nurse is caring for a patient with refractory atrial fibrillation who underwent the maze procedure several months ago. nurse reviews the result of the patient's most recent cardiac imaging, which notes the presence of scarring on the atria.
How should the nurse best respond to this finding? Recognize this as a therapeutic goal of the procedure.
Following cardiac resuscitation, a patient has been placed in a state of mild hypothermia before being transferred to the cardiac intensive care unit. nurse's assessment reveals that the patient is experiencing neuromuscular paralysis.
How should the nurse best respond? Document this as an expected assessment finding.
The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patient's CVP is increasing. Of what may this indicate?
Hypervolemia CVP is a useful hemodynamic parameter to observe when managing an unstable patient's fluid volume status
In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education?
I'll make sure that I don't cross my legs when I'm resting in bed."
A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally.
IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? Control ventricular heart rate
critical care nurse is caring for a patient just admitted in a hypertensive emergency. nurse should anticipate the administration of what medication? Sodium nitroprusside Nitropress.have immediate actions that are short lived
IV vasodilators, including sodium nitroprusside , nicardipine hydrochloride , clevidipine , fenoldopam mesylate, enalaprilat, and nitroglycerin, have immediate actions they are therefore used for initial treatment.
The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include?
Imbalanced nutrition: less than body requirements
The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient?
Improved cardiac output
driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described.In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, peripheral edema.
In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.
The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?
Increase in the size of the artery's lumen
A cardiac care nurse is aware of factors that result in positive chronotropy. These factors would affect a patient's cardiac function in what way?
Increasing the heart rate
The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
physician has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a patient. results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis?
Inflammation
A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. the nurse's most appropriate action?
Inform the physician that the patient has signs and symptoms of VTE.
nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient?
Insertion of an implantable cardioverter defibrillator an implantable cardioverter defibrillator can prevent sudden cardiac death and extend survival.
The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels?
International normalized ratio (INR) between 2 and 3
A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patient's health history creates a heightened risk of intracardiac thrombi?
Intracardiac thrombi are especially common in patients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation.
A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela?Stroke
Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke.
Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject?
Intubation and mechanical ventilation
The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patient's symptoms are due to an MI, what will have happened to the myocardium?
It may have developed an increased area of infarction during the time without treatment.
The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic regurgitation causes what?
Left ventricular hypertrophy
nurse is providing patient education prior to a patient's discharge home after treatment for HF. nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?
Know how to recognize and prevent orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required.
The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?
Lipids and fibrous tissue
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply.
Location and type of pain, Bilateral comparison of peripheral pulses, Comparison of temperature in the patient's legs, Identification of mobility limitations
The nurse is caring for a patient who is scheduled to undergo mechanical valve replacement. Patient education should include which of the following?
Long-term anticoagulant therapy
The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.)
Need for careful monitoring for cardiac symptoms Need for carefully regulated exercise Need for dietary modifications
The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin therapy?
Lower doses of heparin are required for this patient. If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.
A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient's medication administration record, the nurse should anticipate which of the following?An antibiotic
Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment.
The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient?
Maintain adequate cardiac output.
The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do?
Maintain firm contact between paddles and patient skin.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan?Avoiding tight-fitting socks.
Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings.
The nurse is caring for a patient with right ventricular hypertrophy and consequently decreased right ventricular function. What valvular disorder may have contributed to this patient's diagnosis?
Mitral valve stenosis
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
Monitor for hypotension
A patient is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the patient's pacemaker?
Monitoring for pacemaker malfunction or battery failure
The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient?
Morphine The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed
A patient has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. You are aware that the damage occurred where?
Myocardium The myocardium is the layer of the heart responsible for the pumping action
A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency?
Normalizing BP within 24 to 48 hours
An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients?
Numbness Weakness
A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index be most clearly warranted?A patient with poorly controlled type 1 diabetes who is a smoker
Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking.
The nurse is reviewing a newly admitted patient's electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated?Avoid positioning the patient supine.
Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and, consequently, the nurse should avoid positioning the patient supine.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease .What assessment finding is most consistent with this diagnosis?nequal peripheral pulses between extremities
PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg.
A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk?
Patient's consistent performance of deep breathing and coughing exercises
A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care?
Perfusion distal to the insertion site
The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurse's most appropriate initial action?
Place the patient on bed rest in a semi-Fowler's position.
A critical care nurse is caring for a patient with a hemodynamic monitoring system in place. For what complications should the nurse assess?
Pneumothorax Infection Air embolism
The nurse is teaching a patient about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Transient ischemic attacks Cerebrovascular accident Retinal hemorrhage
Potential complications of hypertension include: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks (TIAs); cerebrovascular accident; renal insufficiency and failure; and retinal hemorrhage.
During an adult patient's last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patient's BP be categorized? Prehypertensive
Prehypertension is defined systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg.
A cardiac surgery patient's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action?
Prepare to assist with pericardiocentesis.
The nurse's comprehensive assessment of a patient who has HF includes evaluation of the patient's hepatojugular reflux. What action should the nurse perform during this assessment?
Press the right upper abdomen.
A patient presents to the ED in distress and complaining of "crushing" chest pain. What is the nurse's priority for assessment?
Prompt initiation of an ECG
patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema.nurse is aware that positioning will promote circulation. How should the nurse best position the patient? In a high Fowler's position
Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed.
The critical care nurse is caring for a patient who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the patient's left ventricular function?
Pulmonary artery pressure monitoring (PAPM) PAPM is used to assess left ventricular function. CVP is used to assess right ventricular function
nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of
Pulmonary edema
The nurse is calculating a cardiac patient's pulse pressure. If the patient's blood pressure is 122/76 mm Hg, what is the patient's pulse pressure?
Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46 mm Hg.
The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG?
QRS complex The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle.
The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond?
Recognize that the view of the electrical current changes in relation to the lead placement
A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease?
Recognizing and promptly treating streptococcal infections
A patient with cardiovascular disease is being treated with amlodipine Norvasc, a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following?
Reducing the heart's workload by decreasing heart rate and myocardial contraction
A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency
Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise.
The nurse is caring for a patient who has had a biventricular pacemaker implanted. When planning the patient's care, the nurse should recognize what goal of this intervention?
Resynchronization
The nurse is caring for a recent immigrant who has been diagnosed with mitral valve regurgitation. The nurse should know that in developing countries the most common cause of mitral valve regurgitation is what?
Rheumatic heart disease and its sequelae
The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient's diagnosis? Distended neck veins
Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness.
A patient has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this patient's care, what nursing diagnosis is most appropriate?
Risk for activity intolerance Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance.
nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. nurse should consequently identify what nursing diagnosis in the patient's plan of care?
Risk for falls related to orthostatic hypotension
The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis?
Risk for infection related to Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection.
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence?
SA node to AV node to bundle of His to Purkinje fibers
The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient?A beta-adrenergic blocker
Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis.
A patient is admitted to the critical care unit with a diagnosis of cardiomyopathy. When reviewing the patient's most recent laboratory results, the nurse should prioritize assessment of which of the following?
Sodium Sodium is the major electrolyte involved with cardiomyopathy
The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurse's most appropriate response
Stop the test and monitor the patient closely.
A nurse is planning discharge health education for a patient who will soon undergo placement of a mechanical valve prosthesis. What aspect of health education should the nurse prioritize in anticipation of discharge?
Strategies for infection prevention
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm?
Sudden onset of severe back or abdominal pain Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent.
The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?
T wave inversion
The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics?
Take the diuretic in the morning to avoid interfering with sleep.
The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best response?
Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.
The nurse is caring for a patient with acute pericarditis. What nursing management should be instituted to minimize complications?
The nurse helps the patient with activities until the pain and fever subside.
The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the patient's heart? T wave
The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state
A nurse is reviewing the physiological factors that affect a patient's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference?
The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
A patient is brought into the ED by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain.
The care team recognizes the need to monitor the patient's cardiac function closely while interventions are performed. What form of monitoring should the nurse anticipate? Hardwire continuous ECG monitoring
A patient's declining cardiac status has been attributed to decreased cardiac action potential. Interventions will be aimed at restoring what aspect of cardiac physiology?
The cycle of depolarization and repolarization
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?A systolic blood pressure that is lower during inhalation
The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.
During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response?
The difference is the timing of the delivery of the electric current."
The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF? An S3 heart sound
The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat.
Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient?
The importance of ensuring the stockings are applied evenly with no pressure points
A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following?
The need for regularly scheduled testing of the patient's International Normalized Ratio INR
The physical therapist notifies the nurse that a patient with coronary artery disease experiences a much greater-than-average increase in heart rate during physical therapy.
The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? Myocardial ischemia
A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm.
The nurse should expect that the primary care provider may diagnose the woman with what health problem?Upper extremity arterial occlusive disease
A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate.
The nurse should implement measures to prevent what complication? Deep vein thrombosis .
A patient presents to the ED complaining of increasing shortness of breath. nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum.
The nurse should recognize the signs and symptoms of what health problem?Acute pulmonary edema Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? Improve functional status, Extend survival, Relieve patient symptoms
The overall goals of management of HF are to relieve the patient's symptoms, to improve functional status and quality of life, and to extend survival.
A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause?
The pain occurs immediately following physical exertion.
The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs?
The patient experiences chest pain, palpitations, or dyspnea.
The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class?
Use a conducting medium between the paddles and the skin.
A patient's recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse should closely monitor which of the following?
The patient's potassium level
When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information?
The patient's symptoms and the activities that precipitate attacks
The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years.
The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? "Be sure to practice meticulous foot care."
A nurse is planning an educational campaign addressing hypertension. nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group?
The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having the highest prevalence at approximately 63% and 57%, respectively.
The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored.
The results show decreased CVP. What does this indicate? Possible hypovolemia
The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?Potassium level
The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.
Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
The symptoms indicate an acute coronary episode and should be treated as such.
A patient with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the patient in anticipation of this diagnostic procedure?
The test is noninvasive, and nothing will be inserted into the patient's body.
A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments?
They are the part of an ECG that represents early ventricular repolarization.
A patient's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect?Increased urine output
Thiazide diuretics lower BP by reducing circulating blood volume; this results in a short-term increase in urine output.
The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding?
This is an accurate indicator of myocardial injury. Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?
Throbbing headache or dizziness
The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?Monitor her weight daily
To assess fluid balance at home, the patient should monitor daily weights at the same time every day.
The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question most directly addresses the possibility of worsening hypertension?Do you ever see spots in front of your eyes?
To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital.
To minimize cardiac damage, the nurse should expect to administer which of the following interventions?Morphine sulphate, oxygen, and bed rest
A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this?
To prevent bacterial endocarditis Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after the following invasive procedures, such as bronchoscopy
The nurse is teaching a patient diagnosed with aortic stenosis appropriate strategies for attempting to relieve the symptom of angina without drugs. What should the nurse teach the patient?
To rest and relax before taking nitroglycerin
The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient?
Trancutaneous pacemaker emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform.
The critical care nurse is caring for a patient who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate.
Under normal circumstances where are these cells located? SA node
A nurse is providing health education to a patient scheduled for cryoablation therapy. The nurse should describe what aspect of this treatment?
Using a cooled probe to eliminate the source of dysrhythmia
The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following?
Weight loss, Regular exercise, Smoking cessation
A patient the nurse is caring for has a permanent pacemaker implanted with the identification code beginning with VVI. What does this indicate?
Ventricular paced, ventricular sensed, inhibited
The nurse is caring for a patient who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment?
Vigilant monitoring of the patient's ECG
An occupational nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins?
Walk for several minutes every hour to promote circulation.
The nurse on the hospital's infection control committee is looking into two cases of hospital-acquired infective endocarditis among a specific classification of patients.
What classification of patients would be at greatest risk for hospital-acquired endocarditis? Hemodialysis patients
The nurse is admitting a patient with complaints of dyspnea on exertion and fatigue. The patient's ECG shows dysrhythmias that are sometimes associated with left ventricular hypertrophy.
What diagnostic tool would be most helpful in diagnosing cardiomyopathy? Echocardiogram
patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine.
What guidelines will the nurse follow when administering atropine? Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg.
The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function.
What is an additional function of pulmonary artery pressure monitoring systems? To assess the patient's response to fluid and drug administration
The nurse is caring for a patient with mitral stenosis who is scheduled for a balloon valvuloplasty. The patient tells the nurse that he is unsure why the surgeon did not opt to replace his damaged valve rather than repairing it.
What is an advantage of valvuloplasty that the nurse should cite? Repaired valves tend to function longer than replaced valves.
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation.
What is the most appropriate intervention for this diagnosis? Encourage the patient to engage in a moderate amount of exercise.
The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment.
What is the nurse most likely to find during an assessment of this patient's wound? Heavy exudate
A cardiovascular patient with a previous history of pulmonary embolism is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. nurse recognizes the characteristic signs and symptoms of a PE.
What is the nurse's best action?Patient management in the event of a PE begins with cardiopulmonary assessment and intervention.
The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurse's most recent assessment reveals that the patient's left pedal pulses are not palpable and that the right pedal pulses are rated at +2.
What is the nurse's best response?Inform the patient's physician of this assessment finding.
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI).
What nursing assessment activity is a priority on admission to the CCU? Begin ECG monitoring.
You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being "distressed" and "shocked" by her new diagnosis.
What nursing diagnosis is most clearly suggested by the woman's statement? Anxiety related to cardiac symptoms
The nurse is assessing a patient who had a pacemaker implanted 4 weeks ago. During the patient's most recent follow-up appointment, the nurse identifies data that suggest the patient may be socially isolated and depressed.
What nursing diagnosis is suggested by these data?Ineffective coping related to pacemaker implantation
The nurse is preparing a patient for cardiac surgery. During the procedure, the patient's heart will be removed and a donor heart implanted at the vena cava and pulmonary veins.
What procedure will this patient undergo? Orthotopic transplant
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot.
What risk factors would the nurse list that can be controlled or modified? Obesity, inactivity, diet, and smoking
A patient has been diagnosed with a valvular disorder. The patient tells the nurse that he has read about numerous treatment options, including valvuloplasty.
What should the nurse teach the patient about valvuloplasty?"For some patients, valvuloplasty can be done in a cardiac catheterization laboratory."
The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues.
What technique for achieving these simultaneous goals should the nurse describe?Cardiopulmonary bypass
A 17-year-old boy is being treated in the ICU after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest.
What type of cardiomyopathy is particularly common among young people who appear otherwise healthy? Hypertrophic cardiomyopathy (HCM)
A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension.
What valvular disorder should the nurse anticipate being diagnosed in this patient?Mitral stenosis
patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. patient's recent vital signs prior to discharge are oxygen saturation of 93% on room air, pulse 81 beats per minute, BP of 94/59 mm Hg.
When planning this patient's subsequent care, what nursing diagnosis should be identified?Risk for falls related to hypotension The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls.
A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment?Use Doppler ultrasound to identify the pulses.
When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels.
The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?
Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately
It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias.
While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation
The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult?
Widening of the aorta
A cardiac patient's resistance to left ventricular filling has caused blood to back up into the patient's circulatory system. What health problem is likely to result? Acute pulmonary edema
With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs.
The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care?
With the patient, clarify the surgical procedure that will be performed.
The nurse is caring for a patient on telemetry. The patient's ECG shows a shortened PR interval, slurring of the initial QRS deflection, and prolonged QRS duration. What does this ECG show?
Wolf-Parkinson-White (WPW) syndrome
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection?Provide a high-calorie, high-protein diet.
Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein.
The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous
and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem? Intermittent claudication
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of
gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what?PAD
community health nurse teaching a group of adults about preventing and treating hypertension.nurse should encourage these participants to collaborate with their primary care providers and regularly monitor which of the
following? Blood lipid levels
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his
foot and ankle. What health problem should the nurse suspect? Lymphangitis
The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that
he is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patient's care plan should address what problem?Acute pain related to intermittent claudication
A nurse is caring for an older adult patient who is in cardiac rehabilitation following an MI. nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. patient questions the relationship between walking and
heart function. How should the nurse best reply? "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation,
how will the nurse describe this initial absence of cardiac rhythm? Asystole Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood.
You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? Ineffective tissue perfusion Raynaud's phenomenon
is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk.
Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen the area over the liver
is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does
not exercise. What would be the priority health education for this patient?vCigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.
The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure.
patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload.
The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patient's pain became much worse last night and appeared along with fever, chills, and sweating. The
patient states, "I hit my leg on the car door 4 or 5 days ago and it has been sore ever since. patient has a history of chronic venous insufficiency. What intervention should nurse anticipate for this pt.? Antibiotics to treat cellulitis
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care
should include what intervention? Early ambulation and leg exercises oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis.
A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patient's vital signs, the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patient's BP be defined if a
similar reading were obtained at a subsequent office visit?Stage 2 hypertensive JNC 7 defines stage 2 hypertension as a reading 160/100 mm Hg.
Lowering the BP too fast may cause hypotension in a patient whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes.
so lower blood pressure slow and easy
A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should
suspect that the patient has a history of what health problem? Arterial insufficiency may result in gangrene of the toe digital gangrene, which usually is caused by trauma.
A patient with a history rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the patient knows
the importance of taking which of the following drugs? Amoxicillin (Amoxil)
A patient calls his cardiologist's office and talks to the nurse. He is concerned because he feels he is being defibrillated too often. The nurse tells the patient to come to the office to be evaluated because
the nurse knows that the most frequent complication of ICD therapy is what? Oversensing of dysrhythmias
The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise,
the nurse realizes that the desired goal for cholesterol levels is which of the following? Low LDL values and high HDL values
When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a patient who has such a device in place,
the nurse should check which of the following components? A transducer A flush system A pressure bag
A patient has been admitted with an aortic valve stenosis and has been scheduled for a balloon valvuloplasty in the cardiac catheterization lab later today. During the admission assessment,
the patient tells the nurse he has thoracolumbar scoliosis and is concerned about lying down for any extended period of time. What is a priority action for the nurse Notify the surgeon immediately.
A 55-year-old patient comes to the clinic for a routine check-up. The patient's BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to
treat hypertension. What would be the nurse's best response? "Hypertension greatly increases your risk of stroke and heart disease."
patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing
what health problem? Renal failure When uncontrolled hypertension is prolonged, it can result in renal failure, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure.
A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patient's medication regimen,
what nursing diagnosis should be prioritized? Risk for infection
