CARDIO_____nur165

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? 1. Maintain activity level as prescribed. 2. Maintain the affected leg in a dependent position. 3. Administer an opioid analgesic every 4 hours around the clock. 4. Apply cool packs to the affected leg for 20 minutes every 4 hours.

1. Rationale: Standard management for the client with DVT includes maintaining the activity level as prescribed by the health care provider; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse should maintain the prescribed activity level, which could be bed rest or ambulation. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? 1."This is a normal finding." 2. "This is indicative of atrial flutter." 3. "This is indicative of atrial fibrillation." 4. "This is indicative of impending reinfarction."

1. Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. The remaining options are incorrect and indicate that further education is needed.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1. Listening to lung sounds 2. Palpating for organomegaly 3. Assessing for jugular vein distention 4. Assessing for peripheral and sacral edema

1. Rationale: The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? 1. Hypotension 2. Flat neck veins 3. Complaints of nausea 4. Complaints of headache

1. Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/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.

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy? 1. Tarry stools 2. Nausea and vomiting 3. Orange-colored urine 4. Decreased urine output

1. Rationale: Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1. Keep the legs aligned with the heart. 2. Elevate the legs higher than the heart. 3. Clean the skin with alcohol every hour. 4. Position the client onto the side during every shift.

2. Rationale: In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1. Anxiety related to the need to make lifestyle changes 2. Boredom resulting from having already learned the material 3. An attempt to ignore or deny the need to make lifestyle changes 4. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

3 Rationale: Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1. Use nail polish to protect the nail beds from injury. 2. Wear gloves for all activities involving the use of both hands. 3. Stop smoking because it causes cutaneous blood vessel spasm. 4. Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

3 Rationale: Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. It is not necessary to wear gloves for all activities, nor should warm clothing be worn in warm climates

A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? 1. "Apply warm packs to the leg." 2. "Keep the leg elevated as much as possible." 3. "Your health care provider needs to be contacted to report this problem." 4. "This normally occurs after surgery and will subside when the edema goes down."

3. Rationale: A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. The remaining options are inaccurate responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential complications include bruising, tightness along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy the varices and then removes the pieces via aspiration.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1. A stage 1 ulcer 2. A vascular ulcer 3. An arterial ulcer 4. A venous stasis ulcer

3. Rationale: Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? 1. Heart failure 2. Atrial fibrillation 3. Myocardial infarction 4. Ventricular tachycardia

3. Rationale: Cardiac troponin T or cardiac troponin I have been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation.

The health care provider (HCP) has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? 1. Questions the client about allergies to iodine or shellfish 2. Has the client sign an informed consent form for an invasive procedure 3. Tells the client that the procedure is painless and takes 30 to 60 minutes 4. Keeps the client on nothing by mouth (NPO) status for 2 hours before the procedure

3. Rationale: Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client.

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1. Bananas 2. Broccoli 3. Antacids 4. Cantaloupe

3.Rationale: The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure not to go barefoot around the house." 2. "If I cut my toenails, I need to be sure that I cut them straight across." 3. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

4. Rationale: Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements, and indicate that the teaching has been effective.