Cardiovascular ATI
A nurse is planning a presentation for a group of clients who have hypertension. which of the following lifestyle modifications should the nurse include SATA - Tobacco cessation -Decreased magnesium intake -reduced potassium intake -regular exercise program -limited alcohol intake
- Tobacco Cessation -Regular exercise program -Limited alcohol intake (Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include.)
A nurse is teaching a client who is starting to take an ace inhibitor to treat hypertension . the nurse should instruct the client to notify his provider if he experiences which of the following adverse effects of this medication A- Persistent Cough B- Frequent Urination C- Constipation D- Tendon Pain
A - Persistent Cough A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.Frequent urination is an expected outcome of this medication. Constipation is an adverse effect of ACE inhibitors. However, the client does not need to discontinue use or report this to the provider
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. which of the following statements by the client requires the nurse to contact the provider for possible rescheduling A- I smoked a cigarette this morning to calm my nerves about having this procedure B-I didn't take my heart pills this morning because my doctor told me not to C- I have had chest pain a couple of times since I saw my doctor in the office last week D- Im still hungry after the bowl of cereal I ate at 7 am
A- I smoked a cigarette this morning to calm my nerves about having this procedure *Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.* Episodes of chest pain are not a contraindication to this test. The provider might withhold cardiovascular medications prior to this procedure to effectively monitor cardiovascular response to stress. It is not necessary for the client to be NPO prior to this procedure.
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. which of the following instructions should the nurse include in the teaching. A- Place the patch on an area of skin away from skin folds and joints B- Apply the new patch to the same site as the previous patch C- Replace the patch at the onset of angina D- Keep the patch on 24 hr per day
A- Place the patch on an area of skin away from skin folds and joints *The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.* The nurse should instruct the client to rotate the patch site to help prevent skin irritation. The nurse should instruct the client to have a patch-free interval of 10 to 12 hr each day to prevent tolerance to the medication. The nurse should emphasize that nitroglycerin patches offer ongoing prevention of angina attacks. The nurse should instruct the client that patches do not treat angina attacks because they do not take effect immediately.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. the nurse should plan to monitor for and report which of the following findings to the provider immediately A- slurred speech B- persistent fatigue C- Irregular pulse D- Dependent edema
A- Slurred Speech The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
a nurse is providing health teaching for a group of clients which of the following clients is at risk for developing peripheral arterial disease A- a client who has diabetes mellitus B- a client who has hypothyroidism C- a client who consumes two 12-oz bottles of beer a day D- a client whose daily caloric intake consists of 25% fat
A- a client who has diabetes mellitus *Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.* Hypothyroidism is not a risk factor for developing peripheral arterial disease. Twenty-five percent is within the recommended range for daily fat intake, and diet does not place the client at risk for development of peripheral arterial disease. Two 12-oz bottles of beer a day is considered moderate alcohol intake and does not place the client at risk for development of peripheral arterial disease.
A nurse if performing a cardiac assessment on a client. Identify where the nurse should inspect when evaluating the point of maximal impulse.
Apex of the heart *Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line.*
A nurse is assessing a client who has pulmonary edema related to heart failure. which of the following findings indicates effective treatment of the clients condition A- Decreased Respiratory rate at rest B- Absence of adventitious breath sounds C- Presence of nonproductive Cough D- SaO2 86% on room air
B- Absence of Adventitious breath sounds *Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.* A moist, productive cough usually accompanies pulmonary edema. However, the presence of a nonproductive cough does not indicate that the problem is resolving. The respiratory rate usually decreases while at rest. It is not an indicator of effective treatment. This value is below the expected reference range. It is not an indicator of effective treatment.
A nurse is caring for a client who is 8 hr postoperative following a coronary artery graft. which of the following client findings should the nurse report A- Temp 98.8 B- BP 160/80 C- Potassium 4.0 D- Mediastinal drainage 100 ml/hr
B- BP 160/80 *The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites* A body temperature of 37.1° C is within the expected reference range and is desired following a CABG. A potassium level of 4.0 mEq/L is the expected level during the postoperative period following a CABG. Mediastinal drainage of up to 150 mL/hr is expected during this time.
A nurse in an emergency room is assessing a client who has bradydysrhythmia. which of the following findings should the nurse monitor for? A- Friction Rub B- Confusion C-Dry Skin D-Hypertension
B- Confusion *Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.* The nurse should expect to hear a friction rub during cardiac auscultation for a client who has pericarditis. The nurse should monitor a client who has a bradydysrhythmia for hypotension. The nurse should monitor a client who has a bradydysrhythmia for diaphoresis.
A nurse is assessing a client who has a history of DVT and is receiving warfarin. the nurse should identify that which of the following findings indicates the mediation is effective A- Hemoglobin 14 g/dl B- INR 2.0 C- Minimal bruising of Extremities D- Decreased blood pressure
B- INR 2.0 *The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.* The nurse should recognize that decreased blood pressure is a manifestation of bleeding, which is an adverse effect of warfarin. The nurse should recognize that minimal bruising or no bruising is desired. However, this is not evidence of effective warfarin therapy. The nurse should recognize that a hemoglobin level of 14 g/dL is within the expected reference range. However, this is not evidence of effective warfarin therapy.
A nurse is caring for a client who is being rated for heart failure and has a prescription for furosemide. the nurse should plan to monitor for which of the following as an adverse effect of this medication A- Metallic taste B- Lightheadedness C- Dry Cough D- Shortness of breath
B- Lightheadedness *Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.* Furosemide is used to manage shortness of breath secondary to heart failure. Shortness of breath is not an adverse effect of this medication. A dry cough is an adverse effect of ACE inhibitors. A metallic taste is not an adverse effect of furosemide.
A nurse is caring for client who is receiving heparin therapy and develops hematuria. which of the following actions should the nurse take if the clients aPTT is 96 seconds A- Request a Prothrombin time (PT) B- Stop the heparin infusion C- Continue to monitor the heparin infusion as prescribed D- Increase the heparin infusion flow rate by 2ml/hr
B- Stop the Heparin infusion *The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.* An aPTT of 96 seconds indicates excessive blood levels of heparin. Therefore, the nurse should take corrective action.An aPTT of 96 seconds indicates excessive blood levels of heparin. Therefore, the nurse should not increase the heparin infusion. The nurse should monitor PT for a client who is taking an oral anticoagulant. However, it is not necessary to request a PT before taking any corrective action.
A nurse is monitoring a client ECG monitor and notes the clients rhythm has change from normal signs rhythm to supraventricular tachycardia. the nurse should prepare to assist with which of the following interventions A- Administration of atropine IV B- Vagal Stimulation C- Defibrillation D- Delivery of precordial Thump
B- Vagal Stimulation *The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.* The nurse should initiate chest compressions for pulseless ventricular tachycardia until a defibrillator is available. Supraventricular tachycardia does not require chest compressions. The nurse should identify that atropine is used to treat bradydysrhythmias. Supraventricular tachycardia does not require atropine. The nurse should identify that cardioversion, rather than defibrillation, is used to treat supraventricular tachycardia. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia.
a nurse is caring for a client who has endocarditis. which of the following findings should the nurse recognize as a potential complication A- Guillain- Barre syndrome B- Valvular Disease C- Ventricular Depolarization D- Myelodysplastic syndrome
B- Valvular Disease *Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.*
A nurse is assessing a client who has Left-Sided heart failure. which of the following manifestations should the nurse expect to find A- Increased Abdominal Girth B-Weak Peripheral Pulses C- Dependent Edema D- Jugular Venous Neck Distention
B- Weak Peripheral Pulses *Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.* Jugular venous neck distention is a finding related to systemic congestion resulting from right-sided heart failure. Dependent edema is a finding related to systemic congestion resulting from right-sided heart failure. Increased abdominal girth is a finding related to systemic congestion resulting from right-sided heart failure.
A nurse in an emergency department is caring for a client who had an anterior MI . the clients history reveals she Is 1 week postoperative following an open cholecystectomy . the nurse should recognize that which of the following interventions is contraindicated. A- administering IV Morphine Sulfate B- Assisting with thrombolytic therapy C- administering oxygen at 2 L/min via nasal cannula D-helping the client to the bedside commode
B- assisting with thrombolytic therapy The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy. Using a bedside commode is less stressful than using a bedpan, and most clients are allowed to use a commode following a myocardial infarction.The nurse should administer supplemental oxygen to the client to increase myocardial tissue perfusion.The nurse should administer IV morphine to the client to relieve pain and reduce myocardial oxygen demand.
A nurse in an emergency department s caring for a client who has a blood pressure of 254/139 mm hg. the nurse recognizes that the client is in a hypertensive crisis. which of the following actions should the nurse take first. A- tell the client to report vision changes B- elevate the head of the clients bed C- Start a peripheral IV D- Initiate Seizure precautions
B- elevate the head of the client's bed *The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.* The nurse should initiate seizure precautions because the client is at risk for seizures. However, this is not the first action the nurse should take.The nurse should tell the client to report vision changes because the client is at risk for blurred vision. However, this is not the first action the nurse should take. The nurse should initiate an IV to provide access for medication administration to reduce the client's blood pressure. However, this is not the first action the nurse should take.
a nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. the nurse should plan to provide dietary teaching for the client who has which of the following laboratory values A- Cholesterol 195 HDL 55 LDL 125 B-Cholesterol 185 HDL 50 LDL 120 C- Cholesterol 190 HDL 25 LDL 160 D- Cholesterol 180 HDL 70 LDL 90
C- Cholesterol 190 HDL 25 LDL 160 *These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.*
A nurse is caring for a client who had an onset of chest pain 24hr ago. the nurse recognize that an increase in which of the following is diagnostic of myocardial infarction (MI) A- C Reactive protein B- Myoglobin C- Creatine Kinase- MB D-Homocysteine
C- Creatine Kinase- MB *Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.* Myoglobin is elevated following an MI, and with skeletal muscle injury. However, it is not specific to the cardiac muscle.C-reactive protein increases soon after the beginning of an inflammatory process, such as rheumatoid arthritis, and is not specific to cardiac muscle. Homocysteine is always present in the blood. An increased level might indicate a risk factor for the development of cardiovascular disease.
A nurse is caring for a client following insertion of a permanent pacemaker. which of the following client statements indicates a potential complication of the insertion procedure A- I feel dizzy when I stand B- my incision site stings C- I cant get rid of these Hiccups D- I have a headache
C- I cannot get rid of these hiccups *Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.* Dizziness is not a complication of the insertion procedure and is expected initially as the client adjusts to the pacemaker. Pain or stinging at the incision site is not a complication of the insertion procedure. However, the client should monitor the pacemaker insertion site for manifestations of infection. Headache is not a complication of the insertion procedure. However, it might be related to other disease processes.
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hours. which of the following client statements indicates a need for further clarification by the nurse A- my arthritis is really bothering me because I haven't taken my aspirin in a week B- I will check my blood sugar because I took a reduced does of insulin this morning C- I took my warfarin last night according to my usual schedule D- my blood pressure shouldn't be high because I took my blood pressure medication this morning
C- I took my warfarin last night according to my usual schedule *Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.* The provider might instruct a client who takes insulin to take a reduced dose in the morning of surgery to regulate blood glucose. The provider might instruct the client to administer medications to treat high blood pressure to reduce the risk for hypertension. The provider might have the client discontinue over-the-counter medications, such as aspirin, prior to surgery to reduce the risk for bleeding.
A nurse is preparing a client for coronary angiography. the nurse should report which of the following findings to the provider prior to the procedure A- Hemoglobin 14.4 g/dl B- History of peripheral arterial disease C- Previous allergic reaction to shellfish D- Urine output 200ml/4hr
C- Previous allergic reaction to shellfish The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure
A nurse is providing discharge teaching for a client who has a heart failure. the nurse should instruct the client to report which of the following findings immediately to the provider A- increase of 10 mm/hg in systolic blood pressure B- dizziness when rising quickly C- weight gain of 0.9KG or 2lb in 24 hr D- dyspnea with exertion
C- weight gain of 0.9Kg or 2lb in 24 hrs *When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.* An increase of 10 mm Hg in systolic blood pressure is a nonurgent finding. Although the client should report the increase in blood pressure, there is another finding the client should report immediately. Dyspnea with exertion is a nonurgent finding that is expected for a client who has heart failure. Although the client should report it, there is another finding the client should report immediately. Dizziness when rising quickly is a nonurgent finding that is expected for a client who is taking medications to treat heart failure. Although the client should report it, there is another finding the client should report immediately.
A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. which of the following statements should the nurse include in the teaching A- " your level of activity intolerance will not change" B- " you will be able to stop taking immunosuppressant's after 12 months C- " after 6 months you will no longer need to restrict your sodium intake" D- "You might no longer be able to feel chest pain"
D- "You might no longer be able to feel chest pain" * Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart* The client's activity tolerance should gradually improve as the healing process progresses.The client will need to permanently maintain a diet that is restricted in sodium and fat. The client will remain on immunosuppressants for the remainder of their life to help prevent rejection of the heart.
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. the nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer. A- ask if the client has had a recent infection B- Explore the clients family history of peripheral vascular disease C- Note the presence of absence of pain at the ulcer site D- inquire about the presence or absence of claudication
D- Inquire about the presence or absence of claudication *Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.* Both arterial and venous ulcers have the potential to become infected. Both arterial and venous ulcers cause varying degrees of pain or discomfort. Family history is important, but it does not help to differentiate between arterial and venous ulcers.
A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. the client is experiencing weakness and an irregular hear rate. which of the following actions should the nurse take first? A- obtain clients current weight B-Determine the time of the last digoxin dose C- Check the clients urine output D- Review serum electrolyte Values
D- Review serum electrolyte Values * weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. the first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias for hypokalemia*
a nurse is assessing a client who has dilated cardiomyopathy. which of the following findings should the nurse expect A-weight loss B- pericardial rub C- tracheal deviation D- dyspnea on exertion
D- dyspnea on exertion *The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.* The nurse should identify that tracheal deviation is an expected manifestation of a tension pneumothorax. The nurse should identify that a pericardial rub is an expected manifestation of pericarditis.The nurse should identify that weight gain is an expected manifestation of dilated cardiomyopathy. Weight gain is due to ventricular compromise and fluid retention.
A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. which of the following findings can indicate shock and should be reported to the provider A- urine output of 20ml/hr B- Severe pain with coughing C- Serosanguineous drainage on dressing D- increase in temperature from 98.2 to 99.5
Urine output of 20ml/hr *Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture* Serosanguineous drainage 1 hr postoperative is expected and is not a manifestation of shock. Serosanguineous drainage should decrease over the first few days and discontinue after day 5. Coughing is painful after an aortic aneurysm repair. However, it is not a manifestation of shock. This temperature is within the expected reference range and is not a manifestation of shock.