cardiovascular "U"
A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine. The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days. Which question is most important for the nurse to ask next?
A major problem in long-term management of hypertension is poor adherence to the treatment plan, often due to unpleasant side effects and medication cost. Assessing for medication adherence is important, as abrupt discontinuation of antihypertensive medications can cause rebound hypertension and hypertensive crisis.
The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client?
A major problem with long-term management of hypertension is poor adherence to the treatment plan. The nurse should teach the client the importance of taking blood pressure medications as prescribed.
During assessment of a client who underwent a coronary artery bypass graft 10 hours ago, the nurse notes that the amount of drainage from the mediastinal chest tube has decreased from 100 mL to 20 mL over the last hour. Which of the following nursing actions is appropriate?
A marked decrease in mediastinal chest tube drainage warrants immediate assessment for signs of cardiac tamponade (eg, muffled heart tones, pulsus paradoxus, hypotension). If there are no signs of tamponade, the nurse should troubleshoot other possible causes of chest tube occlusion and contact the health care provider.
The nurse receives hand-off report on assigned clients. Which client should the nurse assess first?
Absent or decreased volume in the peripheral pulses distal to the graft can indicate compromised circulation or graft occlusion and should be reported to the health care provider immediately.
A 3-month-old client has stopped breathing. Identify the area where the nurse should check the client's pulse.
According to the infant cardiopulmonary resuscitation guidelines of the American Heart Association, the brachial artery is used to detect a pulse in an unresponsive client age <1 year.
A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. Which action should the nurse take?
Adenosine is the drug of choice for the treatment of paroxysmal supraventricular tachycardia. It has a short half-life and should be administered rapidly over 1-2 seconds, followed with a 20-mL saline bolus. A brief period of asystole can be common. Flushing from vasodilation is seen frequently.
The clinic nurse is reviewing telephone messages from four clients. Which client's call should the nurse return first?
Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias. Pulmonary toxicity is a life-threatening complication that may cause symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients taking amiodarone with signs of pulmonary toxicity require immediate follow-up.
The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse?
An elevated troponin value holds the highest priority for intervention when a client is experiencing chest pain. Positive troponin levels are indicative of myocardial injury and require immediate attention by the nurse. Normal values are <0.5 ng/mL (<0.5 mcg/L) for troponin I and <0.1 ng/mL (<0.1 mcg/L) for troponin T.
Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis?
Aortic stenosis obstructs blood flow during systole from the left ventricle to the aorta. Clients will develop exertional dyspnea, chest pain, and syncope as the heart is unable to overcome the obstruction to pump enough blood to meet metabolic demands. A systolic ejection murmur over the aortic area, soft or absent second heart sounds, and weak peripheral pulses are characteristic.
A nurse on the telemetry unit observes the following rhythm on the monitor of a client admitted with coronary artery disease. What action should the nurse take first?
Assess the client with second-degree atrioventricular block, type 1 for symptoms associated with the rhythm (eg, hypotension, dizziness, shortness of breath). If no symptoms are present, closely monitor the client. If symptoms are present, anticipate using atropine or temporary pacing.
The nurse is caring for a client with end-stage heart failure. The rhythm shown in the exhibit is seen on the cardiac monitor, and the nurse finds the client unresponsive with no palpable pulse. What is the correct interpretation of this rhythm?
Asystole is characterized by complete absence of electrical activity on the ECG. The client will have no pulse or respirations, and will be unresponsive. The nurse should immediately initiate cardiopulmonary resuscitation, advanced cardiac life support measures, and treatment of any reversible causes.
The nurse prepares to administer 9:00 AM medications to a client. Which data should the nurse evaluate prior to administration? Aspirin: 81 mg orally, daily0900 Metoprolol: 50 mg orally, twice daily0900 & 1700 Quinapril: 10 mg orally, daily0900 Allergies: NoneMedicationsSchedule
Beta blockers lower blood pressure and heart rate. Angiotensin-converting enzyme inhibitors lower blood pressure and increase potassium. Aspirin, an antiplatelet medication, increases the risk for bleeding.
The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first?
Chronic mitral valve regurgitation is often asymptomatic, but many clients eventually develop heart failure; therefore, early recognition of symptoms is a priority. Mitral regurgitation causes a backflow of blood from the left ventricle to the left atrium, resulting in pulmonary edema (eg, dyspnea, orthopnea) and decreased cardiac output (eg, fatigue). Left atrial enlargement can also result in atrial fibrillation (eg, palpitations
The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching?
Clients on warfarin or heparin should avoid using aspirin or nonsteroidal anti-inflammatory drugs, wear a MedicAlert device, avoid activities that increase the risk for bleeding, and limit alcohol intake.
The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which foods?
Clients receiving warfarin therapy should maintain consistent intake of foods high in vitamin K; it is not necessary to remove vitamin K-rich foods completely. Clients should avoid excess or inconsistent intake of green vegetables (eg, broccoli, spinach) and liver to promote steady warfarin efficacy.
The nurse is caring for a client with cardiomyopathy and coronary artery disease. The client is reporting increasing chest pain and has bilateral lung crackles on auscultation. The health care provider has written several new prescriptions. Which new prescription should the nurse clarify? Select all that apply. Vital signs Blood pressure84/58 mm HgHeart rate108/min Respirations28/min Oxygen saturation90%
Clients with cardiomyopathy may develop cardiogenic shock due to the heart's inability to circulate blood effectively, causing reduced cardiac output. Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme testing, and interventions to reduce cardiac workload.
A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?
Clients with cardiovascular disease (eg, coronary artery disease) are cautioned against taking nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen), which increase the risk of thrombotic events (eg, heart attack, stroke). Nurses who identify clients with cardiovascular disease taking NSAIDs should investigate the reasons for use and notify the health care provider.
A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client?
Clients with chronic heart failure experience clinical manifestations of both right-sided and left-sided failure. Therefore, the nurse must be able to assess for the clinical manifestations related to systemic volume increases and pulmonary congestion.
The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask?
Clients with hypertension should be instructed not to take potentially high-risk over-the-counter medications, including high-sodium antacids, appetite suppressants, and cold and sinus preparations, as they can increase blood pressure.
A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock?
Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include change in mental status; tachypnea; tachycardia with thready pulse; cool, clammy skin; and oliguria.
A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure?
Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed.
The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)?
DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.
The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? 0600 Wednesday0600 Thursday Blood pressure 148/84 mm Hg 98/60 mm Hg 24-hour intake/output 1000/3000 mL --------------- Serum sodium 140 mEq/L (140 mmol/L) 150 mEq/L (150 mmol/L) Serum potassium 4.2 mEq/L (4.2 mmol/L) 3.5 mEq/L (3.5 mmol/L) Serum glucose 90 mg/dL (5 mmol/L) 99 mg/dL (5.5 mmol/L)
Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy.
The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure.
Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of diuretics and fluid/salt restriction.
The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription?
Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of diuretics and fluid/salt restriction.
The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching?
Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat; and replacing the bottle every 6 months once opened.
A client is started on lisinopril therapy. Which assessment finding requires immediate action?
Evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury. These include ACE inhibitors (eg, lisinopril, enalapril), aminoglycosides (eg, gentamicin), and digoxin.
The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up?
Following placement of an arteriovenous fistula, it is imperative to monitor for signs of potential clotting of the fistula such as absence of a bruit, absence of a thrill, decreased capillary refill, and coolness of the extremity below the fistula.
The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority?
For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest.
The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect?
High doses of IV furosemide should be administered slowly to prevent ototoxicity.
A nurse is teaching the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells?
Hypercyanotic or tet spells usually occur during stressful or painful procedures; on waking; and with hunger, crying, and feeding. Providing a calm environment; reducing hunger with small, frequent meals; and swaddling during procedures can help prevent hypercyanotic spells.
A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis?
Hypertensive crisis may require continuous infusion of an IV vasodilator. BP should be lowered slowly to prevent organ damage. The initial goal is to lower MAP by 25% or less or to maintain MAP of 110-115 mm Hg.
The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)?
IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur. The onset of hemiplegia or painful, pale, cold foot/leg could indicate embolization and should be reported to the HCP immediately.
The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child's parent wants to know why this treatment is required. The nurse explains that this therapy is given to:
IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.
A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Laboratory results Sodium 134 mEq/L (134 mmol/L) Potassium 3.4 mEq/L (3.4 mmol/L) Chloride 108 mEq/L (108 mmol/L) Magnesium 0.9 mEq/L (0.45 mmol/L)
In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).
A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client?
It is important to educate clients and their partners about sexual activity after an MI. Generally, it is safe for clients to consider resumption of sexual activity when they can walk 1 block or climb 2 flights of stairs without symptoms.
The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension?
Key risk factors for developing hypertension include African American ethnicity, increasing age, positive family history, smoking, excessive sodium and alcohol use, diabetes mellitus, obesity, hyperlipidemia, chronic stress, and sedentary lifestyle. Untreated hypertension increases client risk for coronary artery disease, stroke, heart failure, and renal failure.
A graduate nurse (GN) is caring for a client who underwent a total knee replacement 1 day earlier. Which intervention by the GN would cause the supervising nurse to intervene?
Knee arthroplasty is the surgical replacement of the knee joint. Following a knee arthroplasty, the nurse should avoid placing a pillow behind the client's operative knee due to the risk of contracture. Proper postoperative care includes applying intermittent cold packs to reduce pain and edema, using a continual passive motion device for flexibility, and obtaining a leg immobilizer for joint stability during ambulation.
A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse?
Maintenance drug therapy after a pulmonary embolus typically includes administration of oral anticoagulants such as factor Xa inhibitors (eg, apixaban). NSAIDs (eg, indomethacin) increase the risk of bleeding when used concurrently with apixaban therapy. The nurse should question initiation of apixaban therapy in the context of NSAID use.
A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms?
Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure.
The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially?
Myocardial infarctions in women, the elderly, and diabetics may have gastrointestinal distress as the main symptom; this needs to be evaluated with the institutional protocol for acute coronary syndrome.
The nurse is performing discharge teaching for the parents of a 4-year-old with heart failure. Which statement by the parents indicates the need for further teaching related to the administration of digoxin?
Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity. General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.
A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse?
Nurses caring for clients receiving potassium-wasting diuretics (eg, furosemide) should monitor for and report signs of hypokalemia (eg, muscle cramps), as unmanaged hypokalemia may result in lethal complications. Bruising, a side effect of antiplatelet medications, and fatigue, a side effect of beta blockers, should be monitored, but are not lethal.
A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action?
Nurses must take presenting cardiac symptoms seriously until the cause is determined. Assess airway, breathing, and circulation, and obtain baseline pulse oximetry and vital signs. Then obtain electrocardiogram (ECG) results.
The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department. All ICU beds are currently full. Which client should the charge nurse consider as most appropriate for transfer out of the ICU?
Occasional premature ventricular complexes are common dysrhythmias and usually do not cause hemodynamic instability. Clients with atrial fibrillation and rapid ventricular response, complete heart block, or other threats to cardiovascular stability require continuous observation in the intensive care unit.
A client comes to the emergency department with a "pounding heart beat." The client is diaphoretic and pale and admits to using cocaine approximately one hour ago. The client is connected to a cardiac monitor that shows the rhythm displayed in the exhibit. The nurse recognizes it as which rhythm?
Supraventricular tachycardia (SVT) is a regular narrow-complex (QRS) tachycardia. The heart rate is typically 150-220/min with no visible P wave. Treatment includes vagal maneuvers and IV adenosine. Hemodynamically unstable clients with SVT may require synchronized cardioversion.
The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching?
The American Heart Association provides guidelines for basic life support of infants, including initial client evaluation eg, assess brachial pulse and retrieval of automatic external defibrillator ie, after 2 min of CPR during an unwitnessed collapse with a single rescuer.
The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet?
The Dietary Approaches to Stop Hypertension (DASH) diet is often recommended to reduce blood pressure in clients with hypertension. The client is taught to limit intake of sugar, sodium, cholesterol, and trans or saturated fats, and instead choose healthier options (eg, fresh fruit and vegetables, low-fat dairy products).
The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective?
The ability to perform activities without chest pain is a desirable client outcome of long-acting nitrate use. The nurse would want to assess for this outcome in clients taking these medications.
A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP?
The candidate for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the health care provider if the client has history of arteriovenous malformation, which is an absolute contraindication to the use of thrombolytics.
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.
A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take?
The client with symptomatic bradycardia should be treated initially with IV atropine. Transcutaneous pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective.
Which client is in need of follow-up education by the nurse?
The nurse needs to educate the client with a venous leg ulcer that wearing some kind of compression stockings is essential for healing and prevention of ulcer recurrence.
Beta blockers lower blood pressure and heart rate. Angiotensin-converting enzyme inhibitors lower blood pressure and increase potassium. Aspirin, an antiplatelet medication, increases the risk for bleeding.
The nurse needs to monitor groin puncture sites, peripheral pulses, urine output, and kidney function in the client who has had minimally invasive endovascular repair of an abdominal aneurysm.
The nurse observes the rhythm shown in the exhibit on a client's cardiac monitor. The client reports palpitations and lightheadedness. Which intervention does the nurse anticipate?
The nurse should be able to recognize SB on the ECG and assess for clinical significance (eg, chest pain, syncope, hypotension) in the client. Initial expected treatment for symptomatic clients includes atropine and transcutaneous pacing.
The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse?
The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.
A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)?
The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can potentiate potassium loss and increase the client's risk for hypokalemia. Use of licorice root should be reported to the PCHP.
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?
The nurse should follow the ABCs of assessment with the heart failure client who is short of breath and coughing. Airway, breathing, and circulation should be assessed, including auscultation of breath sounds, measurement of respiratory rate, and oxygen saturation.
The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which finding is most important to report to the health care provider (HCP)?
The nurse should immediately report the new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or jugular venous distension in the post MI client to the HCP. These findings may indicate the development of heart failure or cardiogenic shock.
The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
The nurse should instruct the client with a Holter monitor to keep a diary of activities and any symptoms that occur while wearing it. The client should also be taught not to bathe during the testing period but to continue all other normal activities.
A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement
The nurse should stop the infusion of heparin when there is evidence of bleeding. The HCP should be notified immediately and the nurse should be prepared to give protamine if ordered.
A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse?
The nurse should suspect hypokalemia in the presence of muscle cramps in a client taking diuretics. Hypokalemia can lead to dangerous ventricular dysrhythmias.
The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration?
The nurse should watch for vision changes with ethambutol. Potassium supplements or salt substitutes should not be given to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to prevent irritation of the ulcer. Quinolone antibiotics should not be given with antacids or supplements that reduce drug efficacy. Rifampin commonly causes red-orange discoloration of body fluids.
A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority?
The nurse that suspects DVT should perform a thorough neurovascular assessment of the client's extremities, including presence and quality of DP and PT pulses, temperature of extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. The findings should be reported immediately to the HCP.
The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client's aPTT is 5 times the control value and the PT/INR is 2 times the control value. What action does the nurse anticipate
The therapeutic effect from heparin or warfarin (Coumadin) is 1.5-2.0 times the control value. Heparin is measured with a PTT and warfarin is measured with PT/INR. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.
A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurse's first action?
To relieve a hype cyanotic episode, or "tet spell," the nurse should place the infant or child in the knee-chest position.
The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first?
Ventricular septal defect is a cardiac abnormality, with a septal opening between ventricles, that may progress to congestive heart failure (CHF). The client should be closely monitored for respiratory exertion and signs of CHF (eg, dyspnea, tachypnea)
A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective?
Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3. A diet high in vitamin K may decrease warfarin's anticoagulant effect. Most antibiotics will increase INR by causing a vitamin K deficiency.
The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters?
When administering furosemide, it is important to closely monitor the client's vital signs, serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury.
Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis?
blood flow during systole from the left ventricle to the aorta. develop exertional dyspnea, chest pain, and syncope as the heart is unable to overcome the obstruction to pump enough blood to meet metabolic demands. systolic ejection murmur over the aortic area, soft or absent second heart sounds weak peripheral pulses are characteristic.
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication
clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use increased risk for bleeding reported to the prescribing health care provider before the client is discharged.
A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective?
sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light. The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken.
A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention?
the client with a moderate to large pericardial effusion is at risk for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, narrowed pulse pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The nurse should report these findings to the health care provider immediately and prepare for a pericardiocentesis.
The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect?
the ductus arteriosus of a newborn should close spontaneously when fetal circulation changes to pulmonary circulation. If the ductus arteriosus remains open, blood will shunt from the aorta to the pulmonary arteries. The child will be acyanotic but will have a machine-like murmur heard on both systole and diastole.
The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include?
vasospastic disorder triggered by exposure to cold or stress. acute attacks, avoidance of vasoconstrictive substances (eg, tobacco, cocaine, caffeine), stress reduction, and appropriate clothing (eg, gloves, warm layers).
