Cardiovascular

A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?

... "I took my warfarin last night according to my usual schedule." CORRECT Clients scheduled for a CABG should not take anticoagulants, such as warfarin, for 5 to 7 days prior to the surgery to prevent excessive bleeding.

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 client who has diabetes mellitus CORRECT Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.

A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

...GOOGLE: point of maximal impulse heart -look at images :)

A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?

...Weak peripheral pulses CORRECT Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.

A nurse is caring for a client who has a history of angina and is scheduled for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?

... "I smoked a cigarette this morning to calm my nerves about having this procedure." CORRECT Smoking prior to the test can change the outcome and places the client at additional risk, so the test should be rescheduled.

A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include? (Select all that apply.)

... Limited alcohol intake Regular exercise program Smoking cessation

A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?

... Urine output of 20 mL/hr CORRECT Urine output less than 30 mL/hr can indicate shock because it reflects decreased blood flow to the kidneys, possibly from graft rupture and hemorrhage.

A nurse in the emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week postoperative open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?

...Assisting with thrombolytic therapy CORRECT The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.

A nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade?

...Blood pressure 140/82 mm Hg on inspiration and 154/90 mm Hg on expiration CORRECT Pulsus paradoxus, when the systolic blood pressure is 10 mm Hg or higher on expiration than on inspiration, is an indicator of cardiac tamponade.

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?

... Valvular disease CORRECT Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

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?

... •"I can't get rid of these hiccups." CORRECT Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can indicate a complication such as lead wire perforation.

A nurse 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?

... •"You may no longer be able to feel chest pain." CORRECT Heart transplant clients usually are no longer able to feel chest pain due to the denervation 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?

... Inquire about the presence or absence of claudication. CORRECT 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.

A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following?

... Persistent cough CORRECT A persistent cough is an adverse effect of ACE inhibitors, and the client should discontinue the medication if it occurs.

A nurse is caring for a client who presents to the emergency department with 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?

... Place the head of the bed at 45°. CORRECT The first action the nurse should take when using the airway, breathing, circulation approach to client care is to place the head of the client's bed at 45°. This improves respiratory status and promotes venous return to reduce workload on the heart.

A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect?

... •Confusion CORRECT Bradydysrhythmia can cause decreased tissue perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.

A nurse is reviewing the laboratory results of several 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?

... Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL CORRECT The expected reference range of cholesterol is less than 200 mg/dL, HDL above 40 mg/dL, and LDL less than 100 mg/dL.

A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of deep-vein thrombosis. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96 seconds?

... Stop the heparin infusion. CORRECT The aPTT level is above the therapeutic range of 1.5 to 2 times the control value. The nurse should discontinue the heparin infusion immediately and notify the provider to prevent harm to the client.

A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a heart rate of 200 to 210/min and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions?

... Vagal stimulation CORRECT Vagal stimulation can help the client's heart return to a normal sinus rhythm temporarily.

A nurse is caring for a client who has dilated cardiomyopathy. The client reports increasing difficulty completing her daily 1-mile walks. The nurse should recognize that this is a finding of which of the following?

... •Left ventricular failure CORRECT Activity intolerance is a finding of left ventricular failure and is associated with dilated cardiomyopathy.

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?

... •Slurred speech CORRECT The greatest risk to this client is injury from an embolus caused by the atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. The nurse should report this finding to the provider immediately.

A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?

... •Weight gain of 0.9 kg (2 lb) in 24 hr CORRECT 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 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.

A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. Which of the following client findings should the nurse report to the provider?

...Blood pressure 160/80 mm Hg CORRECT The nurse should report an elevated blood pressure following a CABG procedure because increased vascular pressure can cause bleeding at the incision sites.

A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Identify the area of the strip the nurse should examine to observe for atrial depolarization. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

...CORRECT Click P-Wave The nurse should examine this area of the rhythm strip to evaluate for atrial depolarization.

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction (MI)?

...Creatine kinase-MB CORRECT Creatine kinase-MB is the isoenzyme specific to the myocardium and is elevated when that muscle is injured.

A nurse is caring for a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy?

...INR 2.5 CORRECT The nurse should determine that an INR of 2.5 is within the desired therapeutic range and is the best evidence of effective warfarin therapy.

A nurse is caring for a client who is being treated for heart failure and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications?

...Lightheadedness CORRECT Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness.

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?

...Place the patch on an area of skin away from skin folds and joints. CORRECT The client should apply the patch to an area of skin that is not prone to movement or wrinkling.

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?

...Previous allergic reaction to shellfish CORRECT The contrast medium used is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine.

A nurse is caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client?

...Urine output CORRECT The greatest risk to this client is graft occlusion or rupture. Therefore, monitoring urine output, which reflects blood flow to the kidneys, is the priority assessment.