Care of Adult Exam 2 (Prep-U Cardiac disorders)

The nurse is assessing a client with irreversible shock. The nurse should document which of the following?

circulatory collapse

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and orders sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, which instruction should the nurse provide?

"Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Rationale: commonly causes orthostatic hypotension and dizziness.Change nitroglycerin every 3-6 months

A nurse is preparing a client for an exercise stress test the following morning. Which client statement indicates a need for additional teaching?

"I won't eat or drink anything after midnight tonight." Rationale: Client must be NPO only 4 hours before

The client with heart failure asks the nurse about the reason for taking Enalapril maleate. Which of the following responses by the nurse would be most appropriate?

"This drug will dilate your blood vessels and lower your blood pressure."

When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:

2 inches

The nurse is preparing to administer 0.1 mg of digoxin intravenously. Digoxin comes in a concentration of 0.5 mg/2 ml. How many milliliters should the nurse administer? Record your answer using one decimal place.

0.4 ml

A client with heart failure is receiving furosemide, 40 mg I.V. The physician orders [40 mEq (40 mmol/L)] of potassium chloride in 100 ml of dextrose 5% in water to infuse over 4 hours. The client's most recent serum potassium level is [3.0 mEq/L (3.0 mmol/L)]. At what infusion rate should the nurse set the I.V. pump?

25 ml/hour

The nurse is assessing a client who is at risk for cardiac tamponade from chest trauma sustained in a motorcycle accident. What is the client's pulse pressure if his blood pressure is 108/82 mm Hg? (Record your answer using a whole number)

26 Rationale: Pulse is the difference between systolic and diastolic

A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority?

A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

Assess respiratory status

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member, the monitor exhibits the following. Which interventions should the nurse do first?

Assess the client's airway, breathing, and circulation

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:

BP

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission, what should the nurse assess first?

BP Rationale: BP first because people with pulmonary edema typically experience severe hypertension that requires early intervention

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

Bibasilar crackles

A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine, oxygen, and aspirin. The physician diagnoses acute coronary syndrome. When the client arrives on the unit, his vital signs are stable and he has no complaints of pain. The nurse reviews the physician's orders. In addition to the medications already given, which medication does the nurse expect the physician to order?

Carvedilol

A nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that he thinks he's going to die before a donor heart is found. He also tells the nurse that he hasn't been attending a church but wants to talk with a priest. What action should the nurse take?

Contact the clergy member who is assigned to the transplant team

When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should?

Teach the client to put on clothing on the affected side first

Risk factors for secondary hypertension:

DM, head injury, and hormonal contraceptives

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

Elevated ST segment

A client who has been experiencing angina has a new prescription for nitroglycerin. Which of the following should the nurse include in teaching about the side effects of nitroglycerin?

Headache Rationale: most common side effect of nitroglycerin is a headache. Additional cardiovascular side effects include tachycardia, hypotension, and dizziness

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium Rationale: could increase risk for bleeding

Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease?

High levels of low-density lipid (LDL) cholesterol

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

History of aortic valve replacement

The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse?

Immediate defibrillation

A middle-aged client being admitted to the hospital has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client reports having "indigestion." The nurse connects the client to a cardiac monitor, which reveals 8 premature ventricular contractions (PVCs) per minute. The nurse should next:

Insert an IV Rationale: Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces

Which of the following activities is least effective in preventing sensory deprivation during a client's stay in the cardiac care unit?

Keeping the door closed to provide privacy Rationale: Keeping the client's door closed is likely to contribute to feelings of isolation and sensory deprivation

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

Lie down or sit in a chair for 5 to 10 minutes after taking the drug.

An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after insertion of a permanent pacemaker?

Maintain cardiac conduction stability

The nurse is preparing the client with heart failure to go home. The nurse should instruct the client to:

Monitor weight daily Rationale: People with heart failure are taught to maintain a target weight and to weigh themselves daily to monitor increasing fluid retention.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?

Notify the physician Rationale: Possible PE which is life threatening

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour care ride, what should the nurse should advise the client to do?

Perform ankle pumps and foot range-of-motion exercises

A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?

Potassium level less than 3.5 (risk for hypokalemia)

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?

Stabilizing heart rate and blood pressure and easing anxiety

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?

Rheumatic fever

A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:

Showing the location of the obstruction and the collateral circulation.

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain

A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect?

The number of premature ventricular contractions is decreasing

The nurse's unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught?

The percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity

The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client when inquiring about the purpose of the new diet?

To reduce the metabolic workload of digestion

Which client is at greatest risk for coronary artery disease?

Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD

A client with severe angina pectoris and ST-segment elevation on an electrocardiogram is being seen in the emergency department. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a:

Troponin test Rationale: positive test indicates an MI

A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

Within in 6 hours

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?

confusion, urine output 15 mL over the last 2 hours, orthopnea

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will:

eat food on only half of the plate

Metoprolol is added to the pharmacologic therapy of a woman with diabetes diagnosed with stage 2 hypertension and initially treated with furosemide and Ramipril. An expected therapeutic effect is:

decrease in heart rate

A client whose condition remains stable after a myocardial infarction gradually increases activity. To determine whether the activity is appropriate for the client the nurse should assess the client for:

dyspnea

Automated external defibrillators (AEDs) are used in cardiac arrest situations for:

early defibrillation in cases of ventricular fibrillation

A client is taking spironolactone to control her hypertension. Her serum potassium level is [6 mEq/L (56mmol/L)]. For this client, the nurse's priority should be to assess her:

electrocardiogram (ECG) results

A fourth heart sound (S4) indicates a:

failure of the ventricle to eject all blood during systole

A client is receiving pentoxifylline for intermittent claudication. The nurse should determine the effectiveness of the drug by asking if the client:

has less pain in the legs Rationale: the MOA of drug is to improve circulation

Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which contradiction to administering the drug?

history of cerebral hemorrhage

The nurse monitors the serum electrolyte levels of a client who is taking digoxin. Which electrolyte imbalance is a common cause of digoxin toxicity?

hypokalemia

During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when palpation of the radial pulse reveals:

irregular rhythm with pulse rate greater than 100 bpm

The correct landmark for obtaining an apical pulse is the:

left fifth intercostal space, midclavicular line

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?

leg edema

A client with peripheral artery l disease has femoral-popliteal bypass surgery. The primary goal of the plan of care after surgery is to:

maintain circulation

Which risk factors should the nurse list for primary hypertension?

obesity, stress, high intake of sodium or saturated fat

The client with Raynaud's phenomenon has coldness and numbness in the fingers. Which is an early sign of vasoconstriction?

pallor Rationale: Vasoconstriction causes pallor then cyanosis then rubor

The results of which serologic test should the nurse have on the medical record before a client is started on tissue plasminogen activator or alteplase recombinant?

partial thromboplastin time

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level?

pulse rate

The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye?

retina

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. His cholesterol profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603 mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how to lower his cholesterol. The nurse should tell the client that:

she'll ask the dietitian to talk with him about modifying his diet

Which indicates hypovolemic shock in a client who has had a 15% blood loss?

systolic blood pressure less than 90 mm Hg Rationale: Also narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety

A nurse suspects that a client has digoxin toxicity. The nurse should assess for:

vision changes "halos"

A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which finding should the nurse consider unexpected and report to the health care provider (HCP) immediately?

weakness and numbness in the lower extremities

A client with Raynaud's phenomenon is considering having a sympathectomy. This nurse should tell the client that the surgery is performed:

when all other treatment alternatives have failed