CH 30, Assessment of the Cardiovascular System

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? Select all that apply

B. Serum potassium of 2.9 mEq/L (2.9 mmol/L). D. Expanding groin hematoma. E. Rhythm changes on the cardiac monitor.

An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure?

A. "I get short of breath when I climb stairs."

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? Select all that apply

A. Assess for allergies to iodine. B. Administer intravenous fluids. C. Assess blood urea nitrogen.

A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first?

A. Compare the results with previous blood pressure readings.

A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect?.

A. Heart rate of 120 beats/min

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? Select all that apply

A. Thrombophlebitis. C. Pulmonary embolism. E. Cardiac tamponade.

A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? Select all that apply

A. Total cholesterol: 280 mg/dL (7.3 mmol/L) C. Triglycerides: 200 mg/dL (2.3 mmol/L) E. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take?

B. Notify the primary health care provider before scheduling the MRI.

A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? Select all that apply

B. Prepare for continuous blood pressure and pulse monitoring. D. Give the client nothing by mouth 3 to 6 hours before the procedure. E. Explain to the client that dobutamine will simulate exercise for this examination.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema?

B. "My shoes fit tighter by the end of the day."

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this client's teaching?

B. "You should balance weight loss with consuming necessary nutrients."

An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? Select all that apply

B. Fatigue despite adequate rest. C. Indigestion. E. Shortness of breath.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery?

B. Initiation of an external pacemaker

A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response?

C. "Tell me more about your concerns about the test."

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response?

C. "What do you understand about what happened to you?"

A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease?

C. A 65-year-old woman with diabetes mellitus.

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first?

C. Assess the client's medications.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next?

C. Assess the color and temperature of the left leg.

A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect?

C. Fatigue and shortness of breath

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?

C. Slurred speech and confusion

A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best response?

D. "Use pillows to elevate your head and chest while you are sleeping."

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure?

D. Allergies to iodine-based agents

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?

D. Client who describes intense squeezing pressure across the chest.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?

D. Pulse decreased from 100 to 80 beats/min.