HESI CARDIOVASCULAR

What is the nurse primarily attempting to prevent when caring for a client in the initial stages of chronic lymphocytic leukemia (CLL)? Injury Fatigue Infection Cachexia

C

A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? It should be elevated on a pillow. It should be kept extended while on bed rest. It will be positioned dependent to the level of the heart. It will be put through range-of-motion exercises several times an hour.

B

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? Hypokalemia Hypocalcemia Hyponatremia Hypomagnesemia

A

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement? Fear Depression Dependency Ambivalence

A

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. Which recommendation by the nurse will help the client maintain blood vessel patency? Practice relaxation techniques. Lead a more sedentary lifestyle. Limit cardiovascular exercise. Increase saturated fats in the diet.

A

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? Support systems that can assist the client at home Potential nursing homes in which the client can recuperate Agencies that can help the client regain activities of daily living Ways that the client can develop relationships with neighbors

A

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A 65-year-old with pulmonary fibrosis A 24-year-old with uncontrolled type 1 diabetes A 45-year-old who has been vomiting for 3 days A 54-year-old who takes sodium bicarbonate for indigestion

A

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? Asthma Anemia Endocarditis Reye syndrome

C

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? Obtain vital signs Initiate a cardiac arrest code Administer oxygen using a face mask Encourage the use of an incentive spirometer

C The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted. The client is not experiencing a cardiac arrest, and therefore a code should not be initiated. After more definitive medical intervention, deep breathing and coughing or use of an incentive spirometer may be done to prevent or treat atelectasis

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? "Do you have chest pain?" "Are you feeling anxious?" "Do you have any palpitations?" "Are you feeling short of breath?"

A

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? A loss of atrial kick No physiologic changes Increased cardiac output Decreased risk of pulmonary embolism

A Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The atrioventricular (AV) node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. This irregularity is called "irregularly irregular." The ineffectual contraction of the atria results in loss of "atrial kick." If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The client may or may not be aware of the atrial fibrillation. If the ventricular response is rapid, the client may show signs of decreased cardiac output or worsening of heart failure symptoms.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? Feeling of heaviness in both legs Intermittent claudication of the legs Calf pain on dorsiflexion of the foot Hematomas of the lower extremities

A Impaired venous return causes increased pressure, with symptoms of fatigue and heaviness. Pain when walking relieved by rest (intermittent claudication) is a symptom related to hypoxia. Symptoms of hypoxia are related to impaired arterial, rather than venous, circulation. Calf pain on dorsiflexion of the foot is Homans sign, which is suggestive of thrombophlebitis. Ecchymoses may occur in some individuals, but bleeding into tissue is insufficient to cause hematomas.

A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. Which behavior by the client demonstrates an increase in client autonomy? Active participation in providing self-care Verbalizing realistic expectations of caregivers Discussing necessary lifestyle changes with family members Listing the indicators of recovery after a myocardial infarction

A Planning self-care demonstrates decision-making by the client; participating in care enhances feelings of self-worth and autonomy. Expectations do not reflect autonomy. Discussing necessary lifestyle changes with family members does not reflect autonomy; it may be intellectualization. Listing the indicators for recovery after a myocardial infarction does not reflect autonomy; it may be intellectualization.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? Arteriolar constriction occurs. The cardiac workload decreases. Contractility of the heart decreases. The parasympathetic nervous system is triggered.

A The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? Check for a pulse Start cardiac compressions Prepare to defibrillate the client Administer oxygen via an ambu bag

A The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.

A client who lives with the parents is diagnosed with stage III Hodgkin disease with a grossly involved spleen and is scheduled for a splenectomy. After the nurse performs preoperative teaching, the client appears anxious. What is the best approach for the nurse to use at this time? Allow the client to regress at this time and rest quietly. State that that the client seems anxious and ask whether the client would like to talk for a while. Consider the reaction an unconscious response and inquire about the client's relationship with the parents. Understand that anxiety prevented the client from comprehending and repeat the information in simpler terms.

B

A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction (MI). Which statement by the client indicates the nurse needs to follow up? "I want to stay as pain-free as possible." "I am not good at remembering to take medications." "I should not have any problems in reducing my salt intake." "I wrote down my dietary information for future reference."

B

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? Tell the client to drink more fluids. Instruct the client to remain in bed. Gently rub the client's legs for circulation. Tell the client about the dangers of prolonged bed rest.

B

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? Slide slowly to the floor to prevent a fall and injury. Sit on the edge of the bed while they hold the client upright. Bend forward because this will increase blood flow to the brain. Lie down quickly so the legs can be raised above the heart level.

B

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? Hematocrit 46% Hemoglobin 14.1 g/dL (141 mmol/L) Potassium 3.0 mEq/L (3.0 mmol/L) White blood cell 9200/mm 3 (9.2 × 10 9/L)

B A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm 3is within the normal range of 4000 to 11,000 cells/mm 3 (4 to 11 × 10 9/L).

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? The furosemide is causing dehydration. Cloudy urine may be indicative of infection. The client has inadequate hourly urine output. All of the indications are within normal findings.

B Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session? Elevated blood pressure Increased blood viscosity Fragility of the blood cells Immaturity of red blood cells

B Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation. Hypertension usually is related to narrowing or sclerosing of arteries, not to an increased number of blood cells. The fragility of blood cells does not affect the viscosity of the blood. Erythrocyte immaturity is not related to increased viscosity.

The nurse is assessing a client with the diagnosis of left ventricular failure. Which assessment finding does the nurse expect to identify? Crushing chest pain Dyspnea on exertion Jugular vein distention Extensive peripheral edema

B Pulmonary congestion and pulmonary edema occur because of fluid shift from the pulmonary capillary bed to the alveoli, resulting in difficult breathing. Crushing chest pain is a hallmark of myocardial infarction; it is caused by inadequate oxygen supply to the myocardium. Jugular vein distention results from increased pressure in the right atrium associated with right ventricular failure, not left ventricular failure. Extensive peripheral edema is a sign of right, not left, ventricular failure; a weakened right ventricle causes venous congestion in the systemic circulation.

What must the nurse do to determine a client's pulse pressure? Multiply the heart rate by the stroke volume. Subtract the diastolic from the systolic reading. Determine the mean blood pressure by averaging the two. Calculate the difference between the apical and radial rate.

B Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.

A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client? Renin causes a gradual decrease in arterial pressure. Lipid plaque formation occurs within the arterial vessels. Development of atheromas within the myocardium is characteristic. Mobilization of free fatty acid from adipose tissue contributes to plaque formation.

B The term atherosclerosis means a thickening of the arterial lining by lipid plaques, which become atheromas. Arterial pressure increases, not decreases, as a result of renin. Atheromas develop within the lining of the arteries, not within the cardiac muscle tissue. Mobilization of free fatty acids will produce an acid-base imbalance.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? Apples Broccoli Cherries Cauliflower

B Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea Increased urinary output

BCD

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Increase left ventricular filling and improve cardiac output Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Decrease the workload on the heart and promote maximum coronary artery filling Increase venous return to the right atrium and increase pulmonary arterial blood flow

C

A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension? Mild but persistent depression Transient temporary memory loss Occipital headache in the morning Cardiac palpitation during periods of stress

C Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged. Mild but persistent depression is a nonspecific response; it is not physiologically related to increased arterial blood pressure. Transient temporary memory loss occurs with transient ischemic attacks, which may be a later consequence of prolonged hypertension. Cardiac palpitation during periods of stress is a common physiologic effect; it is not specific to hypertension.

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? Cataracts Esophagitis Kidney failure Diabetes mellitus

C Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures, such as tubules, glomeruli, and nephrons, leading to kidney failure. Retinopathy, resulting in blurred vision, retinal hemorrhage, and blindness, occurs with a long history of hypertension because of increased intravascular pressure, not cataracts. Esophagitis is caused by esophageal reflux disease, not a long history of hypertension. Hypertension does not cause diabetes mellitus; however, chronic elevations of serum glucose accelerate atherosclerosis, resulting in the development of hypertension.

A client has a pulse deficit. Which documentation by the nurse supports this finding? Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. Capillary refill greater than 3 seconds indicating pulse deficit. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.

C The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.

A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent? Pulmonary edema Myocardial infarction Deep vein thrombosis Right ventricular heart failure

D

A nurse is assessing the needs of a client who just learned that a tumor is malignant and has metastasized to several organs and that the illness is terminal. What behavior does the nurse expect the client to exhibit during the initial stage of grieving? Crying uncontrollably Criticizing medical care Refusing to receive visitors Asking for a second opinion

D

The primary healthcare provider prescribes two units of packed red blood cells for a client who is bleeding. Before blood administration, what is the nurse's priority? Obtaining the client's vital signs Letting the blood reach room temperature Monitoring the hemoglobin and hematocrit levels Determining proper typing and crossmatching of blood

D

A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations? Long-term use of an irritant-type laxative Emotional response resulting in physical symptoms Inadequate dietary practices resulting in altered bowel function Systemic responses of the body to a localized inflammatory process

D With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).