Med Surg: Exam #3 chapter 25
Heart failure
A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult patient who has been experienced vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis?
-Pneumothorax -Infection -Air embolism
A critical care nurse is caring for a patient with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply.
Left ventricular preload
A critical care nurse is caring for a patient with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill patients?
Perfusion distal to the insertion site
A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care?
After a 12-hour fast
A lipid profile has been ordered for a patient who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results?
Assess the color and temperature of the left leg.
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. Which action should the nurse take?
Pulse decreased from 100 beats/min to 80 beats/min
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
Heart rate of 120 beats/min
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
Location A
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
b. Serum potassium of 2.9 mEq/L d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor
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.)
Slurred speech and confusion
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
Compare the results with previous pulmonary artery pressure readings.
A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
Allergies to iodine-based agents
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
Assess the client's medications.
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first?
Disorientation and confusion
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
A 45-year-old American Indian woman with diabetes mellitus
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
Document the finding.
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.)
"Use pillows to elevate your head and chest while you are sleeping."
A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble sleeping at night." How should the nurse respond?
Initiation of an external pacemaker
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 should the nurse be prepared to implement while this client waits for surgery?
Notify the health care provider before scheduling the MRI.
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. Which action should the nurse take?
"What do you understand about what happened to you?"
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." How should the nurse respond?
a. Thrombophlebitis c. Pulmonary embolism e. Cardiac tamponade
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.)
Systole
A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what?
Inform the patient that she will remain on bed rest following the procedure.
A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the nurse perform?
"My shoes fit tighter by the end of the day."
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
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 prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.)
"Tell me more about your concerns about the surgery."
A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." How should the nurse respond?
31 drops/min
A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min
a. Total cholesterol: 280 mg/dL c. Triglycerides: 200 mg/dL e. Low-density lipoprotein cholesterol: 160 mg/dL
A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
Establish peripheral IV access
A patient has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the patient for this test, what action should the nurse perform?
Myocardium
A patient has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. You are aware that the damage occurred where?
Hardwire continuous ECG monitoring
A patient is brought into the ED by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain. The care team recognizes the need to monitor the patient's cardiac function closely while interventions are performed. What form of monitoring should the nurse anticipate?
The test is noninvasive, and nothing will be inserted into the patient's body.
A patient with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the patient in anticipation of this diagnostic procedure?
The cycle of depolarization and repolarization
A patient's declining cardiac status has been attributed to decreased cardiac action potential. Interventions will be aimed at restoring what aspect of cardiac physiology?
The pain occurs immediately following physical exertion.
A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause?
A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
"I get short of breath when I climb stairs."
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
Left midclavicular line of the chest at the fifth intercostal space
During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI?
SA node to AV node to bundle of His to Purkinje fibers
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence?
SA node
The critical care nurse is caring for a patient who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located?
Pulmonary artery pressure monitoring (PAPM)
The critical care nurse is caring for a patient who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the patient's left ventricular function?
Hypervolemia
The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patient's CVP is increasing. Of what may this indicate?
To assess the patient's response to fluid and drug administration
The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function. What is an additional function of pulmonary artery pressure monitoring systems?
46 mm Hg
The nurse is calculating a cardiac patient's pulse pressure. If the patient's blood pressure is 122/76 mm Hg, what is the patient's pulse pressure?
Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are.
The nurse is caring for a patient admitted with angina who is scheduled for cardiac catheterization. The patient is anxious and asks the reason for this test. What is the best response?
This is an accurate indicator of myocardial injury.
The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding?
A heart rate of 54 bpm
The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?
Assess the patient for fluid overload and inform the physician.
The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurse's most recent assessment reveals that CVP is 7 mm Hg. What is the nurse's most appropriate action?
Stop the test and monitor the patient closely.
The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurse's most appropriate response?
Widening of the aorta
The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult?
Change the site dressing whenever it becomes visibly soiled.
The nurse is caring for an acutely ill patient who has central venous pressure monitoring in place. What intervention should be included in the care plan of a patient with CVP in place?
Increased LDL and decreased HDL increase my risk of coronary artery disease.
The nurse is conducting patient teaching about cholesterol levels. When discussing the patient's elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what?
An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks.
The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best response?
Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately
The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?
-Excitability -Automaticity -Conductivity
The nurse is relating the deficits in a patient's synchronization of the atrial and ventricular events to his diagnosis. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization? Select all that apply.
Arterial vasoconstriction
The nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. The nurse is aware that afterload influences a patient's stroke volume. The nurse recognizes that afterload is increased when there is what?
Risk for falls related to orthostatic hypotension
The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patient's plan of care?
-A 12-hour fast is necessary before drawing the blood sample. -Genetic factors can elevate homocysteine levels. -A diet low in folic acid elevates homocysteine levels.
The patient has a homocysteine level ordered. What aspects of this test should inform the nurse's care? Select all that apply.
Myocardial ischemia
The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what?
Inflammation
The physician has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a patient. The results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis?
Possible hypovolemia
The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate?
-Need for careful monitoring for cardiac symptoms -Need for carefully regulated exercise -Need for dietary modifications
The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.)
A transducer A flush system A pressure bag
When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a patient who has such a device in place, the nurse should check which of the following components? Select all that apply.
A 20-year-old patient
While auscultating a patient's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in what patient?
chapter 25
chapter 25
"You should balance weight loss with consuming necessary nutrients."
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 should the nurse include in this client's teaching?
