med - surge week 3 question
The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? A. Right atrial pressure is 4 mm Hg. B. Mean arterial pressure (MAP) is 58 mm Hg. C. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. D. PO2 is reported as 78 mm Hg.
B
The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? A. Inferior wall B. Anterior wall C. Lateral wall D. Posterior wall
B
The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? A. ST segment B. Heart rate C. Troponin D. Myoglobin
B
The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? A. Defibrillate the patient at 200 joules. B. Check the patient for a pulse. C. Cardiovert the patient at 50 joules. D. Give the patient IV lidocaine.
B
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? A. Ibuprofen (Motrin) B. Hydrochlorothiazide (HydroDIURIL) C. NPH insulin D. Levothyroxine (Synthroid)
A
The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the primary health care provider by the nurse for further instructions? A. Calcium 8.5 mEq/L (4.25 mmol/L) B. Potassium 3.0 mEq/L (3.0 mmol/L) C. Magnesium 2.1 mEq/L (1 mmol/L) D. International normalized ratio (INR) of 1.0
B
The nurse understands that which assessment finding is the best indicator of fluid retention? A.Tachycardia B.Weight gain C.Crackles in the lungs D.Increased blood pressure
B
Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? A. Client with abdominal pain and belching B. Client with pressure in the mid-abdomen and profound diaphoresis C. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows D. Client with claudication and fatigue
B
Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with heart failure who is receiving dobutamine (Dobutrex) B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea C. Client with pericarditis who has a paradoxical pulse and distended jugular veins D. Client with rheumatic fever who has a new systolic murmur
B
The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? A. Auscultate the client's precordium for murmurs. B. Teach the client about the reason for the TEE. C. Reassure the client that the test is painless. D. Validate that the client has remained NPO.
D
A client who is suffering from dyspnea on exertion and congestive heart failure (CHF) will most likely report which symptom during the health history? A. Fatigue B. Swelling of one leg C. Slow heart rate D. Brown discoloration of lower extremities
A
A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? A. "This is a big warning; I must modify my lifestyle or I am at risk for having a heart attack." B. "Angina is just a temporary interruption of blood flow to my heart." C. "I need to tell my wife I've had a heart attack." D. "Because this was temporary, I will not need to take any medications for my heart."
A
A patient admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? A. Prepare for defibrillation. B. Establish IV access. C. Place an oral airway and ventilate. D. Start cardiopulmonary resuscitation (CPR).
A
A patient is admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF). The patient states, "I feel fine, this rhythm won't hurt me." Which nursing response is appropriate? A. "AF can cause clots to form from the irregular blood flow in the heart." B. "It's important to monitor the AF for 24 hours." C. "AF leads the death of the heart muscle." D. "AF can cause cardiac output to increase."
A
A patient who smokes asks the nurse, "Smoking just hurts my lungs, not my heart, right?" Which nursing response is appropriate? A. "Smoking is a major risk factor for coronary artery disease and peripheral vascular disease." B. "You are correct, smoking only hurts the lungs." C. "The primary impact of smoking is only on the heart." D. "What concerns you most about smoking?"
A
After receiving change-of-shift report about these four clients, which client would the nurse assess first? A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D. A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min
A
After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? A. The client with acute coronary syndrome who has a 3-pound (1.4 kg) weight gain and dyspnea B. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled C. The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min D. A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction
A
The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? A. "I need to avoid eating hamburgers." B. "I must cut out bacon and canned foods." C. "I won't put the salt shaker on the table anymore." D. "I need to avoid lunchmeats but may cook my own turkey."
A
The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? A. Defibrillation B. Cardiopulmonary resuscitation (CPR) C. Administration of epinephrine D. Administration of oxygen
A
The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse plan to administer? A. Heparin B. Atropine C. Dobutamine D. Magnesium sulfate
A
The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? A. "I will call the provider if I have a cough lasting 3 or more days." B. "I will report to the provider weight loss of 2 to 3 pounds (0.9 to 1.4 kg) in a day." C. "I will try walking for 1 hour each day." D. "I should expect occasional chest pain."
A
The nurse working in the outpatient setting identifies which dysrhythmia as the most commonly diagnosed? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular fibrillation
A
Which client has the highest risk for cardiovascular disease? A. Man who smokes and whose father died at 49 of myocardial infarction (MI) B. Woman with abdominal obesity who exercises three times per week C. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL (1.94 mmol/L) D. Man who is sedentary and reports four episodes of strep throat
A
Which laboratory finding is consistent with acute coronary syndrome (ACS)? A. Troponin 3.2 ng/mL (3.2 mcg/L) B. C-reactive protein 13 mg/dL (130 mg/L) C. Triglycerides 400 mg/dL (4.52 mmol/L) D. Lipoprotein-a 18 mg/dL (0.64 mcmol/L)
A
Which patient is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit? A. The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min B. The 71-year-old patient admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min C. The 88-year-old patient admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min D. The 92-year-old patient admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min
A
Which statement reflects correct cardiac physical assessment technique? A. Auscultate the aortic valve in the second intercostal space at the right sternal border. B. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. C. Palpate the apical pulse over the third intercostal space in the midclavicular line. D. Assess for carotid bruit by auscultating over the anterior neck.
A
When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction (MI)? Select all that apply. A. Oxygen B. Morphine sulfate C. Nitroglycerin D. Naloxone E. Acetaminophen F. Verapamil (Calan, Isoptin)
A, B
The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Select all that apply. A. Chest discomfort or pain B. Tachycardia C. Expectorating thick, yellow sputum D. Sleeping on back without a pillow E. Fatigue
A, B, E
The nurse is caring for a patient who has developed a bradycardia. Which possible causes does the nurse investigate? Select all that apply. A. Bearing down for a bowel movement B. Possible inferior wall myocardial infarction (MI) C. Patient stating that he just had a cup of coffee D. Patient becoming emotional when visitors arrived E. Diltiazem (Cardizem) administered 1 hour ago
A, B, E
The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. A. Blurred vision B. Tachycardia C. Fatigue D. Serum digoxin level of 1.5 ng/ml (1.92 nmol/L) E. Anorexia
A, C, E
The nurse is caring for a patient with heart rate of 143 beats/min. For which manifestations does the nurse observe? Select all that apply. A. Palpitations B. Increased energy C. Chest discomfort D. Flushing of the skin E. Hypotension
A, C, E
The nurse in the coronary care unit is caring for a group of clients who have had a myocardial infarction. Which client does the nurse see first? A. Client with normal sinus rhythm and PR interval of 0.28 second B. Client with third-degree heart block on the monitor C. Client with dyspnea on exertion when ambulating to the bathroom D. Client who refuses to take heparin or nitroglycerin
B
A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The risk for hypotension C. The potential for bradycardia D. Liver function tests
B
A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? A. Administers oxygen therapy B. Obtains the client's description of the chest discomfort C. Provides pain relief medication D. Remains calm and stays with the client
B
A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? A. Calls the family to lift the client's spirits B. Considers further assessment for depression C. Sedates the client to decrease myocardial oxygen demand D. Tells the client that things will get better
B
A client who is to undergo cardiac catheterization must be taught which essential information by the nurse? A. "Monitor the pulses in your feet when you get home." B. "Keep your affected leg straight for 2 to 6 hours." C. "Do not take your blood pressure medications on the day of the procedure." D. "Take your oral hypoglycemic with a sip of water on the morning of the procedure."
B
A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? A. Serum sodium level of 135 mEq/L (135 mmol/L) B. Serum potassium level of 2.8 mEq/L (2.8 mmol/L) C. Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) D. Serum magnesium level of 1.9 mEq/L (0.95 mmol/L)
B
After a cardiac catheterization, the client needs to increase his or her fluid intake for which reason? A. NPO status will cause the client to be thirsty. B. The dye causes an osmotic diuresis. C. The dye contains a heavy sodium load. D. The pedal pulses will be more easily palpable
B
After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? A. A 1-inch (2.5 cm) backup of blood in the IV tubing B. Facial drooping C. Partial thromboplastin time (PTT) 68 seconds D. Report of chest pressure during dye injection
B
All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the primary care provider before the procedure begins? A. The client has had intermittent substernal chest pain for 6 months. B. The client develops wheezes and dyspnea after eating crab or lobster. C. The client reports that a previous arteriogram was negative for coronary artery disease. D. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.
B
An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is most appropriate for the RN to assign to the LPN/LVN? A. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures B. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index C. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging D. A client with acute coronary syndrome who has just been admitted and needs an admission assessment
B
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? A. Ejection fraction is 25%. B. Client states that she is able to sleep on one pillow. C. Client was hospitalized five times last year with pulmonary edema. D. Client reports that she experiences palpitations.
B
Prompt pain management with myocardial infarction is essential for which reason? A. The discomfort will increase client anxiety and reduce coping. B. Pain relief improves oxygen supply and decreases oxygen demand. C. Relief of pain indicates that the MI is resolving. D. Pain medication would not be used until a definitive diagnosis has been established.
B
The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? A. Urine output of 1500 mL on the preceding day B. Crackles in the lung fields C. Pedal edema D. Expectoration of yellow sputum
B
The home health nurse visits a client with heart failure who has gained 5 pounds (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? A. Assess the client for peripheral edema. B. Auscultate the client's posterior breath sounds. C. Notify the health care provider about the client's weight gain. D. Remind the client about dietary sodium restrictions.
B
The nurse expects what outcome in a patient who is taking a beta blocker for mild heart failure? A. Improved urinary output B. Improved activity tolerance C. Increased myocardial contractility D. Increased myocardial oxygen
B
The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action would be taken by he nurse? A. No intervention is needed; this is a normal reading. B. Collaborate with the primary health care provider to administer a positive inotropic agent. C. Administer a STAT dose of metoprolol (Lopressor). D. Ask the client to perform the Valsalva maneuver.
B
The nurse is assessing a patient who received a heart transplant. Which symptom suggests that the patient may be experiencing organ rejection? A.Fever B.Weight gain C.Tachycardia Hypertension
B
Which client would the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? A. Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted B. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes C. Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain D. Client who has many questions about the electrophysiology studies (EPS) scheduled for today
B
Which medication, when given in heart failure, may improve morbidity and mortality? A. Dobutamine (Dobutrex) B. Carvedilol (Coreg) C. Digoxin (Lanoxin) D. Bumetanide (Bumex)
B
Which statement about diagnostic cardiovascular testing is correct? A. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. C. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. D. The left side of the heart is catheterized first and may be the only side examined.
B
Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? A. "I don't know how I am going to change my lifestyle." B. "I don't need to change. It hasn't killed me yet." C. "I don't think it is as bad as the doctors say." D. "I will have to change my diet and exercise more."
B
Which teaching is essential for a patient who has had a permanent pacemaker inserted? A. Avoid talking on a cell phone. B. Avoid operating electrical appliances over the pacemaker. C. Avoid sexual activity. D. Do not take tub baths.
B
The nurse administers amiodarone (Cordarone) to a patient with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. A. Respiratory rate B. QT interval C. Heart rate D. Heart rhythm E. Urine output
B, C, D
Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? Select all that apply. A. Sharp, inspiratory chest pain B. Dyspnea C. Dizziness D. Extreme fatigue E. Anorexia
B, C, D
Which risk factors are known to contribute to atrial fibrillation? Select all that apply. A. Use of beta-adrenergic blockers B. Excessive alcohol use C. Advancing age D. High blood pressure E. Palpitations
B, C, D
Which signs and symptoms are seen with suspected pericarditis? Select all that apply. A. Squeezing, vise-like chest pain B. Chest pain relieved by sitting upright C. Chest and abdominal pain relieved by antacids D. Sudden-onset chest pain relieved by anti-inflammatory agents E. Pain in the chest described as sharp or stabbing
B, D, E
Which of these factors contribute to the risk for cardiovascular disease? Select all that apply. A. Consuming a diet rich in fiber B. Elevated C-reactive protein levels C. Low blood pressure D. Elevated high-density lipoprotein (HDL) cholesterol level E. Smoking
B, E
A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and must be communicated immediately to the primary health care provider? A. White blood cell count B. Low-density lipoproteins C. Serum troponin I level D. C-reactive protein
C
A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? A. Maintains NPO (nothing by mouth) until this resolves B. Calls in another nurse for a second opinion C. Performs a complete neurologic assessment and notifies the primary care provider D. Explains to the client and family that this is expected after sedation
C
A client with heart failure reports a 7.6-pound (3.4 kg) weight gain in the past week. What intervention does the nurse anticipate from the primary health care provider? A. Dietary consult B. Sodium restriction C. Daily weight monitoring D. Restricted activity
C
A patient with atrial fibrillation (AF) with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? A. Synchronized cardioversion B. Electrophysiology studies (EPS) C. Anticoagulation D. Radiofrequency ablation therapy
C
A patient's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia D. Sinus rhythm with premature ventricular contractions
C
An LPN/LVN is scheduled to work on the inclient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? A. A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain. B. A 62-year-old who underwent open-heart surgery 4 days ago for mitral valve replacement and who has a temperature of 100.8°F (38.2°C). C. A stable 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is stable and scheduled for discharge to a group home later today. D. A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia.
C
An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? A. No action is required; low blood pressure is normal for older adults. B. No action is required for postsurgical CABG clients. C. Assess pulmonary artery wedge pressure (PAWP). D. Give ordered loop diuretics.
C
The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? A. "How does this make you feel?" B. "This can be caused by taking performance-enhancing drugs." C. "This may be caused by a genetic trait." D. "Just imagine how bad it would be if you weren't in good shape."
C
A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction (MI)? A. C-reactive protein of 1 mg/dL (10 mg/L) B. Homocysteine level of 13 mcmol/L C. Creatine kinase (CK) of 125 units/L D. Troponin of 5.2 ng/mL (5.2 mcg/L)
D
The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, with pink, frothy sputum, and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings Diagnostic Findings Provider Prescriptions Crackles in all fieldsS3 present Oliguria Ejection fraction 30%BNP 560Sodium 130 mEq/L (130 mmol/L)Diagnosis: heart failure Enalapril 10 mg orally daily Heparin 5000 units subcutaneously every 12 hours Furosemide 40 mg IV daily Strict I & O A. Enalapril B. Heparin C. Furosemide D. Intake and output (I & O)
C
The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? A. Friction rub auscultated at the left lower sternal border B. Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Thickening of the endocardium
C
The nurse is assessing a patient's heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate? A. Listen at the base of the heart. B. Listen only for higher pitched sounds. C. Ask the patient to lay on his left side. D. Ask the patient to hold their breath for 15 seconds
C
The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? A. The need to increase activities slowly at home B. Planning and participating in a walking program C. Placing a chair in the shower for independent hygiene D. Consultation with social worker for disability planning
C
The nurse is teaching a group of teens about prevention of heart disease. Which point is most important for the nurse to emphasize? A. Reduce abdominal fat. B. Avoid stress. C. Do not smoke or chew tobacco. D. Avoid alcoholic beverages.
C
The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? A. The patient is semi-recumbent in bed. B. Chest leads are placed as for the previous ECG. C. The patient is instructed to breathe deeply through the mouth. D. The patient is instructed to lie still.
C
The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action would be performed first? A. Assess coping skills. B. Assess for postoperative pain at the client's incision site. C. Monitor the heart rate for dysrhythmias. D. Monitor mental status.
C
What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin? A. "It is important to consume a diet high in green leafy vegetables." B. "You would take aspirin or ibuprofen for headache." C. "Report nosebleeds to your provider immediately." D. "Avoid caffeinated beverages."
C
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? A. Auscultation of crackles B. Pedal edema C. Weight loss of 6 pounds (2.7 kg) since the last visit D. Reports sucking on ice chips all day for dry mouth
C
Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? A. Serum potassium level of 3.2 mEq/L (3.2 mmol/L) B. Ejection fraction of 60% C. B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) D. Chest x-ray report showing right middle lobe consolidation
C
Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A. Monitor pulse oximetry and cardiac rate and rhythm. B. Reassure the client that his distress can be relieved with proper intervention. C. Place the client in high-Fowler's position with the legs down. D. Ask a family member to remain with the client.
C
Which intervention provides safety during cardioversion? A. Setting the defibrillator at 220 joules B. Obtaining informed consent C. Setting the defibrillator to the synchronized mode D. Removing oxygen
C
Which nursing action may be delegated to an unlicensed assistive personnel (UAP) working on the medical unit? A. Determine the usual alcohol intake for a client with cardiomyopathy. B. Monitor the pain level for a client with acute pericarditis. C. Obtain daily weights for several clients with class IV heart failure. D. Check for peripheral edema in a client with endocarditis.
C
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. The client ambulates around the nursing unit with a walker. B. The nurse monitors the client's pulse and blood pressure frequently. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when the client becomes tachycardic.
C
Which statement best reflects correct client education for a client with a blood pressure (BP) of 136/86 mm Hg? A. This blood pressure is good because it is a normal reading. B. This blood pressure indicates that the client has hypertension or high blood pressure. C. This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle. D. This blood pressure seems a little low; the client must be further assessed for orthostatic hypotension.
C
Which waveform indicates proper function of the sinoatrial (SA) node? A. The QRS complex is present. B. The PR interval is 0.24 second. C. A P wave precedes every QRS complex. D. The ST segment is elevated.
C
Which of the following symptoms would the nurse anticipate in a patient with right-sided heart failure? (Select all that apply.) A. Pulmonary congestion B. Shortness of breath C. Neck vein distension D. Enlarged abdominal girth E. A third heart sound
C, D
How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia? A. The patient states he is dizzy and weak. B. The nurse notes dyspnea. C. The patient has a heart rate of 42 beats/min. D. The monitor shows an increase in heart rate.
D
In teaching patients at risk for bradydysrhythmias, what information does the nurse include? A. "Avoid potassium-containing foods." B. "Stop smoking and avoid caffeine." C. "Take nitroglycerin for a slow heartbeat." D. "Use a stool softener."
D
On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse's first action? A. Synchronized cardioversion B. CPR and immediate defibrillation C. Administration of IV amiodarone (Cordarone) and dextrose D. Administration of oxygen and observation of the heart rhythm
D
A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? A. The client has diuresis of 400 mL in 24 hours. B. The client's blood pressure is 122/84 mm Hg. C. The client has an apical pulse of 82 beats/min. D. The client's weight decreases by 2.5 kg.
D
The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? A. Pulse 60 beats/min and regular B. Urinary frequency C. Incisional discomfort D. Respiratory rate 28 breaths/min
D
The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? A. Determines the client's physical limitations B. Encourages alternate rest and activity periods C. Monitors and documents heart rate, rhythm, and pulses D. Positions the client to alleviate dyspnea
D
The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the primary health care provider? A. Saline infusion B. Morphine sulfate C. No treatment, continue monitoring D. Intravenous furosemide
D
The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are as follows: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action does the nurse take? A. Administer atropine. B. Administer digoxin. C. Administer clonidine. D. Continue to monitor.
D
The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information would be included? A. Men do not tend to report chest pain. B. Men are more likely than women to die after MI. C. Men more than women tend to deny the importance of symptoms. D. Women may experience extreme fatigue and dizziness as sole symptoms.
D
The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? A. "This is a noninvasive test performed to assess your heart rhythm." B. "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." C. "This is a painless test that is done to assess the structure of your heart using sound waves." D. "This test evaluates you for potentially fatal cardiac rhythms."
D
The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education? A. "I will be able to shower again soon." B. "I need to take my pulse every day." C. "I might trigger airport security metal detectors." D. "I no longer need my heart pills."
D
The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8°F (37.7°C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action does the nurse take? A. Give the digoxin; reassess the heart rate in 30 minutes. B. Give the digoxin; document assessment findings in the medical record. C. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. D. Hold the digoxin, and obtain a prescription for a potassium supplement.
D
The nurse receives a report that a patient with a pacemaker has experienced loss of capture. Which situation is consistent with this? A. The pacemaker spike falls on the T wave. B. Pacemaker spikes are noted, but no P wave or QRS complex follows. C. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. D. The patient demonstrates hiccups.
D
To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? A. Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase B. Homocysteine and C-reactive protein C. Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol D. Troponin
D
Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? A. Assess preprocedure medications the client took that day. B. Have the client sign the consent form before the procedure is performed. C. Educate the client about the need to remain on bedrest after the procedure. D. Obtain client vital signs and a resting electrocardiogram (ECG).
D
Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? A. "I will be awake during this procedure." B. "I will have a balloon in my artery to widen it." C. "I must lie still after the procedure." D. "My angina will be gone for good."
D
