MEDSURG Prepu: Chapter 25: Caring for Clients with Disorders of Coronary and Peripheral Blood Vessels

The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.)

It is substernal in location. It is sudden in onset and prolonged in duration. It is viselike and radiates to the shoulders and arms. Explanation: Chest pain that occurs suddenly, continues despite rest and medication, is substernal, and is sometimes viselike and radiating to the shoulders and arms is associated with an MI. Angina pectoris pain is generally relieved by rest and nitroglycerin.

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply.

Weight loss Regular exercise Smoking cessation Explanation: Clients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be:

Correct response: Alteplase. Explanation: Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text.

Which of the following assessment results is considered a major risk factor for PAD?

Correct response: BP of 160/110 mm Hg Explanation: Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.

Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?

Correct response: Monitor the site for bleeding or hematoma. Explanation: The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma. A nurse does not advise the client to clean the site with disinfectants or refrain from sexual activity for 1 month.

Which of the following is the most common site for a dissecting aneurysm?

Correct response: Thoracic area Explanation: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

A client has had a 12-lead ECG completed as part of an annual physical examination. The nurse notes an abnormal Q wave on an otherwise unremarkable ECG. The nurse recognizes that this finding indicates

Correct response: an old MI. Explanation: An abnormal Q wave may be present without ST-segment and T-wave changes, which indicates an old, not acute, MI.

The nurse is caring for a client with cellulitis of the left foot. Which treatment will the nurse expect to be prescribed for this client? Select all that apply.

Administer cephalexin Elevate the extremity Apply cool packs every 2 to 4 hours Apply graduated compression stocking to the foot Explanation: Cellulitis occurs when an entry point through broken skin allows microbes to enter and release their toxins in the subcutaneous tissues. The etiologic pathogen of cellulitis is typically either Streptococcus species or Staphylococcus aureus. Treatment of cellulitis includes antibiotics such as cephalexin. The extremity should be elevated 3 to 6 inches above heart level and cool packs applied to the site every 2 to 4 hours until the inflammation subsides. Graduated compression stockings are used to reduce the risk of recurrence of cellulitis. Light massage is not indicated for cellulitis.

A client recovering from percutaneous transluminal coronary angioplasty (PTCA) develops chest pain and an arrhythmia on the electrocardiogram (ECG). Which action(s) will the nurse take to help this client? Select all that apply.

Administer oxygen Obtain a 12-lead ECG Provide nitroglycerine Notify the primary healthcare provider Explanation: In percutaneous transluminal coronary angioplasty (PTCA), a balloon-tipped catheter is used to open blocked coronary vessels and resolve ischemia. It is used in clients with angina, and as an intervention for acute coronary syndrome (ACS). The purpose of PTCA is to improve blood flow within a coronary artery by compressing the atheroma. A client who develops chest pain and a cardiac arrhythmia might be experiencing a myocardial infarction caused by thrombosis or restenosis of a coronary artery. Actions that the nurse should take include administering oxygen, obtaining a 12-lead ECG, providing nitroglycerin, and notifying the cardiologist. Meperidine is not identified as an action to take if a client demonstrates signs of a myocardial infarction after a PTCA. Oxygen is placed to decrease workload of the heart and to perfuse the blood with supplemental oxygen, decreasing the severity of the tissue ischemia. A 12-lead ECG is ordered to monitor heart rhythms. Nitroglycerin is provided as a vasodilator to increase tissue perfusing and to decrease anginal chest pain. The cardiologist should be notified as there is likely a complication of the procedure.

A nurse who works in a busy emergency department provides care for numerous patients who present with complaints of chest pain. Which of the following questions is most likely to help the nurse differentiate between chest pain that is attributable to angina and chest pain due to myocardial infarction (MI)?

Correct response: "Does resting and remaining still help your chest pain to decrease?" Explanation: In most cases, chest pain due to MI is not relieved by rest. Chest pain from angina usually abates with rest. Questions about risk factors or the original onset of the patient's pain do not help differentiate the etiology of a patient's chest pain.

A client is going home with a prescription for nitroglycerin (Nitrostat) for his anginal symptoms. Which of the following statements indicates the client understands the information needed to safely self-medicate?

Correct response: "I should sit down or lie down before taking the nitroglycerin." Explanation: The nurse should encourage the client to sit down or lie down during episodes of angina. Nitroglycerin relaxes smooth muscles and dilates vascular beds; therefore, nitroglycerin causes hypotension and the client could fall, causing injury. Nitroglycerin should be stored in a dark container. It should be taken once every 5 minutes for three doses and is placed sublingually, not swallowed.

The nurse instructs a client with Raynaud phenomenon on actions to improve the symptoms. Which client statement indicates the need for additional instruction?

Correct response: "I will limit the amount of cigarettes I smoke." Explanation: Raynaud phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes. Patients should avoid all forms of nicotine, which may induce attacks; this includes nicotine gum or patches used to aid smoking cessation. The client should be instructed to avoid situations that may be stressful as this could trigger an attack. Wearing gloves before opening a cold car door and when taking food out of the freezer should also be done as this could trigger vasoconstriction and an attack.

In preparation for cardiac surgery, a client was taught about measures to prevent venous thromboembolism. What statement indicates that the client clearly understood this education?

Correct response: "I'll make sure that I don't cross my legs when I'm resting in bed." Explanation: To prevent venous thromboembolism, clients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for angina, the nurse should plan to include which instructions?

Correct response: "See if rest relieves the chest pain before using the nitroglycerin." Explanation: Decreased activity may relieve chest pain; sitting will prevent injury should the nitroglycerin lower BP and cause fainting. The client should expect to feel dizzy or flushed or to develop a headache following sublingual nitroglycerin use. The client should place one nitroglycerin tablet under the tongue if 2-3 minutes of rest fails to relieve pain. Clients may take up to three nitroglycerin tablets within 5 minutes of each other to relieve angina. However, they should call 911 if the three tablets fail to resolve the chest pain.

A client asks the nurse how long to wait after taking nitroglycerin before experiencing pain relief. What is the best answer by the nurse?

Correct response: 5 minutes Explanation: Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch). The nurse should instruct the client to take a second dose five minutes after the first if pain persists. The nurse should instruct the client to take a third dose five minutes after the second if pain still persists. The nurse should advise the client to call 911 if pressure or pain is not releived in 15 minutes by taking 3 tablets at 5-minute intervals.

A client awaiting CABG for coronary artery disease is amazed at the lack of symptoms. The nurse informs the client that symptoms usually do not manifest until an arterial lumen is occluded by at least what percentage?

Correct response: 60 Explanation: Coronary artery disease precedes coronary occlusion which, untreated, leads to myocardial infarction (MI). Symptoms usually do not occur until at least 60% of the arterial lumen is occluded.

An older adult client has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan?

Correct response: A high-protein diet that is rich in vitamins Explanation: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.

The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta?

Correct response: A ripping sensation in the chest Explanation: Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache.

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What is the nurse's priority action?

Correct response: Administer oxygen, attach a cardiac monitor, take vital signs, and alert the cardiac catheterization team. Explanation: Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

A nurse on a medical unit is caring for a client who has been diagnosed with lymphangitis. When reviewing this client's medication administration record, the nurse should anticipate which type of medication?

Correct response: An antibiotic Explanation: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.

The nurse explains to a patient that the primary cause of a varicose vein is:

Correct response: An incompetent venous valve. Explanation: Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

A client is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in client teaching before discharge?

Correct response: Application of graduated compression stockings Explanation: Graduated compression stockings usually are prescribed for clients with venous insufficiency. The required pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may be knee high, thigh high, or pantyhose.

A 79-year-old client is admitted to the medical unit with digital gangrene. The client reports that the problem first began when the client stubbed the toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the client has a history of which health problem?

Correct response: Arterial insufficiency Explanation: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud disease, CAD and varicose veins are not the usual causes of digital gangrene in older adults.

A client reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease?

Correct response: Assess chest pain and administer prescribed drugs and oxygen Explanation: The nurse assesses the client for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing blood pressure or the client's physical history does not clearly indicate that the client has CAD. The nurse does not administer aspirin without a prescription from the physician.

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete?

Correct response: Attempt to palpate the dorsalis pedis and posterior tibial pulses. Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.

A nurse is creating an education plan for a client with venous insufficiency. Which measure should the nurse include in the plan?

Correct response: Avoid normal stockings that are tight. Explanation: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking; sleeping with legs elevated; and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.

The nurse is preparing a teaching plan for a patient with venous insufficiency and plans to address measures to prevent complications from venous insufficiency. What is one measure the nurse should include in the plan?

Correct response: Avoiding tight-fitting socks Explanation: Measures to take to prevent complications include avoiding tight fitting socks and panty girdles, and maintaining activities such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings.

The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments?

Correct response: Balancing myocardial oxygen supply with demand Explanation: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the client with ACS. Treatment is not aimed directly at minimizing heart rate because some clients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardium's energy expenditure is often beneficial, but this must be balanced with productivity.

Pentoxifylline (Trental) is a medication used for which of the following conditions?

Correct response: Claudication Explanation: Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental.

A client is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk?

Correct response: Client's consistent performance of deep-breathing and coughing exercises Explanation: Clearance of pulmonary secretions is accomplished by frequent repositioning of the client, suctioning, and chest physical therapy, as well as educating and encouraging the client to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions.

A nurse has taken on the care of a client who had a coronary artery stent placed yesterday. When reviewing the client's daily medication administration record, the nurse should anticipate administering what drug?

Correct response: Clopidogrel Explanation: Because of the risk of thrombus formation within the stent, the client receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.

A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action?

Correct response: Contact the client's health care provider and continue to assess fluid balance and renal function. Explanation: Nursing management includes accurate measurement of urine output. An output of less than 0.5 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

A nurse is caring for a client who experienced an MI. The client is ordered to received metoprolol. The nurse understands that this medication has which therapeutic effect?

Correct response: Decreases resting heart rate Explanation: The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. In general, the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

The nurse is administering a calcium channel blocker to a patient who has symptomatic sinus tachycardia at a rate of 132 bpm. What is the anticipated action of the drug for this patient?

Correct response: Decreases the sinoatrial node automaticity Explanation: Calcium channel blockers have a variety of effects on the ischemic myocardium. These agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of myocardial contraction (negative inotropic effect).

The nurse working on the coronary care unit is caring for a client with ACS. How can the nurse best meet the client's psychosocial needs?

Correct response: Directly address the client's anxieties and fears. Explanation: Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the client's psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some clients, but it may exacerbate it for others.

A nurse who provides care in a busy postsurgical unit recognizes that patients are at particular risk of thromboembolism during their immediate postoperative recovery. Which of the following interventions best facilitates venous blood flow and the prevention of thrombosis?

Correct response: Early ambulation Explanation: Early ambulation is most effective in preventing venous stasis. Stockings and compression devices are clinically useful interventions for patients who are unable to ambulate, but early mobilization is preferred. Warfarin is not used for the general prevention of DVT in postsurgical patients.

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

Correct response: Elevated ST segment Explanation: Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

A nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. Which intervention is the most appropriate for this diagnosis?

Correct response: Encourage the client to engage in a moderate amount of exercise. Explanation: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the client to engage in a moderate amount of exercise serves to improve circulation. Elevating the client's legs and arms above the heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

A client with advanced venous insufficiency is confined to bed rest following orthopedic surgery. How can the nurse best prevent skin breakdown in the client's lower extremities?

Correct response: Ensure that the client's heels are protected and supported. Explanation: If the client is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.

Which statement is accurate regarding Raynaud disease?

Correct response: Episodes may be triggered by unusual sensitivity to cold. Explanation: Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.

The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response?

Correct response: Explore the factors underlying the client's anxiety. Explanation: An assessment of anxiety levels is required in the client to assist the client in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the client's anxiety before providing interventions such as education or medications.

A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client?

Correct response: Furosemide Explanation: Lymphedema may be primary (congenital malformations) or secondary (acquired obstructions). Tissue swelling occurs in the extremities because of an increased quantity of lymph that results from obstruction of lymphatic vessels. As initial therapy, the diuretic furosemide may be prescribed to prevent fluid overload due to mobilization of extracellular fluid. Opioids are not used to treat lymphedema. Antibiotics would be prescribed only if an infection is present. Anticoagulants are not used to treat lymphedema.

When being assessed by her new nurse practitioner, a woman states that she has had Raynaud's disease for many years, a problem that occasionally affects her quality of life. When performing health education surrounding this problem, what should the nurse emphasize?

Correct response: Helping the woman identify and avoid the specific triggers of her problem Explanation: With appropriate patient teaching and lifestyle modifications, Raynaud's disease is generally benign and self-limiting. The patient is instructed to avoid the stimuli (e.g., cold, tobacco) that provoke vasoconstriction. Raynaud's is not caused by atherosclerosis, and it is not a risk factor for DVT. Anticoagulants do not address the signs, symptoms, or etiology of the disease.

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:

Correct response: Hemorrhage. Explanation: All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention.

The nurse is discussing risk factors for developing CAD with a patient in the clinic. Which results would indicate that the patient is not at significant risk for the development of CAD?

Correct response: High-density lipoprotein (HDL), 80 mg/dL Explanation: A fasting lipid profile should demonstrate the following values (Alberti et al., 2009): LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients); total cholesterol less than 200 mg/dL; HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females; and triglycerides less than 150 mg/dL.

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?

Correct response: Hyperbaric oxygen Explanation: Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production.

While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment finding?

Correct response: Implement interventions relevant to arterial narrowing. Explanation: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and over-the-counter (OTC) medications are not likely causative.

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?

Correct response: In 3 to 5 days Explanation: Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).

The nurse is caring for a client who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?

Correct response: Increase in the size of the artery's lumen Explanation: PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the client's LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?

Correct response: Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

The nurse is caring for an adult patient who had symptoms of unstable angina during admission to the hospital. The most appropriate nursing diagnosis for the discomfort associated with angina is what?

Correct response: Ineffective cardiopulmonary tissue perfusion secondary to coronary artery disease (CAD) Explanation: Ineffective cardiopulmonary tissue perfusion describes the symptoms of discomfort associated with angina. Deficient knowledge describes the patient awareness of disease process and treatment. Anxiety identifies psychological effects of angina, while noncompliance is related to a patient's resistance to changing behaviors/patterns necessary to treat and manage the disease.

A postsurgical client has illuminated the call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the client's left leg is visibly swollen and reddened. Which action by the nurse would be most appropriate?

Correct response: Inform the health care provider that the client has signs and symptoms of venous thromboembolism (VTE). Explanation: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the client's leg and mobilizing the client would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.

A client has been recently placed on nitroglycerin. Which instruction by the nurse should be included in the client's teaching plan?

Correct response: Instruct the client on side effects of flushing, throbbing headache, and tachycardia. Explanation: The client should be instructed about side effects of the medication, which include flushing, throbbing headache, and tachycardia. The client should renew the nitroglycerin supply every 6 months. If the pain is severe, the client can crush the tablet between the teeth to hasten sublingual absorption. Tablets should never be removed and stored in metal or plastic pillboxes. Nitroglycerin is very unstable and should be carried in its original container.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?

Correct response: Intermittent claudication Explanation: The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

The nurse is preparing to administer warfarin to a client with deep vein thrombophlebitis. Which laboratory value would most clearly indicate that the client's warfarin is at therapeutic levels?

Correct response: International normalized ratio (INR) between 2 and 3 Explanation: The INR is most often used to determine whether warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

Correct response: International normalized ratio (INR) is 2.5. Explanation: Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

The triage nurse in the ED assesses an adult client who presents with reports of midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms are due to an MI, what will have happened to the myocardium?

Correct response: It may have developed an increased area of infarction during the time without treatment. Explanation: When the client experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.

The triage nurse in the emergency department assesses a 66-year-old male patient who has presented to the emergency department with complaints of midsternal chest pain that has lasted for the last 5 hours. The care team suspects a myocardial infarction (MI). The nurse is aware that, because of the length of time the patient has been experiencing symptoms, the following may have happened to the myocardium:

Correct response: May have developed an increased area of infarction Explanation: When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated the more likely the treatment will prevent or minimize myocardial tissue necrosis. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage.

A client with type 2 diabetes and hypertension (HTN) has a routine follow-up appointment after a cardiac stent placement. On assessment the nurse notes the client weighs 250 lb/113.4 kg with a waist circumference of 40 inches/101.6 cm, blood pressure is 162/84 mm Hg, and fasting blood glucose is 220 mg/dl. Based on these findings, which syndrome should the nurse most suspect?

Correct response: Metabolic syndrome Explanation: A cluster of metabolic abnormalities known as metabolic syndrome is a major risk factor for cardiovascular disease. This diagnosis is made when the client has 3 of the 5 risk factors. These factors include a waist circumference of greater than 35.4 inches/89.9 cm, elevated triglycerides, reduced high-density lipoprotein cholesterol, HTN with a systolic blood pressure above 130 mm Hg, and fasting glucose greater than 100 mg/dL or drug treatment for elevated glucose. Adams-Nance syndrome is an inherited disorder characterized by paroxysmal tachycardia, arterial HTN, syncope, and seizures. Alagille syndrome is a rare genetic disorder that can affect multiple organ systems including the liver, heart, skeleton, eyes, and kidneys. Based on the information presented neither of the above syndromes is likely. Postpericardiotomy syndrome may occur to clients days or weeks after surgery, so a possibility exists, but the signs and symptoms are not presented. Postpericardiotomy is characterized by fever, pericardial/pleural/joint pain, friction rub, and dyspnea.

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?

Correct response: Moderate to severe arterial insufficiency Explanation: Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.

The ED nurse is caring for a client with a suspected MI. What drug should the nurse anticipate administering to this client?

Correct response: Morphine Explanation: The client with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.

An adult client is admitted to the ED with chest pain. The client states that there was unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?

Correct response: Morphine sulphate, oxygen, and bed rest Explanation: The client with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?

Correct response: Obesity Explanation: Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes early evidence of gangrene on one of the resident's great toes. The nurse should assess for further evidence of which health problem?

Correct response: Peripheral artery disease (PAD) Explanation: In older adults, symptoms of PAD may be more pronounced than in younger people. In older adult clients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud phenomenon do not cause the ischemia that underlies gangrene.

The hospital nurse is caring for a client who reports that an angina attack is beginning. Which action is the nurse's most appropriate initial action?

Correct response: Place the client on bed rest in a semi-Fowler position. Explanation: When a client experiences angina, the client is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. There is no need to have the client put the head between the legs because cerebral perfusion is not lacking

The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received?

Correct response: Protamine sulfate Explanation: Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation after coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect?

Correct response: Reducing the heart's workload by decreasing heart rate and myocardial contraction Explanation: Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are given to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.

Which of the following is the most effective intervention for preventing progression of vascular disease?

Correct response: Risk factor modification Explanation: Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.

The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse?

Correct response: ST elevation Explanation: The first signs of an acute MI are usually seen in the T wave and the ST segment. The T wave becomes inverted; the ST segment elevates (it is usually flat). An elevated ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e., ST-elevation MI). This client requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.

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?

Correct response: Stabilizing heart rate and blood pressure and easing anxiety Explanation: For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.

A client reports chest pain that occurs when playing tennis but resolves when sitting down. The nurse knows these symptoms are common for which type of angina?

Correct response: Stable Explanation: Angina is usually caused by atherosclerotic disease and most often is associated with a significant obstruction of at least one major coronary artery. Normally, the myocardium extracts a large amount of oxygen from the coronary circulation to meet its continuous demands. When demand increases, flow through the coronary arteries needs to be increased. When there is a blockage in a coronary artery, flow cannot be increased and ischemia results. There are different types of angina. Stable angina is predictable and consistent pain that occurs on exertion and is relieved by rest or nitroglycerin. This is the type of angina the client is describing. Variant angina is pain at rest with reversible ST-segment elevation and is thought to be caused by a spasm of a coronary artery. In unstable angina, the symptoms increase in frequency and severity and may not be relieved with rest or nitroglycerin. Intractable angina pectoris causes severe incapacitating chest pain.

A nurse is closely monitoring a client who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the client's aneurysm?

Correct response: Sudden onset of severe back or abdominal pain Explanation: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.

The nurse is caring for a client who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?

Correct response: T-wave inversion Explanation: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?

Correct response: T-wave inversion Explanation: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?

Correct response: Teach the client how to apply an elastic sleeve Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The client is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best action?

Correct response: Teach the client that circulatory changes during pregnancy frequently cause varicose veins. Explanation: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for ABI assessment and increased activity will not likely resolve the problem.

A nurse is reviewing the physiologic factors that affect a client's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference?

Correct response: The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood Explanation: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause?

Correct response: The aneurysm may be preparing to rupture. Explanation: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized to the middle or lower abdomen to the left of the midline. Low-back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing AAA include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.

When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information?

Correct response: The client's symptoms and the activities that precipitate attacks Explanation: The nurse must gather information about the client's symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The client's coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

A patient with angina is beginning nitroglycerin. Before administering the drug, the nurse informs the patient that, immediately after administration, the patient may experience what?

Correct response: Throbbing headache or dizziness Explanation: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the patient usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.

Thrombolytic therapy is being prepared for administration to an older adult patient who has presented to the emergency department with an ST-segment elevation MI (STEMI). The nurse recognizes that the primary goal of this intervention is:

Correct response: To restore the flow of blood through the coronary arteries Explanation: The purpose of thrombolytics is to dissolve and lyse the thrombus in a coronary artery (thrombolysis), allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction, and preserving ventricular function. Thrombolytics are not primarily a pain-control measure, and function cannot be restored to infarcted cardiac cells.

The client has had biomarkers tested after reporting chest pain. Which diagnostic marker of myocardial infarction remains elevated for as long as 2 weeks?

Correct response: Troponin Explanation: Troponin remains elevated for a long period, often as long as 2 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin peaks within 12 hours after the onset of symptoms. Total creatine kinase (CK) returns to normal in 3 days. CK-MB returns to normal in 3 to 4 days.

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities?

Correct response: Ulceration Explanation: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.

A client presents to the clinic reporting the inability to grasp objects with the right hand. The client's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with the left arm. The nurse should expect that the primary provider may diagnose the client with which health problem?

Correct response: Upper extremity arterial occlusive disease Explanation: The client with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynaud disease or lymphedema. The upper extremities are rare sites for VTE.

A nurse is assessing a new client who is diagnosed with peripheral artery disease. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment?

Correct response: Use Doppler ultrasound to identify the pulses. Explanation: When pulses cannot be reliably palpated, a hand-held continuous wave Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Correct response: Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy?

Correct response: a client with a chronic, nonhealing skin lesion Explanation: Chronic, nonhealing skin lesions are treated with topical hyperbaric oxygen therapy. This approach delivers oxygen above atmospheric pressure directly to the wound rather than to the full body as with other disorders such as carbon monoxide poisoning. Necrotic tissue is debrided from a stasis ulcer. A client's infection is treated with an application of Silvadene, an antibacterial cream, or an antibiotic ointment and an occlusive transparent dressing such as Tegaderm that traps moisture and speeds healing.

The laboratory values for a client diagnosed with coronary artery disease (CAD) have just come back from the lab. The client's low-density lipoprotein (LDL) level is 112 mg/dL. The nurse recognizes that this value is

Correct response: above the optimal range. Explanation: If the fasting LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered above the optimal range. The ideal is to decrease the LDL level below 100 mg/dL (< 70 mg/dL for very high-risk patients).

A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD?

Correct response: ankle-brachial index Explanation: The client's symptoms indicate possible peripheral artery disease (PAD). The ankle-brachial index is a simple, noninvasive test used for this diagnosis. An exercise electrocardiography may be ordered for a client with possible CAD. An EBCT is a radiologic test that produces x-rays of the coronary arteries using an electron beam. It is used to diagnose for CAD. Clients with suspected venous insufficiency will undergo photoplethysmography, a diagnostic test that measures light that is not absorbed by hemoglobin and consequently is reflected back to the machine.

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine

Correct response: causes vasospasm. Explanation: Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Nicotine has stimulant effects. Nicotine does not suppress cough; rather, smoking irritates the bronchial tree, causing coughing. Nicotine does not cause diuresis.

A client who has been diagnosed with Prinzmetal's angina will present with which symptom?

Correct response: chest pain that occurs at rest and usually in the middle of the night Explanation: A client with Prinzmetal's angina will complain of chest pain that occurs at rest, usually between 12 and 8:00 AM, is sporadic over 3-6 months, and diminishes over time. Clients with stable angina generally experience chest pain that lasts 15 minutes or less and may radiate. Clients with Cardiac Syndrome X experience prolonged chest pain that accompanies exercise and is not always relieved by medication. Clients with unstable angina experience chest pain of increased frequency, severity, and duration that is poorly relieved by rest or oral nitrates.

The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:

Correct response: diet therapy and smoking cessation. Explanation: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostic findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

The physician has ordered a radiograph for a client. The nurse would expect this client to have presented with which symptoms?

Correct response: dysphagia Explanation: A thoracic aortic aneurysm can cause bronchial obstruction, dysphagia (difficulty swallowing), and dyspnea. An abdominal aortic aneurysm can produce nausea and vomiting from pressure exerted on the intestines. An abdominal aortic aneurysm can cause severe back pain from pressure on the vertebrae or spinal nerves. Many clients with a dissecting aneurysm become suddenly and acutely ill.

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals:

Correct response: elevational pallor. Explanation: If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor on elevation and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

Correct response: forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

A client's lipid profile reveals an LDL level of 122 mg/dL. This is considered a:

Correct response: high LDL level. Explanation: LDL levels above 100 mg/dL are considered high. The goal is to decrease the LDL level below 100 mg/dL.

A client presents to the ED with a myocardial infarction. Prior to administering a prescribed thrombolytic agent, the nurse must determine whether the client has which absolute contraindication to thrombolytic therapy?

Correct response: prior intracranial hemorrhage Explanation: History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. An allergy to iodine, shellfish, radiographic dye, and latex are of primary concern before a cardiac catheterization but not a known contraindication for thrombolytic therapy. Administration of a thrombolytic agent with heparin increases risk of bleeding; the primary healthcare provider usually discontinues the heparin until thrombolytic treatment is completed.

The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the emergency room. What is the most important cardiac marker for the client?

Correct response: troponin Explanation: This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin tests can show evidence of muscle injury, but the studies are less specific indicators of myocardial damage than troponin.

A client who is resting quietly reports chest pain to the nurse. The cardiac monitor indicates the presence of reversible ST-segment elevation. What type of angina is the client experiencing?

Correct response: variant angina Explanation: Variant or Prinzmetal's angina is distinguished by pain occurrence during rest. Stable angina occurs with activity. Silent angina occurs without symptoms, and intractable angina is evidenced by incapacitating pain.

The nurse is evaluating a client's diagnosis of arterial insufficiency with reference to the adequacy of the client's blood flow. On what physiologic variables does adequate blood flow depend? Select all that apply.

Efficiency of heart as a pump Adequacy of circulating blood volume Patency and responsiveness of the blood vessels Explanation: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.

Tobacco use Obesity Hyperlipidemia Explanation: Modifiable risk factors for coronary artery disease include hyperlipidemia, tobacco use, hypertension, diabetes mellitus, metabolic syndrome, obesity, and physical inactivity. Nonmodifiable risk factors include family history, advanced age, gender, and race.

The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply.

adequate cough and gag reflexes acceptable arterial blood gas values breathing without assistance of the ventilator Explanation: Before being extubated, the client should have cough and gag reflexes and stable vital signs; be able to lift the head off the bed or give firm hand grasps; have adequate vital capacity, negative inspiratory force, and minute volume appropriate for body size; and have acceptable arterial blood gas levels while breathing without the assistance of the ventilator. Inability to talk is expected when intubated with an endotracheal tube.

A client with a significant history of mitral valve prolapse is receiving client education regarding dietary recommendations to compensate for symptoms associated with hypovolemia. Which dietary recommendations would be appropriate?

liberal fluid intake adequate sodium intake Explanation: The nurse should recommend adequate sodium and fluid intake to clients with mitral valve prolapse to compensate for symptoms associated with hypovolemia.