Pass Point: Cardio

Promote adequate fluid intake.

A 3-year-old child has a high red blood cell count and polycythemia. When assisting with the planning of care, which action will be of greatest impact in preventing complications?

300

A child is prescribed aspirin as part of the therapy for Kawasaki disease. The order is for 80 mg/kg/day orally in four divided doses until the child is afebrile. The child weighs 15 kg. How much is given in one dose? Record your answer using a whole number.

suppress immune response

A child receives prednisone after undergoing a heart transplant. Which desired outcome will the nurse monitor for?

increased blood pressure

A client develops cardiac tamponade when the client's car hits a telephone pole; the client was not wearing a seatbelt. The nurse helps the health care provider perform pericardiocentesis. Which outcome would indicate that pericardiocentesis has been effective?

digoxin toxicity

A client is admitted to the hospital displaying sinus bradycardia, nausea, anorexia, and blurred vision. What should the nurse suspect this client to be experiencing?

percutaneous transluminal coronary angioplasty (PTCA)

A client is experiencing chest pain at rest that is unresponsive to nitroglycerin. The health care provider diagnoses unstable angina and alerts the nurse that the client will require treatment with immediate surgical intervention. For which treatment does the nurse prepare the client?

heart rate increase from 60 to 88 beats/minute

A client is placed on a medication to stimulate the sympathetic nervous system. Which response should the nurse expect from this medication

Peripheral edema

A client is receiving captopril for heart failure. Which finding indicates that the medication isn't producing the desired treatment outcome and requires the nurse to notify the physician?

Pericardial friction rub

A client is recovering from an acute myocardial infarction (MI). During the first week of recovery, the nurse should stay alert for which abnormal heart sound?

Look at the chart for his last potassium level and contact the physician.

A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take?

cardiogenic shock

A male with heart failure is experiencing tachycardia, decreased blood pressure, and decreased peripheral pulses. The nurse interprets these symptoms as indicating which condition?

administering diuretics

A nurse is caring for a client with left-sided heart failure. Which intervention takes priority in this client's care?

Frequent echocardiography will be needed.

A nurse is preparing the family of a child with Kawasaki disease for discharge. Which instruction is most appropriate?

potassium 3.1 mEq/L (3.1 mmol/L) sodium 151 mEq/L (151 mmol/L)

A nurse is reviewing the laboratory testing for a 17-year-old teenager in the postoperative period. Which findings indicate the need for follow-up? Select all that apply.

Pulsating mass in the periumbilical area

An average-weight client reports of generalized steady abdominal pain. The nurse should suspect an abdominal aortic aneurysm, if the abdominal pain is accompanied by which finding?

"It will be important for me to eat the breakfast my mom makes for me before I take the test."

An exercise stress test has been ordered for a 12-year-old child. Which statement by the child indicates the need for further instruction?

"Audits are an evaluation tool used to improve compliance with hospital policy and standards."

At a staff meeting, a nurse-manager states that the unit performance improvement committee will perform a concurrent audit of the documentation of all coronary artery bypass clients' clinical pathways weekly for 4 weeks. A nurse asks why this is necessary. Which response is the best explanation of the audit's purpose?

It increases heart rate

Atropine is being administered to a child with sinus bradycardia. Which statement is most accurate about the administration of this medication?

"Call the physician if your heart rate goes above 120 beats/minute."

Before discharge, which instruction should the nurse give to a client receiving digoxin?

"My child might have difficulty in school."

Criteria for rheumatic fever are being discussed with parents. The nurse realizes that the parents understand chorea when they make which statement?

bacterial invasion.

Echocardiography reveals vegetation on a client's heart valves. The nurse knows that this finding indicates:

400

Erythromycin is given to a 6-year-old child before dental work to prevent endocarditis. The child weighs 44 lb (20 kg). The order is for 20 mg/kg by mouth 2 hours before the procedure. How many milligrams should be given to this child? Record your answer using a whole number.

Leg edema

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?

The client checks pulse for bradycardia.

Propranalol 80 mg PO BID has been ordered by the health care provider. The nurse reinforces teaching of this medication. Which indicates teaching has been successful?

abdominal aorta, just below the renal arteries.

The most common site of aneurysm formation is in the:

"Children who have chronic health issues may experience developmental delays."

The nurse is talking with the parent of a 3-year-old child who has congenital heart disease. The parent reports feeling concerns that the child does not seem to be maturing emotionally in a manner that is at the same rate as the two older children in the family. Which response by the nurse is most appropriate?

headache

When gathering data from a client admitted with hypertension, the nurse should expect the client to report which symptom?

myocardial infarction (MI)

A client comes to the emergency department reporting chest pain. Upon further evaluation, the nurse suspects unstable angina. Which disease process should the nurse reinforce teaching this client about because it is directly related to unstable angina?

"I should only have approximately 2,400 mg of sodium per day."

A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates an understanding of discharge instructions?

"I should only have approximately 2400 mg of sodium per day."

A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates that the client understands?

Notify the health care provider.

A client prescribed enalapril reports symptoms of a persistent dry cough. What is the nurse's best action?

left-sided heart failure

A client who had an anterior wall myocardial infarction (MI) would have a greater risk for exhibiting crackles in the lungs related to which disorder?

acute pulmonary edema

A client with left-sided heart failure reports of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:

acetaminophen

A client, who is newly prescribed metoprolol, has a headache and asks the nurse what medication to take. The nurse should reinforce the health care provider's instructions to take which of the following medications?

Notify the surgeon.

A cognitively alert client is scheduled for a coronary artery bypass graft surgery in the morning. The nurse checks the chart for preoperative orders and finds that the surgical consent form hasn't been signed. Which of the following is the best action for the nurse to take?

Encourage the teen to participate in planning his or her day.

A hospitalized teen diagnosed with a cardiac disorder reports feeling "trapped in a diseased body." Which action by the nurse will be most therapeutic?

"I will call the physician with this information."

A nurse is attempting to administer lisinopril to a client. The client refuses to take the pill, stating that in the past he developed a rash as an allergic reaction to the medication. Which of the following is the best response by the nurse?

bilateral inspiratory wheezing upon auscultation

A nurse is monitoring a client following an initial administration of sotalol. Which of the following would be of greatest concern to the nurse?

Obtain the client's vital signs and oxygen saturation.

A nurse is monitoring a client who has symptoms of anxiety and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse?

"Since this is a hereditary disorder, my family members should probably be evaluated for similar symptoms."

A client is being discharged home with a diagnosis of hypertrophic cardiomyopathy (HCM). Which statement by the client best demonstrates an understanding of this disease process?

Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

A client is diagnosed with pericarditis. The nurse anticipates that the client may exhibit which signs and symptoms?

Decreased cardiac output and systolic and diastolic blood pressure

A client is evaluated for hypertension. The physician prescribes atenolol, 50 mg by mouth daily. Atenolol should have which therapeutic effect on the client?

Maintain the prescribed medication regimen until the health care provider makes a change.

The nurse is caring for a child undergoing cardiac surgery? Which home care instruction is most appropriate?

leukocytosis

The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child?

Oxygen decreases the work of breathing.

The nurse is caring for a child with heart failure. What should the nurse recognize when monitoring administration of oxygen to avoid complications?

Turn and position the client every 2 hours.

The nurse is caring for a client diagnosed with left-sided cerebrovascular accident, with expressive aphasia and right-sided weakness. When administering care for this client, which intervention should the nurse delegate to unlicensed assistive personnel (UAP)?

frequent respiratory infections

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?

creatine kinase (CK) troponin T and troponin I myoglobin

A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply.

chest pain

A client is suspected to be experiencing a myocardial infarction (MI). Which symptom reported by the client would lead the nurse to this conclusion?

AAA occurs more commonly in men than in women. A client with an AAA may also have "blue toe syndrome." A 3-cm AAA rarely causes symptoms such as back pain.

A nurse is caring for a client who has a known 3-cm infrarenal abdominal aortic aneurysm (AAA). Which statements accurately characterize this disorder? Select all that apply.

a client with acute myocardial infarction (MI)

A nurse is caring for several clients on a medical floor. Which client does the nurse identify to have the greatest chance of developing cardiogenic shock?

Gather information on the client's airway, breathing, and circulation.

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. Based on the data, which intervention should the nurse do first?

Protamine sulfate

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for adverse effects of heparin, especially bleeding. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that's specific to heparin. Which agent fits this description?

Increased abdominal and back pain

Which of the following signs and symptoms suggest that a client's abdominal aortic aneurysm is extending?

Avoid puncture wounds.

Which precaution should a nurse take when caring for a client with a myocardial infarction (MI) who has received a thrombolytic agent?