UWorld Cardiovascular #2

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? a. Clopidogrel for client with hx of stroke and platelet count of 154,000 b. Losartan for client with HTN who is 8 weeks pregnant c. Prednisone for client with herpes simplex lesions and Bell palsy d. Tiotropium for client with PNA and COPD

Losartan is an angiotensin II receptor blocker (ARB) prescribed to treat hypertension. ACE inhibitors (eg, lisinopril, enalapril) and ARBs are teratogenic, causing renal and cardiac defects or death of the fetus. ARBs and ACE inhibitors have black box warnings that indicate contraindication in pregnancy. The nurse should not give an ARB to a pregnant client (Option 2). The health care provider should be notified so that an alternate antihypertensive may be prescribed that is safe to take during pregnancy (eg, labetalol, methyldopa). (Option 1) Antiplatelet agents (eg, clopidogrel) are prescribed to prevent thromboembolic events in clients with increased risk for stroke or myocardial infarction. Laboratory values are monitored periodically as these drugs increase bleeding time (normal, 2-7 minutes [120-420 seconds]) and, rarely, may lower platelet count (normal, 150,000-400,000/mm3 [150-400 × 109/L]) (Option 3) Bell palsy presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus). Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset. (Option 4) Tiotropium is an inhaled anticholinergic drug that inhibits receptors in the smooth muscles of the airways. It is prescribed daily for the long-term management of bronchospasm in clients with chronic obstructive pulmonary disease. Educational objective:Angiotensin II receptor blockers and ACE inhibitors are teratogenic, causing fetal injury or death, and are contraindicated in pregnancy.

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? a. I'm not worried about the device firing now because I know it won't hurt b. I will let my daughter fix my hair until my health care provider says I can do it. c. I will look into public transportation because I won't be able to drive again d. I will notify my travel agent that I can no longer travel by plane

An implantable cardioverter defibrillator (ICD) can sense and defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias that may occur after defibrillation. The ICD consists of a lead system placed into the endocardium via the subclavian vein. The pulse generator is implanted subcutaneously over the pectoral muscle. Postoperative care and teaching are similar to those for pacemaker implantation. Clients are instructed to refrain from lifting the affected arm above the shoulder (until approved by the health care provider) to prevent dislodgement of the lead wire on the endocardium (Option 2). (Option 1) Firing of the ICD may be painful. Clients have described the feeling as a blow to the chest. (Option 3) Driving may be approved by the health care provider after healing has occurred. Long-term decisions are based on the ongoing presence of dysrhythmias, frequency of ICD firings, and state laws regarding drivers with ICDs. (Option 4) Travel is not restricted. The ICD may set off the metal detector in security areas. A hand-held wand may be used but should not be held directly over the ICD. The client should carry the ICD identification card and a list of medications while traveling. Educational objective:After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system.

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply. a. Assess for bruising b. Assess for tarry stools c. Monitor intake and output d. Monitor liver function tests e. Monitor platelets

Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5). (Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients without hepatic impairment. Educational objective:Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) can pose a risk for serious bleeding. Clients should be monitored for bruising, signs of bleeding (eg, tarry stools, hematuria), and decreased platelet counts.

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect? a. Blood glucose of 95 b. Potassium level of 4.2 c. Reduction in dizziness d. Sodium level of 138

Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene eplerenone) are generally very weak diuretics and antihypertensives. However, they are useful when combined with thiazide diuretics to reduce potassium (K+) loss. Thiazide diuretics can cause hypokalemia when used as monotherapy. A potassium level of 4.2 mEq/L (4.2 mmol/L) falls in the normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), which indicates that spironolactone has been effective in preventing hypokalemia in this client receiving a thiazide diuretic (eg, hydrochlorothiazide, chlorthalidone) (Option 2). (Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. (Option 3) All diuretics, including spironolactone, have the potential to cause dizziness. The nurse should monitor the client for orthostatic hypotension and implement safety precautions. (Option 4) Potassium-sparing diuretics exchange sodium for potassium in the kidneys; potassium is saved but sodium is lost. Therefore, a normal sodium level (135-145 mEq/L [135-145 mmol/L]) is not the desired effect. Educational objective:Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss.

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply. a. Alanine aminotransferase from 20 U/L to 80 U/L b. High density lipoprotein cholesterol from 48 mg/dL to 30 mg/dL c. Low density lipoprotein cholesterol from 176 mg/dL to 98 mg/dL d. Total cholesterol from 250 mg/dL to 180 mg/dL e. Triglycerides from 180 mg/dL to 149 mg/dL

Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride levels. This client's LDL level has decreased to a target range (diabetic client <100 mg/dL [2.6 mmol/L]), total cholesterol has decreased to a normal range (adult <200 mg/dL [5.2 mmol/L]), and triglyceride level has decreased to a normal range (adult <150 mg/dL [1.7 mmol/L)); all these changes indicate a therapeutic response (Options 3, 4, and 5). (Option 1) The adult therapeutic range of alanine aminotransferase (ALT) is 10-40 U/L (0.17-0.68 µkat/L). Increased aspartate aminotransferase (AST) and ALT may indicate hepatic dysfunction, a potential adverse effect of statin medication. (Option 2) The therapeutic range of high-density lipoprotein (HDL) cholesterol for adult men is >40 mg/dL (1.04 mmol/L). HDL is good cholesterol. This client's HDL level is below the therapeutic range, indicating a nontherapeutic response. Educational objective:A therapeutic response to statin medication includes a decrease in a client's LDL cholesterol, total cholesterol, and triglyceride levels to within normal range. An increase in HDL cholesterol to within normal range is also an expected outcome. Potential adverse effects include hepatic dysfunction and muscle injury.

A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse? a. I've been better about walking for 20 minutes 3 days a week on my treadmill. b. I've been trying to eat more fruits and vegetable. I discovered that I really like grapefruit c. I've heard that having a glass of red wine with dinner every night is good for my heart d. We no longer add salt when preparing meals. It has really been hard to get used to that.

The nurse should intervene when the client talks about eating grapefruit. Grapefruit inhibits enzyme CYP3A4. The drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects. Calcium channel blocker (eg, nifedipine) use with grapefruit juice can cause severe hypotension; some statins (eg, simvastatin) may result in myopathy. (Option 1) The nurse should praise and encourage the client to continue exercising and possibly increase the amount. This is a positive lifestyle change. The client should engage in moderate-intensity aerobic exercise for at least 30 minutes most days of the week or vigorous-intensity aerobic exercise for 20 minutes 3 days a week. (Option 3) It is thought that red wine in moderation has some beneficial effects on the heart. The nurse would not encourage a client to start drinking red wine if the client didn't already. Excessive alcohol consumption is strongly associated with hypertension. The nurse should encourage the client to discuss alcohol consumption with the health care provider (HCP). (Option 4) Sodium restriction is important in the management of hypertension. This teaching should be reinforced and the client should be encouraged to restrict the use of salt. Educational objective:The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension. The nurse should report this client's statement to the HCP.

The nurse has just administered a dose of 0.5 mg atropine to a client with a heart rate of 48/min and blood pressure of 90/62 mmHg. Which rhythm strip would indicate that the medication achieved the desired outcome?

Atropine is given to the client experiencing symptomatic bradycardia. In symptomatic bradycardia, the heart rate is <60/min and is inadequate for the client's condition, causing symptoms such as hypotension, chest pain, or syncope. Atropine acts to increase the heart rate by inhibiting the action of the vagus nerve (parasympatholytic effect). A normal sinus rhythm and reversal of clinical symptoms indicate that the medication has had the desired effect. (Option 1) A continuation of sinus bradycardia would not indicate that the atropine had been effective. (Option 3) Sinus tachycardia would be an undesirable effect of atropine as the heart rate would be >100/min. (Option 4) The client with first-degree atrioventricular block may have a normal heart rate, but the atrioventricular conduction time is prolonged. Educational objective:Atropine is given to the client with symptomatic bradycardia. The desired outcome would be an increase in heart rate, evidence of normal sinus rhythm on the cardiac monitor, and reversal of any clinical symptoms associated with the bradycardia.

The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker? a. Auscultate the client's apical pulse rate b. Measure the client's BP c. Obtain a 12-lead ECG d. Palpate the client's radial pulse rate

Clients with an implanted permanent pacemaker should be assessed for both electrical capture of heart rhythm and mechanical capture of heart rate. In atrial pacing, pacer spikes precede P waves, whereas in ventricular pacing, pacer spikes precede QRS complexes. Pacing spikes should be immediately followed by their appropriate electrical waveform, indicating electrical capture. Checking for mechanical capture is essential to ensure that the electrical activity of the heart corresponds to a pulsatile rhythm. The best method for checking for a pulsatile rhythm is to assess a central pulse (eg, auscultation of apical, palpation of femoral) (Option 1). This rate should be compared to the electrical rate displayed on the cardiac monitor to assess for pulse deficit. (Option 2) Blood pressure is an important assessment relating to cardiac output and organ perfusion, but it does not determine if the client's pacemaker is capturing the mechanical activity of the heart. (Option 3) A 12-lead ECG does not assess mechanical capture of cardiac activity via the client's pacemaker. (Option 4) Peripheral pulses (eg, radial, pedal, popliteal) are not the best indicators of mechanical action of the heart. Peripheral vasculature may have anatomical changes that impair pulse quality, leading to false perception of a pulse deficit. Educational objective:For clients with a newly implanted permanent pacemaker, the nurse should assess for electrical capture of heart rhythm (eg, ECG) and mechanical capture of heart rate (eg, pulse). A central pulse (eg, auscultation of apical, palpation of femoral) should be assessed to determine mechanical capture.

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed? a. I must visit my HCP to check my drug levels b. I should report to my HCP if I develop n/v c. I should tell my HCP if I feel my heart skip a beat d. I will need to increase my potassium intake

Drug toxicity is common with digoxin due to its narrow therapeutic range. Many contributing factors (eg, hypokalemia) can cause toxicity. However, in the absence of other factors, potassium does not need to be increased just because a client is on digoxin. If the client also takes some other potassium-depleting medications, such as diuretics, potassium supplements may be needed. Signs and symptoms of digoxin toxicity include the following: Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms (Option 2) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness Cardiac arrhythmias - most dangerous (Option 1) Drug levels are frequently monitored until a steady state is achieved and when changes are expected, such as in clients with chronic kidney disease and electrolyte disturbances (eg, hypokalemia, hypomagnesemia). (Option 3) Digoxin toxicity can result in bradycardia and heart block. Clients are instructed to check their pulse and report to the HCP if it is low or has skipped beats. Educational objective:Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized.

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? a. Bronchial breath sounds at lung periphery b. Clear vesicular breath sounds at lung bases c. Diffuse bilateral crackles at lung bases d. Stridor in upper airways

Acute-onset dyspnea and cough productive of pink, frothy sputum indicate severe pulmonary edema, likely a complication from myocardial infarction. Pink sputum results from ruptured bronchial veins due to high back pressure. The mix of blood and airway fluids creates the pink tinge. On assessment, crackles can be heard at the lung bases. (Option 1) Bronchial breath sounds are normally heard over the trachea. These are harsh and high-pitched; inspiration and expiration are of similar duration. The presence of these on lung periphery indicates pneumonia (consolidation). (Option 2) Clear vesicular breath sounds (normal breath sounds) are not expected in pulmonary edema. (Option 4) Stridor is consistent with a laryngospasm or edema of the upper airway. Educational objective:Acute-onset dyspnea and cough with frothy, pink-tinged sputum indicate pulmonary edema. Auscultation reveals crackles at the lung bases.

The nurse receives handoff of care report on four clients. Which client should the nurse see first? a. Client with Afib who reports feeling palpitations and has an irregular pulse of 122/min b. Client with liver cirrhosis who reports bleeding from an IV site and has a platelet count of 48,000 mm c. Client with pericarditis whose blood pressure has decreased from 122/70 to 98/68 over the past hour d. Client with pneumonia whose WBC has increased from 14,000 8 hours ago to 30,000 mm

Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Cardiac tamponade decreases atrioventricular filling and impairs the heart's ability to contract and eject blood; it is life-threatening without prompt recognition and treatment. Clinical features of cardiac tamponade include hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) (Option 3). In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, and tachycardia may be present. (Option 1) Palpitations, tachycardia, and irregular pulse are expected findings in atrial fibrillation. Atrial fibrillation is usually a chronic arrhythmia. The heart rate must be controlled, but this is not a priority over tamponade. (Option 2) Liver cirrhosis causes portal hypertension and splenomegaly. An enlarged spleen sequestrates platelets, causing thrombocytopenia. Spontaneous bleeding requires further investigation after addressing a client with possible cardiac tamponade. (Option 4) Increased white blood cell count in a client with infection may indicate ineffective treatment and/or progression to sepsis, both of which require follow-up. However, this finding is not immediately life-threatening. Educational objective:Cardiac tamponade is a possible complication of acute pericarditis that impairs cardiac output and is life-threatening without immediate intervention. Clinical features of cardiac tamponade include hypotension, muffled heart sounds, and neck vein distension (Beck triad).

A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time? a. Avoid strenuous activity before the surgery b. Continue to exercise, even if angina occurs. It will strengthen your heart muscles c. Take short walks 3 times a day 4. There are no activity restrictions unless angina occurs.

Aortic stenosis is the narrowing of the orifice between the left ventricle and aorta. Many clients with aortic stenosis are asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot pump enough blood to meet the body's demands due to aortic obstruction (stenosis). These include dyspnea, angina, and, in severe cases, syncope (reduced blood flow to the brain). Clients usually do not experience symptoms at rest. (Options 2 and 4) This client already developed syncope and angina (exertional chest pain) and is at high risk for sudden death with exertion. (Option 3) The client should restrict activity. The incidence of sudden death is high in this population, and it is therefore prudent to decrease the strain on the heart while awaiting surgery. Educational objective:Clients with severe aortic stenosis are at risk for developing syncope and sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body's demands due to the valve stenosis.

The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? a. Chest tube output of 175 ml in past hour b. INR of 1.5 c. Temp of 100.3 F d. Total urine output of 85 ml over past 3 hours

Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products. (Option 2) Clients who receive a mechanical valve replacement will be started on anticoagulants. A therapeutic INR is 2.5-3.5. This client just had surgery and so has not received enough anticoagulation to get the INR to a therapeutic level. (Option 3) Although this is an abnormal temperature, it is not as high a priority as the blood loss. The nurse should continue to monitor and administer prescribed postoperative antibiotics. (Option 4) Normal urine output is 30 mL/hr. This urine level is just 5 mL below normal. The nurse should continue to monitor. Educational objective:Postoperative blood loss >100 mL/hr should be reported to the HCP immediately. The client may have a compromised suture site and can rapidly become hemodynamically unstable.

A nurse in the intensive care unit is caring for a postoperative cardiac transplant client. What intervention is most important to include in the plan of care? a. Apply sequential compression devices to prevent dvt b. Assist client to change positions slowly to prevent hypotension c. Encouragedd coughing and deep breathing to prevent PNA d. Use careful handwashing and aseptic techniques to prevent infection

Clients receiving transplanted organs are prescribed lifelong immunosuppressive medications (eg, cyclosporine, mycophenolate) to prevent rejection. Posttransplant infection is the most common cause of death. Signs of infection may include fever >100.4 F (38 C), productive or dry cough, and changes in secretions; however, common signs of infection (eg, redness, swelling) may be absent due to immunosuppression. Critical postoperative infection control measures incorporate vigilant hand washing, aseptic technique for line/dressing changes, and possibly reverse isolation. (Option 1) Sequential compression devices are one of the options available to prevent deep venous thrombosis (DVT) postoperatively. Ideally, anticoagulants are used to prevent DVT. Regardless, in the client's immunosuppressed state, infection prevention is the priority. (Option 2) The newly transplanted heart is denervated from the autonomic nervous system and is unable to appropriately respond to physical demand (eg, increased heart rate with increased activity). The client is taught how to avoid orthostatic hypotension (eg, change positions slowly). However, the priority is careful hand washing and infection prevention. (Option 3) Coughing, deep breathing, and incentive spirometry are important interventions to prevent atelectasis and pneumonia. However, infection prevention is the priority in immunosuppressed clients. Educational objective:Posttransplant infection is the most common cause of death due to immunosuppressive therapy. Strict hand washing and aseptic technique are critical to infection prevention. Symptoms of infection should be monitored and may include fever >100.4 F (38 C), productive or dry cough, and changes in secretions.

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply. a. I need to call the HCP if I have trouble reading b. I need to check my BP before taking my medicine c. I should call the HCP if I develop N/V d. I should check my HR prior to taking this medication e. I will call the HCP if I feel dizzy and lightheaded

Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL). Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness (Option 5). Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold the medication and notify the health care provider (Option 4). Other manifestations of digoxin toxicity that clients should report include: Visual symptoms (eg, alterations in color vision, scotomas, blindness) (Option 1) Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms (Option 3) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) (Option 2) There is no need to routinely check blood pressure before taking digoxin as it does not affect blood pressure. Clients should check the pulse prior to administration. Educational objective:Cardiac glycosides (eg, digoxin) have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). Clients are instructed to check their pulse before administration and to report gastrointestinal (eg, anorexia, nausea), neurologic, and cardiac symptoms and visual changes.

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider? a. Client reports paresthesia bilaterally since the surgery b. Fondaparinux is prescribed for STAT administration c. Lower-extremity muscle strength is 3/5 bilaterally d. Postoperative lab results show hgb of 9.9 g/dL

Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option 2). Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis. (Option 1) Paresthesia is an expected finding from postoperative analgesia for 2-24 hours after surgery, depending on the agent and location. Continuously administered analgesia usually results in some paresthesia until approximately 4-6 hours after discontinuance. As long as the level remains relatively stable or improves, it is an acceptable finding. However, paresthesia or motor weakness is a concern when the sensory or motor block outlasts the expected duration. (Option 3) Client response to operative analgesia and postoperative continued analgesia can range from minimal to significant. As long as the analgesic is infusing and findings remain stable, reduced muscle strength is expected. (Option 4) Major orthopedic surgery can result in significant blood loss, and it is not unusual for the client to have hemoglobin drop of 1-2 g/dL (10-20 g/L). Blood loss should be monitored over time; transfusion usually is not indicated unless hemoglobin is <7-8 g/dL (70-80 g/L). Educational objective:Residual paresthesia and motor weakness for several hours are expected findings after regional anesthesia. Anticoagulants are not given while an epidural catheter is in place.

The nurse is performing an initial assessment on a client in hypertensive crisis. What is the nurse's priority assessment? Click on the exhibit button for additional information. Vital signs Blood pressure 210/120 mm Hg Heart rate 109/min Respirations 20/min O2 saturation 96% a. Heart sounds b. Level of consciousness c. Lung sounds d. Visual fields and acuity

Hypertensive crisis is a life-threatening medical emergency characterized by severely elevated blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure. Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema). The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention (Option 2). Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting. (Options 1 and 3) Assessing heart and lung sounds allows the nurse to identify and monitor for other complications of hypertensive crisis (eg, heart failure, pulmonary edema). However, this client's vital signs do not indicate respiratory distress (ie, normal oxygen saturations and respiratory rate); therefore, neurological assessment is the priority because a change in LOC may indicate a life-threatening hemorrhagic stroke. (Option 4) The nurse should assess for vision changes (eg, blurred vision, blind spot) or papilledema, as these are signs of progressing hypertensive crisis; however, assessment of LOC is the priority. Educational objective:Hypertensive crisis is a life-threatening elevation in blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg) that may cause end-organ damage (eg, stroke, kidney injury, heart failure, papilledema). The client's level of consciousness should be monitored, as a decreased level may indicate onset of hemorrhagic stroke.

The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)? a. Pain and pallor in one foot b. Pain in both knees c. Splinter hemorrhages in the nail beds d. Temp of 102.2 F

In IE, the vegetations over the valves can break off and embolize to various organs, resulting in life-threatening complications. These include the following: Stroke - paralysis on one side Spinal cord ischemia - paralysis of both legs Ischemia to the extremities - pain, pallor, and cold foot or arm Intestinal infarction - abdominal pain Splenic infarction - left upper-quadrant pain The nurse or the client (if at home) should report these manifestations immediately to the HCP. (Options 2 and 4) IE commonly presents with fever, arthralgias (multiple joints pains), weakness, and fatigue. These are expected and do not need to be reported during the initial stages of treatment. IE clients typically require intravenous antibiotics for 4-6 weeks. Fever may persist for several days after treatment is started. If the client is persistently febrile after 1-2 weeks of antibiotics, this must be reported as it may indicate ineffective antibiotic therapy. (Option 3) Splinter hemorrhages can occur with infection of the heart valves (endocarditis). They may be caused by vessel damage from swelling of the blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli). The presence of splinter hemorrhages is not as critical as the macroemboli causing stroke or painful cold leg. Educational objective:IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur. The onset of hemiplegia or painful, pale, cold foot/leg could indicate embolization and should be reported to the HCP immediately.

A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)? a. I like to have a banana every morning with my breakfast b. I occasionally experience slight dizziness when I get up in the morning c. I started taking licorice root for my occasional heartburn d. I usually take my hydrochlorothiazide first thing in the morning.

Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client's use to the PHCP. (Option 1) Bananas are rich in potassium. Eating one each morning is beneficial. (Option 2) Diuretics and calcium channel blockers (eg, nifedipine, amlodipine, felodipine) commonly cause postural hypotension or dizziness on rising. The nurse should encourage the client to rise slowly and sit on the side of the bed for a few minutes before getting up. Persistent dizziness should be reported to the PHCP. (Option 4) Diuretics should be taken in the morning as nighttime dosing will cause nocturia and interrupted sleep. Educational objective:The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can potentiate potassium loss and increase the client's risk for hypokalemia. Use of licorice root should be reported to the PCHP.

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. a. I will apply moisturizing lotion on my legs everyday b. I will elevate my legs at night when I am sleeping c. I will heep my legs below heart level when sitting d. I will start walking outside with my neighbor e. I will use a heating pad to promote circulation

Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene). Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development (Option 2) Elevating the legs promotes venous return, but does not promote arterial circulation. (Option 5) Heating pads should not be used in clients with altered perfusion or sensation due to the increased risk for burns. Educational objective:Peripheral artery disease increases the risk of tissue necrosis and limb loss. Management focuses on improving blood flow and circulation to the extremities through lifestyle changes and medications.

The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? a. At the end of the day, my shoes and socks are tight b. I have a slow healing sore right above my ankle c. My legs ache when I stand for extended periods d. When I sit down to rest and elevate my legs, the pain increases

Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation. (Options 1, 2, and 3) Chronic venous insufficiency refers to inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle. By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation. Educational objective:The pain of peripheral artery disease is arterial in nature and results from decreased blood flow to the legs. It is made worse with leg elevation. Arterial ulcers are formed at the most distal end of the body. Venous ulcers form over the medial malleolus, and compression bandaging is needed to reduce the pressure.

An 8-month-old infant is scheduled for a femorally inserted balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider that could possibly delay the procedure? a. Auscultation of a loud heart murmur b. Infant has been NPO for 4 hours c. Infant has a severe diaper rash d. Slight cyanosis of the nail beds

Pulmonic stenosis causes increased pressure in the right side of the heart as the ventricle tries to push blood through the narrowed pulmonary area to the lungs. In severe pulmonic stenosis, higher pressure in the right side of the heart causes unoxygenated blood to travel to the left side through the foramen ovale (or other congenital defect) and into the systemic circulation, leading to chronic hypoxia and cyanosis and requiring repair (interventional catheterization or surgery). The presence of severe diaper rash should be reported to the health care provider (HCP). This could delay the procedure if the rash is in the groin area where access is planned for a femorally inserted arterial cannula. Yeast or bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick (Option 3). (Option 1) A loud heart murmur can be an expected finding in a child with pulmonic stenosis. (Option 2) Children are NPO for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter period of NPO status and should be fed right up to the time recommended by the HCP. (Option 4) Cyanosis indicates severe pulmonic stenosis with right-to-left shunt and the need for interventional catheterization or surgery without delay. Educational objective:The nurse should report the presence of severe diaper rash in an infant who has an interventional catheterization procedure planned. The rash may delay the procedure due to possible contamination at the insertion site.

The unlicensed assistive personnel reports a client blood pressure of 90/60 mm Hg to the nurse. The client's prescriptions say to notify the health care provider (HCP) if systolic blood pressure is <100 mm Hg. What should the nurse do first? a. Assess the client for other signs and symptoms b. Immediately notify the client's HCP c. Notify the charge nurse on duty for the shift. d. Review the client's medication administration record.

The nurse should follow the client's prescriptions and notify the HCP, after first assessing for any other signs and symptoms that may be associated with the low blood pressure (eg, dizziness, pallor, signs of poor perfusion, confusion). The HCP will most likely ask the nurse about the type of symptoms as well as past vital signs, medications, and laboratory results. The nurse should utilize SBAR, a common tool for communication with HCPs that includes Situation, Background, Assessment, and Recommendation. The nurse should have all of this information on hand prior to calling the HCP. (Options 2, 3, and 4) These options are appropriate after the nurse has assessed the client. Educational objective:The nurse should have current assessment data and access to the client's recent laboratory data, diagnostic studies, and medication administration record before calling the HCP.

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply.Click on the exhibit button for additional information. Vital signs Temperature 98.4 F (36.9 C) Blood pressure 124/78 mm Hg Heart rate 46/min and irregularly irregular Respirations 22/min a. Diltiazem extended release PO b. Heparin SQ c. Lisinopril PO d. Metoprolol PO e. Timolol ophthalmic

Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate [HR] <60/min). Therefore, medications that can decrease HR should be held and the health care provider (HCP) notified. The reason for holding the medication (HR 46/min) and an HCP contact note should be documented. Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and is safe to administer (Option 2). Lisinopril, an ACE inhibitor, does not lower HR and is not contraindicated in clients with bradycardia (Option 3). The client is not hypotensive; therefore, lisinopril is safe to administer. (Option 1) Non-dihydropyridine calcium channel blockers (eg, diltiazem, verapamil) can decrease HR and should be held in clients with bradycardia. (Options 4 and 5) All beta blockers (eg, metoprolol, timolol, atenolol), including eye drops that can be absorbed systemically, can decrease the HR and should be held until the prescriptions can be clarified by the HCP. Educational objective:Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol and timolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil).

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client? a. A client from the cardiac catheterization lab with a BP of 102/58 b. A client just admitted from the ER with a BP of 150/72 c. A client with a BP of 92/60 who just received a dose of NTG d. A client with a heart failure on Metoprolol with a BP of 106/42

The MAP refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is between 70-105 mm Hg. If the MAP falls below <60 mm Hg, vital organs may be underperfused and can become ischemic. MAP can be calculated using the formula below: Mean Arterial Pressure =Systolic Blood Pressure + (Diastolic Blood Pressure × 2)3 A normal MAP is 70-105 mm Hg. The client with the BP of 106/42 mm Hg has a MAP of 63 mm Hg, in the abnormal range. The nurse should report this to the HCP and monitor the client closely. (Options 1, 2, and 3) These MAPs are within the 70-105 mm Hg normal range. Educational objective: Mean Arterial Pressure =Systolic Blood Pressure + (Diastolic Blood Pressure × 2)3 A normal MAP is 70-105 mm Hg. A MAP <60 mm Hg will not allow for adequate perfusion of vital organs.

What intervention is essential prior to starting a client on atorvastatin therapy? a. Assessing for muscle strength b. Assessing the client's dietary intake c. Determining if the client is on digoxin therapy d. Monitoring liver function tests

Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. (Option 1) Statins can also cause muscle aches and, rarely, severe muscle injury (rhabdomyolysis). Clients should be educated to report the development of muscle pains while on therapy. Assessment of muscle strength is not necessary prior to starting therapy. (Option 2) Assessment of dietary intake prior to therapy is not essential. Dietary teaching would have been performed prior to determining that medication therapy was necessary. (Option 3) Atorvastatin may slightly increase serum digoxin levels; however, it is not essential to determine if the client is on this medication prior to starting therapy. Educational objective:Statin medications (eg, rosuvastatin, atorvastatin) can cause hepatotoxicity and muscle aches. Liver function tests should be assessed prior to the start of therapy.

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? a. Bradycardia b. Hypokalemia c. Nephrotoxicity d. Ototoxicity

IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min (Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide. (Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. (Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration. Educational objective:High doses of IV furosemide should be administered slowly to prevent ototoxicity.

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up? a. Abdomen is soft, non distended and tender to touch b. BP is 96/66 mm Hg and apical pulse is 112/min c. Client rates pain as 4 on a scale of 0/10 d. Green bile is draining from the nasogastric tube

Abdominal aortic aneurysms are surgically repaired when they measure about 6 cm or are causing symptoms. Repair can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm with synthetic graft placement. The client must be monitored postoperatively for graft leakage and hemodynamic stability. Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the formation of graft thrombosis. Signs of graft leakage include a decreasing blood pressure and increasing pulse rate. (Option 1) Following surgery, the client will experience abdominal tenderness. The abdomen should remain soft and nondistended. A rigid, distended abdomen would indicate possible blood (graft leakage) in the cavity. (Option 3) Pain is an expected finding following abdominal surgery. However, increasing pain that is not relieved by medication can indicate possible graft leakage and should be investigated. (Option 4) During abdominal surgeries, it is customary to insert a nasogastric tube that is left in place during the immediate postoperative period. Green bile-colored drainage would be expected. Bloody drainage would cause concern. Educational objective:Following repair of an abdominal aortic aneurysm, hemodynamic stability is a priority. Prolonged hypotension can lead to graft thrombosis. A falling blood pressure and rising pulse rate can also signify graft leakage.

A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. Which action should the nurse take? a. Adenosine is contraindicated for SVT. Verify the order with the HCP b. Administer medication only through a central venous access c. Administer medication rapidly over 1-2 seconds followed by a saline flush d. Mix medication in 50 ml normal saline and administer over 10 minutes

Adenosine is the first-line drug of choice for the treatment of paroxysmal supraventricular tachycardia (SVT; a rapid rhythm exceeding 150/min). The half-life is <5 seconds, so adenosine should be administered rapidly as a 6-mg bolus IV over 1-2 seconds followed by a 20-mL saline flush. Repeat boluses of 12 mg may be given twice if the rapid rhythm persists. The injection site should be as close to the heart as possible (eg, antecubital area). The client's ECG should be monitored continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the atrioventricular node. The client should be monitored for flushing, dizziness, chest pain, or palpitations during and after administration. (Option 1) Adenosine is the first-line drug for paroxysmal SVT. (Option 2) Although the drug should be administered as close to the heart as possible, central venous access is not required. (Option 4) Because of the drug's short half-life (5-10 seconds), it should be administered rapidly, not slowly, and should not be diluted. Educational objective:Adenosine is the drug of choice for the treatment of paroxysmal supraventricular tachycardia. It has a short half-life and should be administered rapidly over 1-2 seconds, followed with a 20-mL saline bolus. A brief period of asystole can be common. Flushing from vasodilation is seen frequently.

A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor? Click on the exhibit button for additional information. a. Atrial paced rhythm b. Atrioventricular paced rhythm c. Biventricular paced rhythm d. Ventricular paced rhythm

An atrioventricular pacemaker (also known as a sequential or dual chamber pacemaker) paces the right atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy. (Option 1) An atrial paced rhythm would have a pacer spike before the P wave only. The P wave may appear normal or abnormal; the QRS complex will appear normal. (Option 3) Biventricular pacemakers (also known as sequential biventricular pacemakers) generate impulses in both ventricles. Two ventricular pacing spikes may be seen on the ECG, and one spike may appear after the beginning of the QRS complex. (Option 4) A ventricular paced rhythm would only have a pacer spike prior to a wide QRS complex. Impulses are generated in only one ventricle (typically the right ventricle). Educational objective:An atrioventricular pacemaker (also known as sequential or dual chamber) paces the right atrium and right ventricle in sequence. Two pacer spikes are visible on the ECG, one prior to the P wave and a second prior to the QRS complex. Atrioventricular pacemakers improve cardiac synchrony between the atria and ventricles.

The nurse is teaching a client who is scheduled to have an inferior vena cava filter inserted via the right femoral vein. Which statement by the client requires further teaching? a. I need to make all health care providers aware of my filter before I have body scans b. I need to stay active and avoid crossing my legs for extended periods when I get home c. I should call the health care provider if I develop numbness, tingling, and swelling in my right leg d. It is normal to have some chest or back discomfort for a few days after filter placement.

An inferior vena cava filter is a device that is inserted percutaneously, usually via the femoral vein. The filter traps blood clots from lower extremity vessels (eg, embolus from deep venous thrombosis) and prevents them from migrating to the lungs and causing a pulmonary embolism (PE). It is prescribed when clients have recurrent emboli or anticoagulation is contraindicated. Clients should be questioned about and report any metallic implants (eg, vascular filters/coils) to the health care team prior to radiologic imaging, specifically MRI (Option 1). Physical activity should be promoted, and clients should avoid crossing their legs to promote venous return from the legs (Option 2). Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be reported immediately (Option 3). (Option 4) Symptoms of PE (eg, chest pain, shortness of breath) and vascular injury (bleeding causing back pain) are not expected findings after the procedure and should be reported immediately. Educational objective:An inferior vena cava filter traps thrombi migrating from the lower extremities to the lungs. Discharge teaching includes promotion of physical exercise, reporting of symptoms of pulmonary embolism (eg, chest pain, shortness of breath) and impaired lower extremity circulation (eg, pain, numbness), and notification of the health care team prior to MRI.

A client recently diagnosed with heart failure is being discharged with a prescription for lisinopril. Which client teaching related to this new medication is important to review at discharge? a. Instruct cliet to report for monthly blood work to monitor drug levels b. Review foods high in potassium that cliet should include in diet c. Teach client to count their own pulse for 1 minute;hold medication if pulse <60/min d. Teach client to rise slowly and sit on side of bed for several minutes before rising.

Angiotensin converting enzyme (ACE) inhibitors (eg, captopril, enalapril, lisinopril, ramipril) prevent the pathological enlargement of the left ventricle of the heart. They work by blocking a crucial step in the renin-angiotensin-aldosterone system, the main hormonal mechanism involved in blood pressure regulation. Interrupting this step of the renin-angiotensin-aldosterone system has following effects: A shortage of angiotensin II results in an absence of the vasoconstrictive responses (orthostatic reflex, renal blood flow regulation) causing orthostatic hypotension. Clients may be more prone to experiencing orthostatic hypotension early in treatment with ACE inhibitors and should be taught ways to prevent it. A shortage of aldosterone causes hyperkalemia. Aldosterone Saves Sodium and Pushes Potassium out of the body. ACE inhibitors are contraindicated in pregnancy due to teratogenic effects on the fetus (eg, oligohydramnios, fetal kidney injury). The other important side effects of ACE inhibitors, cough and angioedema, are thought to be due to the accumulation of bradykinin. (Option 1) Renal function (blood urea nitrogen, creatinine) is commonly checked during the first week of treatment. Regular measurements to ensure therapeutic drug levels are required for lithium, phenytoin, and digoxin. (Option 2) A common side effect of ACE inhibitor is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium. (Option 3) ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/min. Educational objective:Client education after initiation of an angiotensin converting enzyme inhibitor (eg captopril, lisinopril) includes a discussion on development of a dry cough, taking several minutes to get out of bed, possible allergic reactions (rash, angioedema), and the teratogenic effects of the drug.

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis? a. Bounding peripheral pulses b. Diastolic murmur c. Loud second heart sound d. Syncope on exertion

Aortic stenosis is a narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. As stenosis progresses, the heart cannot overcome the worsening obstruction, and ejects a smaller fraction of blood volume from the left ventricle during systole. This decreased ejection fraction results in a narrowed pulse pressure (ie, the difference between systolic and diastolic blood pressures) and weak, thready peripheral pulses. With exertion, the volume of blood that is pumped to the brain and other parts of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea, anginal chest pain, and syncope. (Option 1) In aortic stenosis, pulses are weak due to obstruction of outflow from the left ventricle. Pulses would be bounding in aortic regurgitation due to more blood being pumped each time (blood accumulation from regurgitation of the previous systole). (Option 2) On auscultation, aortic stenosis produces a loud, ejection systolic murmur over the aortic area as blood is ejected from the left ventricle through the stenosed aortic valve during systole. (Option 3) The second heart sound (S2) is produced by the closure of aortic and pulmonic valves. When these valves are stiff and difficult to close (as with aortic stenosis), S2 is soft or absent. Educational objective:Aortic stenosis obstructs blood flow during systole from the left ventricle to the aorta. Clients will develop exertional dyspnea, chest pain, and syncope as the heart is unable to overcome the obstruction to pump enough blood to meet metabolic demands. A systolic ejection murmur over the aortic area, soft or absent second heart sounds, and weak peripheral pulses are characteristic.

A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for? a. Erectile dysfunction b. Dizziness c. Dry cough d. Leg edema

Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. The most important adverse effects of calcium channel blockers include dizziness (Option 2), flushing, headache, peripheral edema (Option 4), and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods. (Option 3) Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, which may produce a nonproductive cough in susceptible individuals. Discontinuation of the medication stops the cough. (Option 1) Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction. Educational objective:Calcium channel blockers are utilized to treat hypertension and chronic stable angina. Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation.

The nurse is caring for a client with cardiomyopathy and coronary artery disease. The client is reporting increasing chest pain and has bilateral lung crackles on auscultation. The health care provider has written several new prescriptions. Which new prescription should the nurse clarify? Select all that apply. Vital signs Blood pressure 84/58 mm Hg HR -108/min RR -28/min O2 sat% - 90% a. Administer 2,000 ml NS bolus b. Administer IV NTG c. Apply 4 L oxygen by n/c d. Obtain a STAT 12-lead ECG e. Obtain blood for cardiac enzyme testing

Cardiomyopathy is a group of diseases in which the heart muscle (ie, myocardium) has a reduced ability to pump blood effectively, placing clients at risk for cardiogenic shock. Cardiogenic shock is manifested by reduced cardiac output (eg, hypotension, narrow pulse pressure), which can lead to pulmonary edema (eg, tachypnea, bibasilar crackles, decreased oxygen saturation) caused by blood "backing up" into the pulmonary capillaries. To compensate, catecholamines (eg, epinephrine) and vasopressin are released by the adrenal glands to increase cardiac output. However, this compensatory mechanism eventually fails, causing decreased perfusion and oxygenation of tissues as well as death. The client may need additional support with ionotropic agents (eg, norepinephrine) in these situations. Supplemental oxygen is appropriate for treatment given low oxygen saturation, chest pain, and tachypnea (Option 3). If chest pain is present, obtaining an ECG and testing cardiac enzymes (eg, creatine kinase-MB, troponin I) are appropriate (Options 4 and 5). (Option 1) IV fluids should not be given rapidly (ie, bolused) in cardiogenic shock as this will suddenly increase circulating volume and cardiac workload, which may precipitate pulmonary edema. (Option 2) Nitroglycerin can worsen hypotension and should be held. Other pain medications (eg, morphine) may be given for chest pain if blood pressure is low. Educational objective:Clients with cardiomyopathy may develop cardiogenic shock due to the heart's inability to circulate blood effectively, causing reduced cardiac output. Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme testing, and interventions to reduce cardiac workload.

The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures? a. Client who had a large anterior wall myocardial infarction (MI) with subsequent heart failure b. Client who had a mitral valvuloplasty repair c. Client with a mechanical aortic valve replacement d. Client with mitral valve proplapse with regurgitation

Certain individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis (IE). These include the following: Prosthetic heart valve or prosthetic material used to repair heart valve Previous history of IE Some forms of congenital heart diseaseUnrepaired cyanotic congenital defectRepaired congenital defect with prosthetic material or device for 6 months after procedureRepaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device Cardiac transplantation recipients who develop heart valve disease (Option 1) The client with acute MI and heart failure is not at risk for IE. (Option 2) The client with mitral valve repair without the use of prosthetic material is at low risk for IE. (Option 4) The client with mitral valve prolapse with or without regurgitation, or aortic valve disease does not require prophylaxis for IE. Educational objective:Clients with any form of prosthetic material in their heart valves or who have unrepaired cyanotic congenital heart defect or prior history of IE should take prophylactic antibiotics prior to dental procedures to prevent development of IE.

A 3-month-old who weighs 8.8 lb (4 kg) has just returned to the intensive care unit after surgical repair of a congenital heart defect. Which finding by the nurse should be reported immediately to the health care provider? a. Chest tube output of 50 ml in the past hour b. HR of 150/min c. Temp of 97.5 F d. Urine output of 8 ml in the past hour.

Chest tubes may be placed during cardiac surgery to help drain fluid and air and to ensure room for lung expansion. The chest tube and chamber should be assessed every hour for color and quantity of drainage. Drainage >3 mL/kg/hr for 3 consecutive hours or >5-10 mL/kg in 1 hour should be reported immediately to the health care provider (Option 1). This could indicate postoperative hemorrhage and requires immediate intervention. Cardiac tamponade can develop rapidly in children and can be life-threatening. This child weighs 4 kg and an output of 50 mL in 1 hour is excessive. (Option 2) For infants age 1-12 months, the normal heart rate is 90-160/min. (Option 3) Hypothermia is common after surgery. Warmers may be used to correct the client's temperature. (Option 4) Hourly urine output should be measured in the postoperative infant. A urinary catheter is often placed during surgery, allowing for accurate measurement. Urine output should be 1-2 mL/kg/hr. Educational objective:The nurse should immediately report chest tube drainage >3 mL/kg/hr over 3 consecutive hours or >5-10 mL/kg over 1 hour, which could indicate postoperative hemorrhage. Cardiac tamponade can occur rapidly in children and can be life-threatening.

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up? a. Client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg b. Client with heart failure who has a BNP level of 800 pg/ml c. Client with infected pressure ulcer who has a WBC of 13,000/mm d. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds

Clients with pulmonary embolism or deep venous thrombosis are treated with anticoagulation. Unfractionated heparin is one such agent, and its efficacy is measured through partial thromboplastin time (PTT) levels. The goal during anticoagulation therapy is a PTT 1.5-2 times the normal reference range of 25-35 seconds. A PTT of 127 seconds is much too prolonged, and spontaneous bleeding could occur. (Option 1) Clients with chronic obstructive pulmonary disease typically have elevated PaCO2 levels secondary to air trapping. A PaCO2 of 52 mm Hg (6.9 kPa), although elevated from the normal range of 35-45 mm Hg (4.7-6.0 kPa), is not extreme for this client. (Option 2) Clients with heart failure are expected to have elevated brain natriuretic peptide (BNP) levels. The nurse should compare BNP levels with those from the previous day. The client is likely receiving therapy for heart failure and is therefore not a priority. (Option 3) A normal white blood cell (WBC) count is 4,000-11,000/mm3 (4.0-11.0 x 109/L). A WBC count of 13,000/mm3 (13.0 x 109/L) is elevated but would be expected in a client with an infection. Even if this is the client's first WBC result, it is not a priority over the client with elevated PTT. Educational objective:Clients who are receiving heparin infusion for pulmonary embolism or deep venous thrombosis should be maintained with a partial thromboplastin time of 1.5-2 times the reference range used by the laboratory measuring the level. The normal reference range is typically 25-35 seconds.

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. a. Clubbing of fingertips b. Cyanosis when crying c. Diaphoresis during feedings d. Heart murmur e. Poor weight gain

Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow.Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion (Option 3) Heart murmur or extra heart sounds (Option 4) Signs of congestive heart failure Increased metabolic rate with poor weight gain (Option 5) (Option 1) Clubbing of the fingertips is associated with chronic hypoxia caused by decreased pulmonary circulation as occurs with right-to-left heart defects. (Option 2) Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident shortly after birth and during periods of physical exertion. Educational objective:Left-to-right cardiac shunts (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) result in excess blood flow to the lungs. Manifestations include heart murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure.

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? a. I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out b. I can still take this with my vardenafil prescription c. I can take up to 3 pills in a 15-minurw period if I am experiencing chest pain d. I should stop taking the pills if I experience a headache

Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina. Instructions for proper NTG administration include: Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1). Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3). Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension (Option 2). Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation (Option 4). Educational objective:The nurse should instruct the client who is taking sublingual NTG to keep the tablets in a tightly capped, dark bottle away from heat and light. The client should be taught to take 1 tablet every 5 minutes (up to 3 tablets), but notify EMS if the pain does not improve or worsens 5 minutes after the first pill has been taken. These instructions should be reinforced at each appointment.

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP? a. BP of 140/8 b. Difficulty swallowing c. Dry, hacking cough d. Low back pain

Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment. (Option 1) This BP reading is slightly elevated. The nurse would need to assess further to find out if this is a typical BP for this client. Given the client's history of aneurysm, this elevated BP may warrant treatment. (Option 3) The nurse would need to assess the client further as there are multiple causes of cough. (Option 4) Low back pain would be a concern if the client had a history of abdominal aortic aneurysm. Educational objective:The nurse should report swallowing difficulty immediately in a client with a thoracic aortic aneurysm. This could indicate that the aneurysm has increased in size and may require treatment.

The nurse is performing discharge teaching for the parents of a 4-year-old with heart failure. Which statement by the parents indicates the need for further teaching related to the administration of digoxin? a. If our child vomits after a dose, we won't give a second dose b. Symptoms of nausea and vomiting should be reported to our health care provider. c. We will hold the dose if out child's heart rate is above 90/min d. We will not mix the medication with other foods or liquids.

Digoxin is a cardiac glycoside given to infants and children in heart failure. It is given to increase myocardial contraction, which increases cardiac output and improves circulation and tissue perfusion. Digoxin is a potentially dangerous drug due to its narrow margin of safety in dosage. Parents should receive thorough education and in return demonstrate appropriate administration procedures for this medication. Parent teaching for administration of digoxin includes the following: Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child. Administer oral liquid in the side and back of the mouth Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication (Option 4) If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule. If more than 2 doses are missed, notify the HCP If the child vomits, do not give a second dose (Option 1). Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP (Option 2). Give water or brush the client's teeth after administration to remove the sweetened liquid Educational objective:Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity. General guidelines are to hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD? a. HOB elevated to a 45 degree angle b. HOB elevated to a 60 degree angle c. HOB elevated to a 90 degree angle d. HOB flat

Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a 30- to 45-degree angle. The nurse will observe for distension and prominent pulsation of the neck veins. The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload. (Options 2 and 3) JVD may still be present at 60- and 90-degree angles if marked fluid overload is present. Placement this high might miss mild to moderate JVD. (Option 4) JVD may be present while the client is flat. This is not considered abnormal, and the client with possible fluid overload or respiratory issues may not be able to lie flat. Educational objective:The nurse should position the client with the head of the bed at a 30- to 45-degree angle to assess for the presence of JVD.

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. Home medications Aspirin: 81 mg PO, daily Clopidogrel: 75 mg PO, daily Metoprolol XL: 50 mg PO, daily Furosemide: 40 mg PO, twice daily Fish oil: 4 g PO, daily a. Bruising easily, especially on the arms b. Fatigue c. Feeling depressed d. Muscle cramps in the legs

Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia (Option 4). Additional causes of hypokalemia include gastrointestinal losses (eg, vomiting, diarrhea, nasogastric suctioning) and medications (eg, insulin). To combat hypokalemia in clients receiving potassium-wasting diuretics, supplemental potassium and/or a high-potassium diet may be required. (Option 1) Bruising is common with the use of antiplatelet agents (eg, aspirin, clopidogrel). However, the nurse should monitor for and report signs of uncontrolled bleeding, such as bloody stools and signs of stroke (eg, headache, slurred speech). (Option 2) Myocardial infarction and heart failure often cause activity intolerance and fatigue due to decreases in heart muscle function. In addition, fatigue is a common side effect experienced on initiation of beta blocker (eg, metoprolol) therapy, but typically improves over time. (Option 3) Feelings of depression are common after an acute health-related event such as a myocardial infarction. The nurse should further explore and evaluate feelings of depression; however, these symptoms are not immediately life-threatening unless the client exhibits suicidal ideation. Educational objective:Nurses caring for clients receiving potassium-wasting diuretics (eg, furosemide) should monitor for and report signs of hypokalemia (eg, muscle cramps), as unmanaged hypokalemia may result in lethal complications. Bruising, a side effect of antiplatelet medications, and fatigue, a side effect of beta blockers, should be monitored, but are not lethal.

A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Click on the exhibit button for additional information. Lab results: Sodium - 134 mEq/L Potassium - 3.4 mEq/L Chloride - 108 mEq/L Magnesium 0.9 mEq/L a. Atrial fibrillation b. Atrial flutter c. Mobits II d. Torsades de pointes

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate. (Option 1) Characteristics of atrial fibrillation (AF) include an irregularly irregular rhythm and replacement of P waves by fibrillatory waves. Although electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening. (Option 2) Atrial flutter is characterized by sawtooth-shaped flutter waves. There is no clinical evidence suggesting that hypomagnesemia leads to atrial flutter, which is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale). (Option 3) Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers). Educational objective:In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).

A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action? a. Attach defibrillator pads to the client's chest b. Check the lipid profile lab results c. Obtain a 12- lead ECG d. Prepare to administer a heparin drip

It is very important to rapidly diagnose and treat the client with chest pain and potential myocardial infarction to preserve cardiac muscle. Initial interventions in emergency management of chest pain are as follows: Assess airway, breathing, and circulation (ABCs) Position client upright unless contraindicated Apply oxygen, if the client is hypoxic Obtain baseline vital signs, including oxygen saturation Auscultate heart and lung sounds Obtain a 12-lead electrocardiogram (ECG) Insert 2-3 large-bore intravenous catheters Assess pain using the PQRST method Medicate for pain as prescribed (eg, nitroglycerin) Initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor) Obtain baseline blood work (eg, cardiac markers, serum electrolytes) Obtain portable chest x-ray Assess for contraindications to antiplatelet and anticoagulant therapy Administer aspirin unless contraindicated (Option 1) The defibrillator may be used if the 12-lead electrocardiogram (ECG) or cardiac monitoring shows a lethal and shockable rhythm, such as ventricular fibrillation; however, the 12-lead electrocardiogram (ECG) is priority. (Option 2) Elevated cholesterol (lipids) are indicative of long-term lifestyle behaviors and eating habits; a fasting lipid panel needs to be checked within 24 to 48 hours in all clients with presenting coronary artery disease, but this is not an emergency. (Option 4) Anticoagulation with heparin is indicated if the client's pain is determined to be due to acute coronary syndrome. There are many other causes of chest pain that do not require anticoagulation or may be contraindicated (eg, aortic dissection). Educational objective:Nurses must take presenting cardiac symptoms seriously until the cause is determined. Assess airway, breathing, and circulation, and obtain baseline pulse oximetry and vital signs. Then obtain electrocardiogram (ECG) results.

During assessment of a client who underwent a coronary artery bypass graft 10 hours ago, the nurse notes that the amount of drainage from the mediastinal chest tube has decreased from 100 mL to 20 mL over the last hour. Which of the following nursing actions is appropriate? a. Auscultate the client's heart sounds b. Notify the client's HCP c. Position the tubing with a dependent loop d. Strip the chest tube to remove possible clots

Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated. If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade (Option 1) and if no such signs are present should troubleshoot other possible causes of chest tube occlusion. (Option 2) The health care provider should be notified after relevant assessment data has been gathered and troubleshooting has been performed. (Option 3) The chest tube should be kept free of dependent loops and kinks. This assists with proper drainage and prevents fluid from accumulating and backflowing into the mediastinum. (Option 4) Stripping (or milking) a chest tube should not be performed, unless specifically prescribed, as it can exert excessively high negative pressure and traumatize tissues within the mediastinum. Educational objective:A marked decrease in mediastinal chest tube drainage warrants immediate assessment for signs of cardiac tamponade (eg, muffled heart tones, pulsus paradoxus, hypotension). If there are no signs of tamponade, the nurse should troubleshoot other possible causes of chest tube occlusion and contact the health care provider.

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? a. I can continue to take my prescription of sildenafil b. I should take the patch off when I shower c. I will remove the patch if I develop a headache d. I will rotate the site where I apply the patch

Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. (Option 1) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. (Option 2) Patches may be worn in the shower. (Option 3) Headaches are common with the use of nitrates. The client may need to take an analgesic. Educational objective:Nursing education about transdermal nitroglycerin includes application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation? a. 10 mg Isosorbide dinitrate BID b. 20 mg Atorvastatin once daily c. 500 mg Naproxen BID d. 2,000 mg fish oil once daily

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) are common medications used for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. The nurse should investigate the reason a client with cardiovascular disease is taking an NSAID and alert the health care provider of the medication usage (Option 3). (Option 1) Isosorbide dinitrate (Isordil) is a long-acting nitrate medication prescribed to prevent angina in clients with CAD. Nitrate medications prevent angina by causing vasodilation of the peripheral vessels (decreasing cardiac workload) and the coronary arteries (improving coronary artery perfusion). (Option 2) Atorvastatin (Lipitor) is a statin drug prescribed to lower cholesterol, which can reduce the risk of atherosclerosis and coronary artery disease. (Option 4) Fish oil is an over-the-counter nutritional supplement often taken by clients with heart disease or individuals at risk. Fish oil contains omega-3 fatty acids, which may decrease blood triglyceride levels with consistent use. Educational objective:Clients with cardiovascular disease (eg, coronary artery disease) are cautioned against taking nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen), which increase the risk of thrombotic events (eg, heart attack, stroke). Nurses who identify clients with cardiovascular disease taking NSAIDs should investigate the reasons for use and notify the health care provider.

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? a. Assess and compare blood pressure in each arm b. Assess character and quality of peripheral pulses c.Assess for presence or absence of hair on lower extremities d. Assess for presence of bowel sounds

Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm. Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require reoperation. (Option 1) Comparison of blood pressures in each arm may be helpful in an assessment of an upper aortic dissection or congenital aortic coarctation, but not in assessing an abdominal aortic aneurysm. (Option 3) Absence of hair growth on the lower extremities is more specific for peripheral artery disease. (Option 4) Although auscultation of bowel sounds is part of a basic assessment, it is not considered a key assessment preoperatively. It will become more of a priority postoperatively in assessment of ileus. Educational objective:Preoperative assessment of the character and quality of peripheral pulses provides a baseline for rapid postoperative assessment and identification of emergent complications (embolization, graft occlusion).

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. a. Ecchymosis of the scrotum b. Increased abdominal girth c. Increased urinary output d. Report of groin pain e. Report of increased thirst and appetite loss.

Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output (Options 1, 2, and 4). (Option 3) Urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension. (Option 5) Increased thirst and appetite loss are not signs of graft leakage. Educational objective:Signs of graft leakage that are important to monitor after repair of an abdominal aortic aneurysm include pain in the back, pelvis, or groin; ecchymosis of the groin, scrotum, or penis; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased abdominal girth; and decreased urinary output.

A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? a. If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP b. Inform the client with medications such as sildenafil or tadalafil are available as prescriptions from the HCP c. It will be 6 months before the heart is healthy enough for sexual activity d. The client will be ready for sexual activity after completion of the cardiac rehabilitation.

Sexual counseling is important for cardiac clients, yet can be difficult for clients and HCPs to discuss and is often neglected. Clients' concern about resumption of sexual activity can prove to be more stressful than would be the activity itself. The nurse should encourage clients to discuss concerns with the HCP; in general, if a client can walk 1 block or climb 2 flights of stairs without symptoms, the client can resume sexual activity safely. (Option 2) The use of erectile agents is contraindicated if the client is consuming any form of nitrates. (Option 3) Resumption of sexual activity depends on the emotional readiness of the client and the client's partner and on the HCP's assessment of recovery. In general, it is safe to resume sexual activity 7-10 days after an uncomplicated MI. (Option 4) The client may participate in cardiac rehabilitation, but this should not impact the ability to engage in sexual activity, especially if the client remains asymptomatic. Educational objective:It is important to educate clients and their partners about sexual activity after an MI. Generally, it is safe for clients to consider resumption of sexual activity when they can walk 1 block or climb 2 flights of stairs without symptoms.

A client is admitted to the emergency department after a fall with dizziness and light-headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the exhibit. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. a. Complete heart block b. 1st-degree heart block c. Sinus bradycardia d. Sinus rhythm

Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate of <60/min. SB is classified as symptomatic if, in addition to a heart rate <60/min, the client experiences such symptoms as dizziness, syncope, chest pain, and hypotension. The clinical significance of SB depends on how the client tolerates it. The client with symptomatic SB is first treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine is considered. A permanent pacemaker may be needed. If SB is the result of a medication (eg, beta blocker, digoxin), the drug may need to be held, discontinued, or given in a reduced dosage. (Option 1) Complete heart block, or 3rd-degree atrioventicular (AV) block, is a form of AV dissociation in which no impulses from the atria are conducted to the ventricles. The atria are stimulated and contract independently of the ventricles. The ventricular rhythm is an escape rhythm. (Option 2) In 1st-degree AV block, every impulse is conducted to the ventricles, but the time of AV conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. (Option 4) Sinus rhythm has a rate of 60-100/min. Educational objective:The nurse should be able to recognize SB on the ECG and assess for clinical significance (eg, chest pain, syncope, hypotension) in the client. Initial expected treatment for symptomatic clients includes atropine and transcutaneous pacing.

The charge nurse is assisting with a nonemergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene? a. Administer a one-time dose of IV midazolam b. Disengages the "sync" function on the defibrillator c. Places defibrillator pads on upper right and lower left chest d. Turns off the client's oxygen and moves it away from the bed

Synchronized cardioversion is a procedure used to convert tachyarrhythmias (eg, supraventricular tachycardia, ventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The shock in cardioversion is timed by the defibrillator ("sync" feature enabled) to be delivered only during the R wave of the QRS complex, when the ventricles depolarize. Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, causes R-on-T phenomenon, which frequently results in lethal arrhythmias (eg, ventricular fibrillation). The nurse must ensure that the defibrillator's "sync" feature is enabled when preparing to perform synchronized cardioversion. Disabling or failing to enable the "sync" feature may result in a potentially lethal, asynchronous shock being delivered to the client (Option 2). (Option 1) During nonemergent cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. (Option 3) Defibrillator pads should be placed on the right upper chest next to the sternum and on the left lower chest. (Option 4) Prior to delivery of electrical shock (eg, cardioversion, defibrillation), oxygen should be turned off and moved away. Oxygen is flammable and may explode when subjected to electric currents. Educational objective:Synchronized cardioversion is a cardiac procedure used to convert tachyarrhythmias with a pulse to stable cardiac rhythms. Nurses preparing to perform cardioversion must verify that the defibrillator's "sync" feature is engaged to prevent delivery of an asynchronous shock, which may cause life-threatening arrhythmias.

A nurse is teaching the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply. a. Encourage smaller, frequent feedings b. Offer a pacifier when the infant begins to cry c. Promote a quiet period upon waking in the morning d. Swaddle the infant during procedures e. Turn the infant frequently during sleep.

Tetralogy of Fallot is a complex heart defect that results in decreased pulmonary blood flow, mixing of oxygenated and unoxygenated blood, and inadequate blood flow into the left side of the heart. Hypercyanotic episodes (ie, "tet" spell) occur when unoxygenated blood enters the systemic circulation, resulting in cyanosis and hypoxemia. Tet spells usually occur during stressful or painful procedures; on waking; and with hunger, crying, and feeding. Home interventions to reduce the incidence of tet spells include: Providing a calm environment, particularly on waking (Option 3) Soothing and quieting the infant when crying or distressed Offering a pacifier (Option 2) Swaddling or holding the infant during procedures or times of stress (Option 4) Providing frequent smaller feedings to reduce frustration due to hunger and limit sucking fatigue (Option 1) During an acute tet spell, the infant may be placed in the knee-chest position to improve pulmonary blood flow by increasing systemic vascular resistance; older children may assume a squatting position. Intermittent oxygen can also be used to treat the spell, if necessary. (Option 5) Tet spells occur more often during stressful situations or on waking, so sleep should not be interrupted whenever possible. Educational objective:Hypercyanotic or tet spells usually occur during stressful or painful procedures; on waking; and with hunger, crying, and feeding. Providing a calm environment; reducing hunger with small, frequent meals; and swaddling during procedures can help prevent hypercyanotic spells.

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply. a. No sexual activity for at least 6 weeks postoperatively b. Notify HCP of redness, swelling, or drainage at the incision site c. Refrain from lifting objects weighing >5 lbs until approved by the HCP d. Take a shower daily without soaking chest and leg incisions e. Use lotion on incision sites with dressing changes if the area is dry

The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. Clarify no driving for 4-6 weeks or until the HCP approves. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). Notify the HCP if the following symptoms occur:Chest pain or shortness of breath that does not subside with restFever >101 F (38.3 C)Redness, drainage, or swelling at the incision sites (Option 2). Educational objective:Discharge teaching for a client recovering from a CABG should include instructions related to medications, activity level, driving, sexual activity, and symptoms to report to the HCP.

A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the nurse suspect as the most likely cause? Click the exhibit button for more information. a. Captopril b. Carvedilol']c. Glimepiride c. Glimepiride d. Levothyroxine

The client has sinus bradycardia, which can be caused by: Drugs (eg, beta blockers, calcium channel blockers, digoxin). Consider withholding beta blockers if systolic blood pressure <100 mm Hg or heart rate <60 and notify the provider. Vagal stimulation (eg, carotid sinus massage, Valsalva maneuver) Diseases (eg, hypothyroidism, myocardial infarction, increased intracranial pressure) The clinical significance of sinus bradycardia depends on how the client tolerates the effect of slow heart rate on cardiac output. Sinus bradycardia is usually asymptomatic. However, symptomatic bradycardia can manifest as pale, cool skin; hypotension; weakness; confusion; dyspnea; chest pain; and syncope. (Options 1, 3, and 4) The side effects of these drugs include tachycardia (Table). Educational objective:Sinus bradycardia may be caused by drugs (eg, beta blockers), vagal stimulation, hypothyroidism, inferior wall myocardial infarction, and increased intracranial pressure. It is normal in some people (eg, trained athletes). *Review sinus brady EKG strip

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client? a. Diet recall for this current week b. Fluid intake for the past 2 days c. Medications and dosages taken over the past 2 days d. Presence of shortness of breath, coughing, or edema

The client with chronic heart failure is at risk for exacerbations that may require hospitalization. The priority for the nurse on the phone is to ascertain if the client is experiencing any physiological symptoms such as shortness of breath, coughing, or edema (Option 4). These could indicate fluid overload. This information can help the nurse direct the client to come in for further assessment, follow a protocol to make changes in medications/dosages, or restrict fluids. (Options 1, 2, and 3) These are all important in assessment of the possible cause of the weight gain. They should be addressed after the nurse has questioned the client about physiological symptoms. Educational objective:The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse? a. Nurse has client lie supine for 5-10 minutes prior to starting procedure b. Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding c. Nurse starts by measuring BP and HR witha client standing d. Nurse takes BP and HR after standing at 1- and 3-minute intervals

The experienced nurse should intervene if the new RN starts BP measurement with the client in the standing position. Orthostatic BP measurement may be done to detect volume depletion or postural hypotension caused by medications or autonomic dysfunction. Procedure for measurement of orthostatic BP Have the client lie down for at least 5 minutes (Option 1) Measure BP and HR Have the client stand Repeat BP and HR measurements after standing at 1- and 3-minute intervals (Option 4) A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal (Option 2). Educational objective:To measure orthostatic BP, the nurse should have the client lie supine for 5-10 minutes and then measure BP and HR. The nurse should then have the client stand for 1 minute, measure BP and HR, and repeat the measurements at 3 minutes. Findings are significant if the systolic BP drops ≥20 mm Hg or the diastolic BP drops ≥10 mm Hg.

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following? a. Coughing and deep breathing b. Left lateral position c. Pursed-lip breathing d. Sitting up and leaning forward

The most common cause of acute pericarditis is a recent viral infection. It is an inflammation of the visceral and/or parietal pericardium. Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. This position reduces pressure on the inflamed parietal pericardium, especially during lung inflation. The pain is different than that experienced during myocardial infarction. Assessment shows a pericardial friction rub (scratchy or squeaking sound). Treatment includes a combination of nonsteroidal anti-inflammatory drugs (NSAIDS) or aspirin plus colchicine. (Option 1) Pericarditis causes pain on inspiration, not expiration. This pleuritic-type pain also increases with coughing. (Option 2) The supine or lying-down position worsens pericarditis pain. (Option 3) The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease. Educational objective:Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. Treatment includes a combination of NSAIDs or aspirin plus colchicine.

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? a. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline b. 2 days postcoronary bypass graft surgery with a WBC count of 18,000 c. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion. d. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival. (Option 2) An elevated white blood cell count (>11,000/mm3 [11.0 x 109/L]) could be caused by an underlying infection or the stress of the surgery. This needs to be assessed as soon as possible, but it does not take priority over the possible limb loss with graft occlusion. (Option 3) A decreased ejection fraction (normal 55%-70%) results in decreased cardiac output and inability to meet oxygen demand, leading to shortness of breath and activity intolerance. The nurse should assess lung sounds. However, this is an expected finding, so the nurse does not need to assess this client first. (Option 4) Subcutaneous emphysema is air in the tissue surrounding the chest tube insertion site and can occur in a client with a pneumothorax. The nurse should assess lung sounds and palpate to determine the degree of emphysema. However, this is an expected finding, so the nurse does not need to assess this client first. Educational objective:A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity in a client who is postoperative abdominal aortic aneurysm repair can indicate the presence of an arterial or graft occlusion and poses the greatest threat to survival.

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information. 0600 Wednesday 0600 Thursday BP - 148/84 BP - 98/60 I/O - 1000/3000ml. I/O - ___________ Sodium - 140 mEq/L. Sodium - 150 mEq/L Potassium - 4.2 mEq/L. Potassium - 3.5 mEq/L Glucose - 90 mg/dL Glucose - 99 mg/dL Allergies: None Medications Thursday Furosemide: 40 mg IVP, once daily 0700 Levofloxacin: 500 mg IV, once daily 0700 Glipizide: 5 mg orally, twice daily 0700-1700 Potassium chloride: 20 mEq/L orally, once daily 0700 a. Furosemide b. Glipizide c. Levofloxacin d. Potassium chloride

The nurse should question the prescription for furosemide (Lasix), a potent loop diuretic, before administering the medication. The client has a significant decrease in systolic blood pressure (50 mm Hg), a negative fluid balance of 2000 mL for 24 hours, hypernatremia (normal sodium, 135-145 mg/dL [135-145 mmol/L]), and a potassium level that is trending downward. These parameters indicate hypotonic dehydration, which is often caused by diuretic use. If the diuretic were administered, the fluid volume deficit would increase further. (Option 2) Glipizide, an oral sulfonylurea drug used to control blood sugar, is prescribed once or twice a day 30 minutes before meals. The client's blood sugar is within normal limits (70-99 mg/dL [3.9-5.5 mmol/L]), so there is no need for the nurse to question the prescription. (Option 3) Antibiotic therapy with levofloxacin (Levaquin) is appropriate for a client with a urinary tract infection, so there is no need for the nurse to question the prescription. (Option 4) Potassium chloride is usually prescribed with a diuretic to prevent hypokalemia. The potassium is within normal limits (normal, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) but is trending downward. A further decrease in potassium from the diuretic would increase the risk for cardiac dysrhythmias associated with hypokalemia. Most clients need a potassium level of around 4.0 mEq/L (4.0 mmol/L) to prevent arrhythmias. If the furosemide is discontinued, the health care provider and nurse should check serum potassium levels the next day to determine whether further dosing is necessary. Educational objective:Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy.

The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client? a. Decreasing sodium intake b. Decreasing stress levels at work and home c. Increasing activity level d. Taking BP medications as prescribed.

The priority teaching topic for this client is taking blood pressure medications as prescribed. A major problem with long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant side effects, including fatigue, dizziness, and erectile dysfunction. Client may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. The nurse should determine whether the client has been taking the medications consistently. There may be a need for a dosage change or addition of another medication. The client's blood pressure is not well controlled, and the TIA places this client at a high risk for a stroke. (Options 1, 2, and 3) Decreasing sodium intake and stress levels, plus increasing activity level, are all helpful in managing hypertension. The client should be doing all these, and the teaching topics need to be reinforced. However, they are a lower priority than taking the blood pressure medications as prescribed. Educational objective:A major problem with long-term management of hypertension is poor adherence to the treatment plan. The nurse should teach the client the importance of taking blood pressure medications as prescribed.

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN? a. Nurse carefully auscultates heart murmurs at Erb's point b. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry c. Nurse places client in semi-Fowler's position to assess for jugular distension d. Nurse positions client supine to assess the point of maximal impulse.

The pulses in the neck should be palpated for information on arterial blood flow. The carotid arteries should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a syncopal episode. Pulse symmetry for other key arteries (eg, temporal, brachial, radial, posterior tibial) is assessed by bilaterally palpating each pair simultaneously. (Option 1) Erb's point is located at the third left intercostal space (ICS) near the sternum and is an appropriate location to auscultate heart sounds for murmurs. (Option 3) Jugular venous distension should be assessed with the client in semi-Fowler's position (ie, head of the bed elevated at a 30- to 45-degree angle). (Option 4) To assess the point of maximal impulse (PMI) the client is positioned supine or with the head of the bed elevated to 45 degrees; the nurse should palpate for a short tap at the midclavicular line of the fourth or fifth ICS (pulsation may or may not be visible). A displaced PMI (eg, below the fifth ICS) may be an indication of an enlarged heart. Educational objective:The nurse should not palpate the carotid arteries simultaneously due to possible vagal stimulation resulting in bradycardia or syncope. Each carotid artery should be palpated separately.

A nurse on the telemetry unit observes the following rhythm on the monitor of a client admitted with coronary artery disease. What action should the nurse take first? Click the exhibit button for additional information. a. Administer atropine 0.5 mg IVP b. Measure the client's VS c. Move the client back to be bed from chair d. Obtain a temporary pacemaker

The rhythm shows that the client is experiencing a second-degree atrioventricular (AV) block, type 1. This is an intermittent block usually occurring at the level of the AV node characterized by a progressively lengthening PR interval until a QRS complex is dropped. AV block can be associated with myocardial ischemia (eg, coronary artery disease) or certain medications (eg, beta blockers, digoxin). Assess the client first for any evidence of symptoms associated with the rhythm (eg, hypotensive, dizzy, shortness of breath). Treatment is only indicated if the client is symptomatic. If the client is experiencing symptoms, atropine and temporary pacing may be indicated. If there are no associated symptoms, the nurse should continue to closely monitor the client and be ready to intervene if symptoms arise. (Option 1) Atropine is indicated in clients with symptomatic bradycardia (heart rate <60/min). (Option 3) If the client is experiencing symptoms associated with the rhythm, it would be advisable to put the client back to bed for safety reasons. Assessing vital signs would help the nurse determine if the client is symptomatic. (Option 4) The nurse should measure the client's vital signs first. A temporary pacemaker may be indicated if the client is symptomatic. Educational objective:Assess the client with second-degree atrioventricular block, type 1 for symptoms associated with the rhythm (eg, hypotension, dizziness, shortness of breath). If no symptoms are present, closely monitor the client. If symptoms are present, anticipate using atropine or temporary pacing.

The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip? a. Atrial paced rhythm b. 1st degree atrioventricular block with bigeminy c. Sinus rhythm with premature ventricular contractions d. Ventricular paced rhythm with failure to sense

The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks). (Option 2) In first-degree atrioventricular block, every impulse is conducted to the ventricles, but the time of atrioventricular conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option 3) Normal sinus rhythms do not have pacer spikes. Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option 4) Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations (eg, pacer spike on the T wave). It should not be confused with failure to capture, in which pacer spikes are located appropriately but there is no electrical response elicited from the heart (eg, no QRS complex after a pacer spike). Educational objective:An atrial paced rhythm displays a pacer spike followed by a normal or distorted P wave, then a QRS complex. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks).

A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority? a. Administer Digoxin 0.25 mg b. Administer furosemide 40 mg IVP c. Initiate dopamine infusion at 5 mcg/kg/min d. Obtain blood sample for arterial blood gases

This client is exhibiting signs of pulmonary edema, a life-threatening condition. In the presence of acute left ventricular failure, pulmonary vasculature overload causes increased pulmonary venous pressure that forces fluid out of the vascular space into the pulmonary interstitium and, if untreated, into the alveoli. Clinical manifestations of pulmonary edema include: A history of orthopnea and/or paroxysmal nocturnal dyspnea Anxiety and restlessness Tachypnea (often >30/min), dyspnea, and use of accessory muscles Frothy, blood-tinged sputum Crackles on auscultation The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema (Option 2). Management of acute decompensated heart failure (ADHF) may also include oxygen therapy, vasodilators (eg, nitroglycerin, nesiritide), and positive inotropes (eg, dopamine, dobutamine). Vasodilators decrease preload thus improving cardiac output and decreasing pulmonary congestion. Positive inotropes improve contractility but are only recommended if other medications have failed or in the presence of hypotension. (Option 1) Digoxin is a positive inotropic drug (improves contractility) used in long-term treatment of heart failure. (Option 3) Dopamine, a positive inotropic drug, is used as a short-term treatment for ADHF; however, it does not resolve the fluid overload affecting oxygenation. (Option 4) Drawing arterial blood gases is appropriate in the setting of ADHF, but it is not the priority in this situation. Educational objective:In the presence of acute decompensated heart failure (ADHF) and pulmonary edema, diuretic (eg, furosemide) administration is effective in removing excess fluid to reduce pulmonary congestion and improve oxygenation. Vasodilators (eg, nitroglycerin, nesiritide) and positive inotropes (eg, dopamine, dobutamine) are also used in the treatment of ADHF.

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider? a. Breast tenderness b. Generalized weight gain c. Leg swelling d. Nausea and vomiting

Transgender women clients are often prescribed antiandrogen medications (eg, spironolactone) to reduce androgen levels (eg, testosterone) and estrogen therapies to induce feminizing traits (eg, breast enlargement, reduction in body hair, decrease in testicular size and erectile function). Estrogen places clients at an increased risk for developing blood clots, due to hypercoagulability, and therefore adverse thrombotic events (eg, stroke, myocardial infarction, venous thromboembolism). Signs and symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider (HCP) immediately (Option 3). The client should also be taught smoking cessation and diabetes management, and to avoid long periods of immobilization to further decrease the risk of thrombus formation. (Option 1) Breast tenderness and enlargement are common, expected side effects of estrogen therapy. (Option 2) Generalized weight gain during estrogen therapy is caused by fluid retention and is generally mild. However, if weight gain with cardiovascular symptoms (eg, pedal edema) occurs, the HCP should be notified. (Option 4) Nausea and vomiting can occur with estrogen therapy and may be remedied with dosage adjustments or taking oral estrogen with food. Educational objective:Clients taking estrogen therapy are at an increased risk for hypercoagulability and thromboembolic complications. Signs or symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider immediately.

The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? a. A 25 year old client with abdominal pain who smokes cigaretted and takes oral contraceptives b. A 55 year old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% c. A 72 year old client with a fever who is 2 days post coronary stent placement d. An 80 year old client who is 4 days postop from repair of fractured hip

Venous thromboembolism includes both DVT and pulmonary embolism (PE). DVT is the most common form and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: Trauma (endothelial injury and venous stasis from immobility) Major surgery (endothelial injury and venous stasis from immobility) Prolonged immobilization (eg, stroke, long travel) causing venous stasis Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) Oral contraceptives (estrogen is thrombotic) Underlying malignancy (cancer cells release procoagulants) Smoking (produces endothelial damage by inflammation) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase blood viscosity) The 80-year-old 4-day postoperative client has the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age, and is at greatest risk for developing a DVT. (Option 1) Smoking cigarettes and using oral contraceptives increase plasma fibrinogen and coagulation factors and cause hypercoagulability of blood, but the client is not at greatest risk. Hormonal contraceptives are not recommended if the client is age >35 and also smokes. (Option 2) Elevated hemoglobin/hematocrit level (erythrocytosis) causes increased blood viscosity and hypercoagulability of blood, which increases the risk for DVT. However, the client is not at greatest risk. (Option 3) Anticoagulants and antiplatelet agents are administered before and after coronary stent placement. This client is at increased risk due to endothelial damage and advanced age but is not at greatest risk. Educational objective:DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.

The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take? a. Administer the next scheduled dose of warfarin b. Anticipate infusing fresh, frozen plasma c. Call the pharmacy to see if protamine is available d. Request a prescription from the health care provider for Vitamin K

A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 2-3) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote. (Option 1) The warfarin should not be administered with an INR of 5. The nurse should hold the dose until further instructions have been received by the HCP. (Option 2) Fresh, frozen plasma is considered when major bleeding is occurring related to warfarin overdose, but this is typically after the vitamin K has been administered. (Option 3) Protamine is the reversal agent for heparin overdoses. Educational objective:The nurse should hold a dose of warfarin for an INR over 4 and notify the HCP. Vitamin K may need to be administered for INRs of 5 or greater. A therapeutic INR level is dependent on the reason the client is receiving the warfarin (an anticoagulant). Typically the therapeutic INR range should be 1.5-2 times the normal "control" value (INR of 2-3) for medical reasons such as deep vein thrombosis, atrial fibrillation, or stroke. An INR of 3 to 3.5 is desired for the client with a mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote. (Option 1) The warfarin should not be administered with an INR of 5. The nurse should hold the dose until further instructions have been received by the HCP. (Option 2) Fresh, frozen plasma is considered when major bleeding is occurring related to warfarin overdose, but this is typically after the vitamin K has been administered. (Option 3) Protamine is the reversal agent for heparin overdoses. Educational objective:The nurse should hold a dose of warfarin for an INR over 4 and notify the HCP. Vitamin K may need to be administered for INRs of 5 or greater.

The nurse is caring for a client with end-stage heart failure. The rhythm shown in the exhibit is seen on the cardiac monitor, and the nurse finds the client unresponsive with no palpable pulse. What is the correct interpretation of this rhythm? Click on the exhibit button for additional information. a. Asystole b. Complete heart block c. Disconnected lead wire d. Pulseless electrical activity

Asystole is characterized by no electrical activity or obvious wave. Clients will have no pulse or respirations, and will be unresponsive (Option 1). Clients with advanced cardiac disease or heart failure are at increased risk for developing asystole. Cardiopulmonary resuscitation (CPR) should be initiated, followed by advanced cardiac life support measures, including administration of epinephrine, placement of an advanced airway, and treatment of any reversible causes. (Option 2) Complete heart block (third-degree atrioventricular block) is characterized by dissociated atrial and ventricular rhythms. The ECG will still show electrical activity. (Option 3) Lead connections should be checked when the ECG shows asystole, but the nurse has already assessed for the absence of pulse and unresponsiveness in the client. (Option 4) Pulseless electrical activity is characterized by organized electrical activity on the ECG but no discernible pulse. The ECG for this client shows no electrical activity. Educational objective:Asystole is characterized by complete absence of electrical activity on the ECG. The client will have no pulse or respirations, and will be unresponsive. The nurse should immediately initiate cardiopulmonary resuscitation, advanced cardiac life support measures, and treatment of any reversible causes.

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate's vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next? Click on the exhibit button for additional information. Vital signs Temperature 98.6 F (37 C) Heart rate 146/min Respirations 42/min O2 saturation 98% a. Call the HCP immediately b. Document the assessment finding c. Place the neonate in a knee-chest position d. Provide oxygen to the neonate

Atrioventricular (AV) canal defect is a cardiac anomaly often associated with trisomy 21 (Down syndrome). As an echocardiogram is already scheduled for that day, documenting the assessment finding would be the appropriate action for the nurse to complete at this time. (Option 1) The neonate has stable vital signs and the echocardiogram will be completed. This is not an emergency and the HCP does not need to be contacted immediately. (Option 3) A knee-chest position is used to treat episodes of hypoxia and cyanosis in infants and young children with tetralogy of Fallot (TOF). This neonate likely has an AV canal defect, not TOF. There is also no indication of cyanosis or hypoxia that would necessitate knee-chest positioning. (Option 4) The normal respiratory rate in a neonate is 30-60/min; pulse can be up to 160/min. The vital signs are stable and the oxygen saturation level is appropriate for a neonate. Educational objective:Trisomy 21 (Down syndrome) is often associated with the cardiac anomaly AV canal defect. Assessment typically includes a loud murmur that requires no immediate action when vital signs are stable. Surgery will correct the anomaly when the neonate grows in size and can tolerate the invasive procedure better.

A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take? a. Give scheduled dose of metoprolol 50 mg PO b. Instruct client to cough forcefully c. Place client in reverse Tredelenburg position d. Prepare to administer atropine 0.5 mg IVP

Clients with symptomatic bradycardia should be treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine should be considered. (Option 1) Metoprolol is a beta blocker and would further reduce the heart rate. The nurse should not administer this medication and instead notify the health care provider. (Option 2) A forceful cough may cause a vasovagal reaction and further reduce the heart rate. (Option 3) The Trendelenburg position, not the reverse Trendelenburg position, is used with clients with hypotension. Educational objective:The client with symptomatic bradycardia should be treated initially with IV atropine. Transcutaneous pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective.

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required? a. I may experience flushing but will continue to take the medication as prescribed b. I should lie down before taking the medication c. I should not swallow the tablet d. I will wait to call 911 if I don't experience relief after the third tablet

Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment (Option 4). NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed (Option 3). If using a spray, the client should not inhale it but direct it onto/under the tongue instead. (Option 1) Headache and flushing are common side effects of NTG due to systemic vasodilation. (Option 2) The client should lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension. Educational objective:The nurse should instruct clients taking sublingual NTG that they should call EMS if their chest pain is unrelieved or worsening 5 minutes after the first tablet. The tablet should be allowed to dissolve under the tongue to allow for adequate absorption and should never be swallowed.

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? a. Hematocrit of 30% b. Partial thromboplastin time of 110 seconds c. Platelet count of 80,000/mm d. Prothrombin time of 11 seconds

Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds. (Option 1) A normal hematocrit for a female is 35%-47% (0.35-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm3 (150-400 x 109/L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mm3 (80 x 109/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm3 (50 x 109/L). (Option 4) A normal prothrombin time is 11-16 seconds, and so a level of 11 seconds would not be concerning. Educational objective:Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin.

The nurse is providing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? a. Fever b. Irritability c. Knee pain d. Skin peeling

(KD) is a systemic vasculitis of childhood that presents with ≥5 days of fever, nonexudative conjunctivitis, lymphadenopathy, mucositis, hand and foot swelling, and a rash. First-line treatment consists of IV immunoglobulin and aspirin to prevent coronary artery aneurysms. When children with KD are discharged home, parents are instructed to monitor them for fever by checking the temperature (orally or rectally) every 6 hours for the first 48 hours following the last fever. Temperature should also be checked daily until the follow-up appointment. If the child develops a fever, the health care provider should be notified as this may indicate the acute phase of KD recurrence. The child may require additional treatment with IV immunoglobulin to prevent development of coronary artery aneurysms and occlusions. (Option 2) Irritability is a hallmark finding in a child with KD, especially during the acute phase (due to fever and inflammation). Parents should be advised that irritability can last up to 2 months. (Option 3) Temporary joint pain and other manifestations of arthritis (eg, stiffness, decreased range of motion) may occur and persist for several weeks. Parents should be informed that range of motion exercises and warm baths will help reduce these symptoms and minimize discomfort. (Option 4) Desquamation (skin peeling) of the hands and feet is an expected finding in KD. Parents should be informed that the peeling itself is not painful but that the new skin underneath may be red and sore. Educational objective:Once children with KD are discharged home, parents should be instructed to check their temperature every 6 hours for the first 48 hours following the last fever and then daily until the follow-up visit. The health care provider should be notified if the child has fever as this may indicate a need for further treatment.

A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? Click on the exhibit button for additional information a. Atrial flutter b. Sinus rhythm with premature atrial contractions c. Sinus rhythm with premature ventricular contractions d. Ventricular tachycardia

A PVC is a contraction coming from an ectopic focus in the ventricles. It is a premature (early) conduction of a QRS complex. PVCs are wide and distorted in shape compared to a QRS conducted through the normal conduction pathway. PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). The nurse should assess the client's physiological response, including apical-radial pulse. Treatment is based on the underlying cause of the PVCs (eg, oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement). (Option 1) Atrial flutter is an atrial dysrhythmia identified by recurring, regular, sawtooth-shaped flutter waves that originate from a single ectopic focus in the atria. (Option 2) A PAC is a contraction starting from an ectopic focus in the atrium (other than the sinus node) and coming sooner than the next sinus beat. The P wave has a different shape than the P wave that originated in the sinus node. (Option 4) Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. Educational objective:PVCs are wide and distorted and occur early in the underlying rhythm. They are usually not harmful in the client with a healthy heart. PVCs in the client with myocardial infarction indicate ventricular irritability and should be assessed immediately.

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply. a. Client may be required to lie flat for several hours following the procedure b. Client may feel warm or flushed when contrast dye is injected during the procedure c. Client should expect to stay in the hospital for 1-3 days following the procedure d. Client should not eat or drink anything for 6-12 hours before the procedure e. Client will receive general anesthesia and will not be awake during the procedure.

A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) (Option 4) The client may feel warm or flushed while the contrast dye is being injected (Option 2) Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis (Option 1) (Option 3) If the procedure is just a diagnostic study, the client often goes home the same day. Hospitalization for 1-3 days may be required if angioplasty or stent placement is performed. (Option 5) General anesthesia is not used during coronary angiography. Sedating medications are given during the procedure. Educational objective:Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed.

A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? Click the exhibit button for additional information. Laboratory results Sodium 126 mEq/L (126 mmol/L) Potassium 4.8 mEq/L (4.8 mmol/L) Calcium 9.0 mg/dL (2.25 mmol/L) a. 0.45% sodium chloride b. Calcium Gluconate c. Furosemide d. Sodium polystyrene sulfonate

In heart failure, cardiac output is reduced because the heart is unable to pump blood adequately. This reduction in cardiac output reduces perfusion to the vital organs, including the kidneys. Decreased renal blood flow triggers the kidneys to activate the renin-angiotensin system as a compensatory mechanism, which increases blood volume by increasing water resorption in the kidneys. This compensatory mechanism results in fluid volume excess and dilutional hyponatremia (more free water than sodium). Dilutional hyponatremia can be treated with fluid restriction, loop diuretics, and ACE inhibitors (eg, lisinopril, captopril). Furosemide works to resolve hyponatremia by promoting free water excretion, allowing for hemoconcentration and increased sodium levels (Option 3). (Option 1) 0.45% sodium chloride is a hypotonic solution. Giving hypotonic saline would provide more free water than sodium, thereby worsening fluid overload and hyponatremia. (Option 2) The client's calcium is within normal limits and does not need replacement. (Option 4) Sodium polystyrene sulfonate (Kayexalate, Kionex) is a medication used to treat hyperkalemia that works by exchanging sodium for potassium across the mucous membranes of the bowel and then excreting potassium via stool. Sodium polystyrene sulfonate is not indicated if potassium is within normal limits. Educational objective:Heart failure is characterized by reduced cardiac output, which can reduce renal blood flow. Reduced renal blood flow activates the renin-angiotensin system, resulting in fluid volume excess and dilutional hyponatremia. Loop diuretics (eg, furosemide) promote free water excretion, allowing for hemoconcentration and increased sodium levels.

The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department. All ICU beds are currently full. Which client should the charge nurse consider as most appropriate for transfer out of the ICU? a. b. c. d.

Occasional premature ventricular contractions (PVCs) are common dysrhythmias that may be precipitated by several factors, including electrolyte imbalances (eg, potassium), stimulants (eg, caffeine, nicotine), and stress. Occasional PVCs typically do not cause hemodynamic instability. The client who is stable one day post extubation can be safely transferred to a telemetry or medical-surgical unit, where the occasional PVCs may be further investigated and treated (Option 3). (Option 1) Sinus tachycardia may not present an immediate risk of hemodynamic instability; however, the client who recently underwent arterial sheath removal may be tachycardic due to bleeding. This client requires further investigation and continuous monitoring, and is not appropriate for transfer. (Option 2) The client with atrial fibrillation and rapid ventricular response has decreased cardiac output and may progress to hemodynamic instability. Treatment goals include reducing the ventricular rate to <100/min with medications (eg, diltiazem), preventing thrombotic events (eg, ischemic stroke) with anticoagulants (eg, warfarin), and possibly conversion to normal sinus rhythm with antiarrhythmics (eg, amiodarone). This client is not the best choice for transfer. (Option 4) Complete heart block (ie, third-degree atrioventricular block) requires temporary pacing followed by permanent pacemaker insertion. This client, who is at risk for severe bradycardia and hemodynamic instability, should not be transferred. Educational objective:Occasional premature ventricular complexes are common dysrhythmias and usually do not cause hemodynamic instability. Clients with atrial fibrillation and rapid ventricular response, complete heart block, or other threats to cardiovascular stability require continuous observation in the intensive care unit.

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information. a. Administer atropine 0.5 mg IV b. Administer dopamine 5 mcg/kg/min IV c. Initiate transcutaneous pacing d. Notify the health care provider

The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client. (Option 1) Atropine is administered to clients with symptomatic bradycardia; however, this client's symptoms are caused by failure to capture. Therefore, obtaining capture via transcutaneous pacing should resolve the client's symptoms. (Option 2) Dopamine is an inotrope used to treat hypotension due to bradycardia. This client is bradycardic and hypotensive due to failure to capture. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. (Option 4) The health care provider needs to be notified, but the nurse should first use the transcutaneous pacemaker to stabilize the client. Educational objective:Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension. The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced.

A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI). Which laboratory test should the nurse monitor to determine if the client has had an MI? a. D-dimer test b. LDL c. Myoglobin d. Troponin

Troponin is a cardiac specific serum marker that is a highly specific indicator of MI and has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) or CK-MB. Serum levels of troponin T and I increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline in 10-14 days. However, MI is not diagnosed alone by serum cardiac markers. Electrocardiogram findings and client health history along with a history of pain and risk factors are also used to make the diagnosis of MI. (Option 1) D-dimer is a laboratory test that measures the amount of cross-linked fibrin fragments resulting from clot degradation. It is ordered for clients with suspected pulmonary embolism. (Option 2) LDL is used in determining cardiac disease risk, not for diagnosing MI. (Option 3) Myoglobin is released into the circulation within 2 hours after MI. Although it may be the first serum cardiac marker to appear after MI, it lacks cardiac specificity and its role in diagnosing MI is limited. Educational objective:The nurse should monitor serum troponin levels when there is suspicion of MI as it is the most sensitive and specific serum cardiac marker.

The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription? a. Furosemide 20 mg IVP twice daily b. Maintenance IV line of NS at 0.9% at 85 ml/hr c. Potassium Chloride 20 mEq PO twice daily d. Sodium restricted diet

Chronic heart failure involves the inability of the heart to fill and pump blood effectively to meet the body's oxygen demands. As a result, clients can develop dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]), an electrolyte disturbance caused by an excess of total body water in relation to total sodium content. The nurse should question the prescription for the maintenance IV line. An infusion of an isotonic solution of 0.9% normal saline at 85 mL/h is contraindicated in this client as it would increase the circulating extracellular fluid volume, worsen the symptoms, and exceed the <2 L/day fluid restriction (ie, 85 mL × 24 hours = 2040 mL). Converting the running IV line to a lock for medication administration would be appropriate. (Option 1) Furosemide (Lasix) is a fast-acting loop diuretic prescribed to decrease preload in clients with heart failure who are fluid overloaded and experiencing manifestations of pulmonary congestion (eg, crackles, dyspnea). Appropriate diuresis in this client would remove excess free water and correct dilutional hyponatremia. (Option 3) Potassium chloride is administered to clients receiving furosemide to prevent or treat diuretic-associated hypokalemia. The nurse should not question this prescription. (Option 4) Fluid restriction is prescribed to correct dilutional hyponatremia (sodium <135 mEq/L [135 mmol/L]) in a client with heart failure. In addition, all heart failure clients require a low-salt diet. Excess salt causes retention of more water. This client's low sodium is due to excess free water and not to low dietary sodium. Educational objective:Dilutional hyponatremia (serum sodium <135 mEq/L [135 mmol/L]) is an electrolyte disturbance caused by an excess of total body water in relation to total sodium content and can occur in clients with heart failure. Treatment includes the administration of diuretics and fluid/salt restriction.

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action? a. Auscultate the client's lungs b. Check the client's capillary refill c. Measure the client's BP d. Review the client's ECG

Sodium nitroprusside is a highly potent vasodilator (both venous and arteriolar). Venous dilation reduces preload (volume of blood in ventricles at the end of diastole), and arterial dilation reduces afterload (resistance ventricle must overcome to eject blood during systole). Sodium nitroprusside is commonly used in hypertensive emergencies and for conditions in which blood pressure control is of utmost importance (eg, aortic dissection, acute hypertensive heart failure). Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely due to hypotension. Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally develop fatal cyanide toxicity. (Option 1) Auscultation of lung sounds is a common assessment for the client in heart failure. However, in this client the signs and symptoms indicate hypotension and make checking the blood pressure a higher priority. (Option 2) Checking capillary refill can give the nurse information about perfusion status. Capillary refill may be prolonged and should be checked in this client, but after blood pressure is measured. (Option 4) The ECG of this client should be reviewed. The client is at risk for rhythm abnormalities, but because hypotension is the main adverse effect of nitroprusside, the blood pressure should take precedence. Educational objective: Sodium nitroprusside is given as an infusion for the short-term treatment of acute decompensated heart failure, especially in clients with markedly elevated blood pressure. It is a potent vasodilator and reduces preload and afterload. The main adverse effect is symptomatic hypotension, necessitating close monitoring of blood pressure.

A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP? a. Client has a hx of cerebral arteriovenous malformation b. Client is currently menstruating c. Client rates chest pain 8/10 d. BP is 170/92 mm Hg

Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium. This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication. Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) (Option 1). (Option 2) Active menstruation is not a contraindication for thrombolytic therapy. Research shows that the risk of increased menstrual bleeding due to thrombolytic administration is low and not life-threatening. Physiologic menstrual bleeding is also not a contraindication for anticoagulation therapy. (Option 3) Chest pain is one of the inclusion criteria for thrombolytic therapy. (Option 4) Uncontrolled blood pressure of >180 mm Hg systolic or >110 mm Hg diastolic is a relative contraindication for thrombolytic therapy. This client's blood pressure (170/92 mm Hg) is elevated but not uncontrolled, which does not rule out this therapy. Educational objective:The candidate for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the health care provider if the client has history of arteriovenous malformation, which is an absolute contraindication to the use of thrombolytics.

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? a. Assess incision for bleeding or hematoma formation b. Auscultate bilateral anterior and posterior lung sounds c. Initiate continuous cardiac monitoring d. Reestablish IV fluids and postoperative antibiotics

When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker. If the atrioventricular (dual-chambered) pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes (electrical capture). If the pacemaker is not working properly (eg, failure to capture, failure to sense), the health care provider should be contacted immediately (Option 3). The nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure. (Option 1) Checking for bleeding or hematoma formation at the insertion site is appropriate but should occur after attaching the cardiac monitor. (Option 2) Postoperative lung sounds are auscultated to assess for atelectasis, but lung assessments do not take priority over ensuring pacemaker functionality. (Option 4) IV fluids and postoperative antibiotics help to reestablish fluid volume and prevent infection, respectively, and should be initiated after cardiac monitoring. Educational objective:Assessing the function of a new permanent pacemaker is a priority after operative placement. The nurse should immediately attach the cardiac monitor before making other appropriate assessments.

The nurse prepares to administer 9:00 AM medications to a client. Which data should the nurse evaluate prior to administration? Select all that apply. Click the exhibit button for additional information. Medication administration record Allergies: None Medications Schedule Aspirin: 81 mg orally, daily 0900 Metoprolol: 50 mg orally, twice daily 0900 & 1700 Quinapril: 10 mg orally, daily 0900 a. Blood pressure b. Blood sugar c. Heart rate d. INR e. Potassium level

Beta blockers (eg, metoprolol, carvedilol) and angiotensin-converting enzyme (ACE) inhibitors (eg, quinapril, lisinopril, enalapril) are antihypertensive medications. The nurse should assess blood pressure prior to administration (Option 1). Beta blockers lower heart rate by blocking the action of beta receptors that increase heart rate and contractility. The nurse should assess blood pressure and heart rate prior to administration (Option 3). ACE inhibitors increase serum potassium by decreasing urinary potassium excretion. The nurse should assess blood pressure and serum potassium levels prior to administration (Option 5). (Option 2) Clients with diabetes require blood sugar checks, but administration of beta blockers, ACE inhibitors, or antiplatelet medications will not require monitoring of blood sugar. (Option 4) Aspirin, an antiplatelet medication, reduces clot formation and can increase the risk for bleeding. The nurse assesses for bruising, bleeding gums, blood in stool, and gastrointestinal upset. International Normalized Ratio should be monitored in clients taking warfarin. Educational objective:Beta blockers lower blood pressure and heart rate. Angiotensin-converting enzyme inhibitors lower blood pressure and increase potassium. Aspirin, an antiplatelet medication, increases the risk for bleeding.

The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply. a. Avoid salt substitutes when taking Valsartan for HTN b. Take levofloxacin with an aluminum antacid to avoid gastric irritation c. Take Sucralfate after meals to minimize gastric irritation associated with a gastric ulcer d. When taking ethambutol, notify the HCP of any changes in vision e. When taking RIfampin, notify the HCP if the urine turns red-orange

Both ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be consumed unless approved by the health care provider (HCP) (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). (Option 2) Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between drug ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. These substances can bind up to 98% of the drug and make it ineffective. (Option 3) Sucralfate (Carafate, Sulcrate), prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy. (Option 5) Rifampin (Rifadin), used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change but does not need to notify the HCP. Educational objective:The nurse should watch for vision changes with ethambutol. Potassium supplements or salt substitutes should not be given to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to prevent irritation of the ulcer. Quinolone antibiotics should not be given with antacids or supplements that reduce drug efficacy. Rifampin commonly causes red-orange discoloration of body fluids.

The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply. a. Bananas b. Broccoli c. Liver d. Oranges e. Spinach

Warfarin (Coumadin) is a vitamin K antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis. Excessive intake of vitamin K-rich foods (eg, broccoli, spinach, liver) can decrease the anticoagulant effects of warfarin therapy (Options 2, 3, and 5). Clients should be consistent with intake of foods high in vitamin K after initiation of warfarin because dosing is individualized to the client and dietary changes may require dose adjustment. (Options 1 and 4) Bananas and oranges are rich in potassium, not vitamin K, and are not known to interact with warfarin. The chemical symbol for potassium (K+) should not be confused with vitamin K because they are two different micronutrients; potassium (K+) is an element involved in muscle contraction, whereas vitamin K is a fat-soluble vitamin involved in blood clotting. Educational objective:Clients receiving warfarin therapy should maintain consistent intake of foods high in vitamin K; it is not necessary to remove vitamin K-rich foods completely. Clients should avoid excess or inconsistent intake of green vegetables (eg, broccoli, spinach) and liver to promote steady warfarin efficacy.

The nurse is caring for a client who experienced an anterior wall myocardial infarction 24 hours ago. The nurse recognizes the rhythm on the cardiac monitor as which rhythm? Click on the exhibit button for additional information. a. Premature ventricular contractions b. Sinus tachycardia c. Ventricular fibrillation d. Ventricular tachycardia

(VT) is a potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-250/min. The rhythm is often regular, but it can be irregular. QRS complexes are wider than 0.12 seconds and the P wave is usually buried in the QRS complex, making a PR interval unmeasurable. Pulseless VT is treated with cardiopulmonary resuscitation (CPR) and defibrillation. (Option 1) A premature ventricular contraction (PVC) is a contraction originating from an ectopic foci in the ventricle. It appears early in the rhythm and has a wide and distorted shape as compared to the underlying rhythm. A consecutive run of ≥3 PVCs is considered VT. (Option 2) The rate in sinus tachycardia is 101-200/min and regular. The P wave, PR interval (0.12-0.20 sec), and QRS complex (<0.12 sec) will be normal. Sinus tachycardia may be caused by hypovolemia, hypotension, pain, anxiety, stress, or fever. Treatment is based on the underlying cause. (Option 3) Ventricular fibrillation is characterized on the electrocardiogram by irregular waveforms of varying shapes and amplitude. It represents the firing of multiple ectopic foci in the ventricle. The client in ventricular fibrillation will not have a pulse, and defibrillation is essential in addition to CPR under the ACLS guidelines. Educational objective:VT has a rate of 100-250/min with monomorphic, wide QRS complexes. Pulseless VT is treated with CPR and defibrillation.

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine. The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days. Which question is most important for the nurse to ask next? a. Have you noticed any abnormal swelling in your legs? b. How are you currently taking your BP meds?c. How has your stress level been in the past few weeks? d. What OTC meds have you taken today?

A major problem in the long-term management of hypertension is poor adherence to the treatment plan, often due to unpleasant side effects (eg, fatigue, dizziness, reduced libido, erectile dysfunction) and medication cost. This problem can worsen if a client must take multiple medications. Determining whether a client is taking medications as prescribed is a priority, as sudden or abrupt discontinuation of antihypertensive medications can cause rebound hypertension and possibly hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath) (Option 2). (Option 1) The nurse should assess for peripheral edema, which may indicate heart failure. However, this can be done after assessing medication adherence. (Options 3 and 4) Stress can elevate blood pressure. Some over-the-counter medications (eg, decongestants, NSAIDs) can also increase blood pressure. However, poor adherence to prescribed medications is the number one cause of uncontrolled hypertension. The nurse should ask about all other medications the client has taken and the client's stress level after confirming that the prescribed blood pressure medications are being taken correctly. Educational objective:A major problem in long-term management of hypertension is poor adherence to the treatment plan, often due to unpleasant side effects and medication cost. Assessing for medication adherence is important, as abrupt discontinuation of antihypertensive medications can cause rebound hypertension and hypertensive crisis.

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation? a. B-type natriuretic peptide (BNP) 1382 pg/mL b. Flat jugular veins when seated at a 45-degree angle c. Sodium 150 mEq/L d. Urine output greater than 100 ml/hr

Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of left ventricular filling pressure elevation and mortality. A normal BNP level is <100 pg/mL [<100 pmol/L]. The nurse would expect a high BNP in a client exhibiting symptoms of acute decompensated heart failure. (Option 2) Jugular veins should normally flatten and disappear as the client is raised to an upright position. Jugular venous distension present above a 45-degree seated position indicates fluid volume excess and elevated cardiac filling pressures that occur with heart failure. (Option 3) Normal sodium level is 135-145 mEq/L [135-145 mmol/L]. Serum sodium can be normal or low in heart failure clients. Low levels are due to dilution from excess free water. (Option 4) Urine output of 100 mL/hr should be adequate to maintain fluid volume status. Inadequate urine output may cause fluid retention and volume overload, precipitating an exacerbation of heart failure. A state of low cardiac output may also decrease renal perfusion, resulting in renal dysfunction and decreased urine output. Diuretic therapy is the mainstay treatment for fluid volume overload. The nurse should expect to see an increase in urine output in response to diuretic administration. Educational objective:The nurse should assess the BNP level in clients admitted with heart failure exacerbations. Elevated BNP levels indicate increased ventricular stretch and correlate with severity of heart failure and fluid volume overload. Heart failure clients may also present with jugular venous distension, low serum sodium, and decreased urine output.

The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially? a. Food poisoning b. Influenza c. Myocardial infarction d. Stroke

Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. (Option 1) Taking a careful history and evaluating for any sick contacts would be helpful in identifying food poisoning, but a more important initial step is to assess for a heart attack. (Option 2) A viral infection is a possibility, but fever and myalgia are usually present during an episode of influenza. (Option 4) Early intervention in stroke is also critical, and a neurologic assessment would take place after the acute coronary syndrome algorithm, especially with negative electrocardiography and serum heart enzyme levels. Educational objective:Myocardial infarctions in women, the elderly, and diabetics may have gastrointestinal distress as the main symptom; this needs to be evaluated with the institutional protocol for acute coronary syndrome.

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply. a. Avoid excessive caffeine b. Immerse hands in cold water c. Practice yoga or tai chi d. Refrain from using tobacco products e. Wear gloves when handling cold objects

Raynaud phenomenon is a vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: Wear gloves when handling cold objects (Option 5). Dress in warm layers, particularly in cold weather. Avoid extremes and abrupt changes in temperature. Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). Avoid excessive caffeine intake (Option 1). Refrain from use of tobacco products (Option 4). Implement stress management strategies (eg, yoga, tai chi) (Option 3). If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes. (Option 2) Cold water will cause vasoconstriction and worsen the condition. Educational objective:Raynaud phenomenon is a vasospastic disorder triggered by exposure to cold or stress. Key elements of client teaching include management of acute attacks, avoidance of vasoconstrictive substances (eg, tobacco, cocaine, caffeine), stress reduction, and appropriate clothing (eg, gloves, warm layers).

The nurse is performing a cardiac assessment. Where does the nurse expect to feel the client's point of maximal impulse (PMI)?

The PMI is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular line, the heart may be enlarged. Educational objective:During cardiac assessment, the nurse should palpate the PMI medial to the midclavicular line at the 4th or 5th intercostal space. Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement.

The nurse is preparing to discharge a client who developed heart failure after a myocardial infarction. Based on the discharge data, the nurse plans to include which topics during teaching? Select all that apply. Click on the exhibit button for additional information. Vital signs Temperature 98.2 F ( 36.7 C ) Blood pressure 108/72 mm Hg Heart rate 62/min Respirations 16/min SpO2 96% on room air a. Daily weighing b. How to take own pulse c. Need for monthly INR d. Need to increased foods high in potassium e. Reduction of sodium in diet f. Use of home oxygen

This client with heart failure would need to measure weight daily, restrict sodium and fluid intake, and know how to take a pulse. (Option 3) This client is not taking warfarin, so monthly testing of INR is not indicated. (Option 4) Spironolactone is a potassium-sparing diuretic, and so increasing dietary potassium is not necessary. Angiotensin-converting enzyme inhibitors such as captopril can cause hyperkalemia. (Option 6) The client's SpO2 was 96% on room air and home oxygen has not been prescribed. Educational objective:The client being discharged with heart failure should receive teaching related to weight monitoring, diet, medication regimen, activity, and symptoms to report.

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching? a. I will call my HCP if I notice red urine or blood in my stool b. I will not stop taking dabigatran even if I get a stomachache c. I will place capsules in my pill box so I will not forget to take a dose d. I will swallow the capsule whole with a full glass of water.

Thrombin inhibitors such as dabigatran (Pradaxa) reduce the risk of clot formation and stroke in clients with chronic atrial fibrillation. The nurse should educate the client about implementing bleeding precautions (eg, using a soft-bristle toothbrush, shaving with an electric razor). Dabigatran capsules should be kept in their original container or blister pack until time of use to prevent moisture contamination (Option 3). (Option 1) Red urine or blood in the stool may indicate internal bleeding caused by thrombin inhibitors. The client should report these symptoms to the health care provider. (Option 2) Thrombin inhibitors should only be stopped under the direction of the health care provider. The nurse should educate the client that stopping dabigatran will increase the risk for stroke. Taking the medication with food will not affect how much is absorbed, and food or a full glass of water may prevent gastrointestinal side effects (eg, nausea, indigestion). (Option 4) Thrombin inhibitor capsules should not be crushed or opened as crushing pills increases absorption and risk of bleeding. Educational objective:Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.

The nurse observes the rhythm shown in the exhibit on a client's cardiac monitor. The client reports palpitations and lightheadedness. Which intervention does the nurse anticipate? Click on the exhibit button for additional information. a. Adenosine IVP b. Atropine IVP c. Defibrillation d. External pacing

This client is experiencing paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced cardiac output such as hypotension, palpitations, dyspnea, and angina. Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of choice for PSVT treatment. Due to its very short half-life, adenosine is administered rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be given twice if previous administration is ineffective. Beta blockers, calcium channel blockers, and amiodarone can also be considered as alternatives. If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion may be used. (Option 2) Atropine is an anticholinergic agent used to increase heart rate in clients with symptomatic bradycardic (<60/min) rhythms. (Option 3) Defibrillation is used only in clients with ventricular fibrillation and pulseless ventricular tachycardia. Cardioversion would be considered if drug therapy is ineffective for PSVT. (Option 4) External pacing is indicated in symptomatic bradycardic (<60/min) rhythms. Educational objective:The drug of choice in clients with PSVT is adenosine. It is given rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be administered 2 more times if previous administration is ineffective.

A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse? a. Client eats a vegetarian diet b. Client has chronic atrial fibrillation c. Client takes indomethacin for osteoarthritis d. Client's platelet count is 176 x 10/mm (176 x 10/L)

A pulmonary embolism (PE) occurs when the pulmonary arteries are blocked by a thrombus. Initial management of PE includes low-molecular-weight heparin (eg, enoxaparin, dalteparin) or unfractionated IV heparin. Once the PE is resolved, maintenance drug therapy often includes oral anticoagulants such as factor Xa inhibitors (eg, apixaban, rivaroxaban, dabigatran). Anticoagulants place the client at increased risk of bleeding, and the nurse should provide education regarding signs and symptoms of bleeding (eg, bruising; blood in the urine; black, tarry stools) and bleeding precautions (eg, use of an electric razor and soft-bristled toothbrush). Concurrent NSAID use (eg, indomethacin, ibuprofen, meloxicam) significantly increases the risk of bleeding. The nurse should discuss this risk with the health care provider prior to initiation of apixaban therapy (Option 3). (Option 1) Vegetarian diets and the consumption of leafy green vegetables high in vitamin K affect the action of warfarin. However, factor Xa inhibitors such as apixaban are not affected by vitamin K. (Option 2) Chronic atrial fibrillation increases the risk for thromboembolic events and would be an indication for anticoagulant therapy, such as apixaban. (Option 4) The current platelet count is within a normal range (150-400 x103/mm3 [150-400 x109/L]) and is not a concern. Educational objective:Maintenance drug therapy after a pulmonary embolus typically includes administration of oral anticoagulants such as factor Xa inhibitors (eg, apixaban). NSAIDs (eg, indomethacin) increase the risk of bleeding when used concurrently with apixaban therapy. The nurse should question initiation of apixaban therapy in the context of NSAID use.

The client is scheduled to have a cardiac catheterization. Which of the following findings would cause the nurse to question the safety of the test proceeding? Select all that apply. a. Elevated serum C-reactive protein level b. Hx of previous allergic reaction to IV contrast c. Prolonged PR interval on ECG d. Received Metformin today for type 2 DM e. Serum creatinine of 2.5 mg/dL

Cardiac catheterization involves injection of IV iodinated contrast to assess for obstructed coronary arteries. Potential complications of IV iodinated contrast include: Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast medium (Option 2). Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore, health care providers may discontinue metformin 24-48 hours before administration of contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option 4). Contrast-induced nephropathy: Iodinated contrast can cause acute kidney injury in clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]). Therefore, clients with renal impairment should not receive iodinated contrast unless absolutely necessary (Option 5). (Option 1) C-reactive protein, produced during acute inflammation, may indicate elevated risk for coronary artery disease. However, it is not an indicator of an acute cardiac event and is not a safety concern for cardiac catherization. (Option 3) First-degree atrioventricular block may precede more serious conditions. However, clients are usually asymptomatic and do not require treatment except for stopping the causative medication (eg, beta blocker, digoxin). This would not prevent the procedure from proceeding. Educational objective:Cardiac catheterization uses IV iodinated contrast to assess for obstructed coronary arteries. IV iodinated contrast is avoided in clients who had a previous allergic reaction to contrast agents; have renal impairment; or, in some cases, who recently received metformin.