Adult Health - Archer Review (1/8) - Cardiovascular

Choice A is correct. This rhythm represents a 3rd-degree heart block because there is no QRS complex after every other p wave. This is because the AV node has no conduction during a 3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with each other.

What EKG rhythm represents a third-degree heart block?

pulmonary edema; serum sodium level

The nurse's greatest concern is that the client is at risk for_____ based on the client's _____

Choice A is correct. To answer this question correctly, you must know the right formula for Cardiac Output (CO). CO = Heart Rate (HR) x Stroke Volume (SV). Heart rate is measured in beats per minute, and stroke volume is measured in milliliters (mL). The HR is the number of times per minute the heart beats, whereas the SV is the mL of blood that the heart pumps out with each contraction. By multiplying the two together, you get how many mL of blood the heart is pumping out each minute. This is the cardiac output. Cardiac output is usually reported in liters/min; the average is about 5 L/min but varies greatly depending on the patient's size. A decreased cardiac output (low-output failure) is seen in congestive heart failure. A high cardiac output state refers to resting cardiac output more significant than 8 L/min. An increased cardiac output (high-output failure) may be seen in hyperthyroidism, thiamine deficiency, and severe uncorrected anemia. For this problem: Cardiac Output (CO) = 102 beats per minute (HR) x 72 mL (SV) = 7,344 mL/min or 7.344 L/min.

You are attending to a male client on a postoperative day one following mitral valve replacement. He is getting ready to ambulate for the first time. His heart rate is 102 beats/minute, and the stroke volume based on the echocardiogram is 72 mL. Which of the following represents his cardiac output (CO)? A. 7.344 L/min B. 30 L/min C. 55% D. 73.444 mL/min

Choice A is correct. This client displays signs and symptoms of an ST-segment elevation myocardial infarction (STEMI). In a STEMI, myocardial necrosis occurs, with the client exhibiting ECG changes showing ST-segment elevation not quickly reversible by nitroglycerin administration. The primary focus should be on improving myocardial oxygenation and reducing cardiac workload, as these measures will reduce the further expansion of myocardial necrosis.

A client arrives at the emergency department (ED) complaining of substernal chest pain. A 12-lead electrocardiogram (ECG) showed ST-segment elevation and laboratory findings showed an elevated troponin level. Based on these findings, the priority treatment goal for the client is A. reducing cardiac workload and improving myocardial oxygenation. B. reducing modifiable risk factors to prevent re-occurrence. C. planning outpatient cardiac rehabilitation. D. providing a quiet environment and reducing anxiety.

Choice C is correct. Generally, a lack of decision-making capacity with inadequate time to find an appropriate proxy without harming the client, such as a life-threatening emergency where the client is not conscious, is a situation that allows informed consent to be waived. Here, the delay in providing an emergency craniotomy to an unconscious client would likely result in the client's death, making this case a situation where informed consent would be waived.

A client arrives at the emergency department (ED) via emergency medical services (EMS) after being hit by a car. The name of the client is unknown. The client is unconscious, having sustained a severe head injury and multiple fractures. An emergency craniotomy is indicated. Regarding informed consent for the surgical procedure, which of the following is the best action? A. Obtain a court order for the surgical procedure in place of an informed consent B. Ask the head of the EMS team to sign the informed consent C. Transport the client to the operating room for surgery immediately D. Call the police to report the incident, identify the client, and locate the family

Choice D is correct. Red meats are rich in saturated fat and should therefore be consumed less often by this client based on the recent diagnosis of hyperlipidemia. Red meats contribute to high cholesterol levels and would contribute to increasing, not decreasing the client's already elevated hyperlipidemia levels. Therefore, this choice is incorrect.

A client has just been diagnosed with hyperlipidemia. Aside from the prescribed atorvastatin, the client has been advised to lose weight and implement dietary changes. During the discussion with the client, the nurse discusses all the following dietary modifications except: A. Replace hydrogenated vegetable oils with canola oil when cooking. B. Eat fish like tuna and salmon more often. C. Eat more fruits and vegetables. D. Consume red meat more often.

Choice D is correct. For a client with a pacemaker, it is recommended that they talk on their cellular phone opposite of the pulse generator to prevent electromagnetic interference.

A client is being discharged following the insertion of a permanent pacemaker. Which of the following should be included in the client's discharge instructions? A. Air travel will not be possible due to airport screening equipment. B. You will need to discard any radios at home that have antennas. C. Computed tomography (CT) scans are not permitted with this device. D. You should use your cellular phone on the opposite side of the generator.

Choices A, B, and D are correct. Several interventions may be necessary to manage fluid volume overload in a client with heart failure. Administering diuretics helps promote the excretion of excess fluid and decrease fluid volume. Monitoring daily weights is crucial to assess changes in fluid status. Assessing lung sounds for crackles is important to detect pulmonary congestion, a sign of fluid overload.

A nurse is caring for a client with heart failure. Which of the following interventions should the nurse implement to manage fluid volume overload? Select all that apply. - Administer diuretics as prescribed - Monitor daily weights - Restrict fluid intake to 500 mL per day - Assess lung sounds for crackles - Encourage high-sodium diet - Assess lung sounds for rhonchi

Choice C is correct. To yield valuable, quality results from an angiogram, the use of contrast media is essential. Like all medications and substances, risks are present even when utilizing the minimum amount required. Two documented risks of contrast media are contrast-associated acute kidney injury (CA-AKI) and contrast-induced nephropathy (CIN), as contrast media is metabolized in the kidneys. To assess for kidney damage, kidney function tests are performed one day after the client receives contrast media to evaluate renal function and compare the result to the pre-procedure testing result.

A nurse is caring for a post-angiography client. The physician utilized a femoral approach during the procedure, and the client received contrast media. Based on this information, which intervention should the nurse include in the client's plan of care? A. Keep the hips in a bent position for 6-8 hours after the procedure B. Discontinue IV fluids immediately after the procedure C. Assess kidney function via lab testing on the day following the procedure D. Maintain NPO status for 4 hours following the procedure

Choice B is correct. This statement by the nurse is incorrect and, therefore, the correct answer to the question. Typically, clients scheduled to undergo an exercise electrocardiography (ECG) (i.e., exercise stress test) are instructed to remain NPO for 4 to 6 hours before the stress test. Additionally, caffeine intake by a client may cause an alteration in the procedure's findings.

A nurse is reviewing instructions with a client for the client's upcoming exercise electrocardiography (ECG). All of the following are appropriate statements by the nurse, except for which? A. "Please wear loose, comfortable clothing with non-slip athletic footwear." B. "You may have a light breakfast and a small cup of coffee before the exam." C. "We will monitor your blood pressure, heart rate, and rhythm before, during, and after the stress test." D. "You should not do any strenuous activity before your stress test."

Choice C is correct. In myocardial ischemia, the ST-segment may appear elevated or depressed. In the presence of acute myocardial ischemia, ST-segment changes result from lack of oxygen to a specific region of the cardiac muscle. If treatment has been successful, the ST-segment will return to baseline.

After presenting with acute myocardial ischemia, a client was given 324 mg PO aspirin, three doses of 0.4 mg SL nitroglycerin tablets (taken five minutes apart), and oxygen via nasal cannula at 2L/minute. Which ECG change would indicate these interventions have been effective? A. Widening of the QRS complex B. Decrease in ectopic heartbeats C. ST-segment has returned to the baseline D. Reduction of the significant Q-wave

Choice C is correct. Heart failure (HF) is a syndrome of ventricular dysfunction. When occurring on the left side, left ventricular (LV) failure (also known as left-sided heart failure) causes shortness of breath and fatigue. In these clients, cardiac output decreases and pulmonary venous pressure increases as the heart failure worsens. As the amount of blood ejected from the left ventricle diminishes, hydrostatic pressure builds in the pulmonary venous system and results in fluid-filled alveoli and pulmonary congestion, which results in a cough. Dyspnea also results from increasing pulmonary venous pressure and pulmonary congestion. The client's tripod positioning (also known as the orthopneic position) is one in which the client is in a forward-bending posture with their arms held forward in an attempt to facilitate breathing.

An emergency department nurse is caring for a client who presented with fatigue, muscular weakness, and dyspnea. Upon assessment, the client was noted to be coughing frequently and sitting in a tripod position. A subsequent diagnosis of left ventricular failure was made. The nurse understands that manifestations of left-sided heart failure present as respiratory issues because: A. There is venous congestion in the liver. B. There is hypoperfusion of tissue cells. C. There is pulmonary congestion. D. Despite normal cardiac output, the heart cannot meet the accelerated demands of the body.

Choice C is correct. Pressure-reduction mattresses and beds are available to decrease the pressure on the client's pressure points when the client is in bed. More specifically, these support surfaces are used to prevent (or treat) pressure ulcers by attempting to redistribute pressure beneath the skin of the client's body to increase blood flow to tissues and relieve skin and soft tissue distortion. However, implementing measures to ease the stress on the pressure points is the lowest priority when managing a client experiencing acute pulmonary edema.

An intensive care unit nurse is caring for a client with left-sided heart failure experiencing pulmonary edema as a complication. The nurse identifies a nursing diagnosis of "impaired gas exchange related to ineffective breathing patterns." Which nursing intervention would be the lowest priority based on the nursing diagnosis? A. Administer oxygen and monitor for drying of the nasal mucus membranes. B. Place the client in a semi-Fowler's position. C. Provide a pressure-reducing mattress. D. Encourage the client to turn, deep breathe, cough, and use the incentive spirometer.

Choice A is correct. Enalapril is an ACE inhibitor and this drug class is indicated in the treatment of heart failure to prevent ventricular remodeling.

The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication? A. Enalapril B. Verapamil C. Lovastatin D. Gemfibrozil

Choice A is correct. This tracing reflects sinus tachycardia (ST). ST can be caused by an array of conditions such as dehydration, hypo- and hyperglycemia, stress, anxiety, and thyroid conditions such as hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism, and this increased metabolic and sympathetic activity would cause tachycardia.

The nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below. A. Graves' disease B. Increased intracranial pressure C. Severe hypothermia D. Myxedema coma

Choice B is correct. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference regularly. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if the patient experiences any chest pain or dyspnea. The patient should be instructed not to massage the legs.

How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg? A. By palpating the skin over the tibia and fibula B. By documenting daily calf circumference measurements C. By recording vital signs obtained four times a day D. By noting difficulty with ambulation

- stop the diltiazem infusion - notify the primary healthcare provider

The ICU nurse reviewed the client's medical record Based on the 2000 vital signs, select two (2) immediate actions the nurse should take - stop the diltiazem infusion - apply supplemental oxygen via nonrebreather face mask - stop the 0.9% saline infusion - notify the primary healthcare provider - assess the client for back pain - request a prescription to change the intravenous fluids to hypertonic saline

Choice D is correct. CK-MB, or creatine kinase myocardial muscle, levels measure muscle cell death and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels first begin elevating about 3 to 6 hours after a cellular injury or myocardial infarction and stay elevated for about 48 to 72 hours.

The cardiac nurse is evaluating cardiac markers to determine whether or not their client's heart has suffered from muscle damage. The nurse is aware if damage has occurred, CK-MB levels will be their highest after how many hours? A. 3 to 6 B. 1 to 2 C. 48 to 72 D. 18

Choice C is correct. ST-segment elevation isolated in two leads is consistent with an acute ST-elevation myocardial infarction. A 12-lead electrocardiogram is a high-yield test to determine if the client is actively experiencing an infarction. Myocardial infarction may also present without ST elevations (NSTEMI or non-ST elevation MI) - EKG findings in NSTEMI may include normal EKG, ST segment depressions, and T-wave inversions.

The emergency department nurse suspected a client may have an acute myocardial infarction. Which finding on the electrocardiogram (ECG) abnormality would support this possibility? A. U-waves B. T-wave inversion C. ST-segment elevation D. Prolonged PR-interval

Choice C is correct. This statement requires immediate follow-up by the nurse because this client experienced a myocardial infarction (MI) two weeks ago and is at risk of reinfarction. Antiplatelet medications such as clopidogrel are prescribed after an MI to prevent another infarction, and the sudden abandonment of the treatment could be a precipitating factor for another MI. Clients are usually prescribed a one-year course of therapy after an MI, which may be continued indefinitely depending on their risk factors.

The home health nurse is caring for a client who experienced a myocardial infarction two weeks ago. Which of the following client statement requires immediate follow-up? A. "I am having difficulty coping with the stress at work." B. "I am unsure if I want to continue with cardiac rehabilitation." C. "I have not been taking my prescribed clopidogrel because I cannot afford it." D. "I started using nicotine patches to help me quit smoking."

epinephrine; resuming CPR

The next essential intervention is the administration of ____ followed by _____

Choice B is correct. The client is exhibiting signs and symptoms of cardiac tamponade following surgical trauma. Cardiac tamponade is a medical emergency where an accumulation of blood or fluid in the pericardial sac of sufficient volume and pressure occurs to the point of impairing cardiac filling. As a result, obstructive shock occurs. Clients with cardiac tamponade typically exhibit Beck's triad, consisting of hypotension, muffled heart tones, and neck vein distention. Treatment of cardiac tamponade includes immediate pericardiocentesis (inserting a needle into the pericardial cavity to drain the fluid or blood).

The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate A. thoracentesis. B. pericardiocentesis. C. arthrocentesis. D. paracentesis.

Choice D is correct. Based on the acute symptoms (unilateral leg swelling and tenderness) following a risk factor (a long flight trip), the client has a high clinical probability of deep vein thrombosis (DVT). The gold standard for diagnosing a DVT is venous duplex ultrasonography. This noninvasive test is an ultrasound that assesses the flow of blood through the veins of the arms and legs.

The nurse assesses a client with acute left leg swelling and calf tenderness following a long car ride. The nurse anticipates that the primary healthcare provider (PHCP) will order which diagnostic test? A. D-dimer test B. Ankle-Brachial Index C. Radiograph (X-Ray) D. Venous Duplex Ultrasonography

Choice C is correct. The EKG strip shows normal sinus rhythm with occasional premature ventricular contractions (PVCs). A PVC produces wide, bizarre complexes, with the P wave hidden within the QRS complex (not visible). After assessing the client, the nurse should review the client's most recent laboratory data because low levels of magnesium and potassium may cause PVCs.

The nurse assesses the following telemetry strip for a client on a medical-surgical unit. Based on the rhythm, what is the priority action for the nurse to take? See the exhibit. View Exhibit A. Prepare for synchronized cardioversion B. Obtain a prescription for intravenous (IV) atropine C. Review the most recent labs D. Ask the patient about palpitations

Choice A is correct. A third-degree heart block (complete heart block) is a medical emergency because electrical communication is lost between the atria and the ventricles. On an electrocardiogram, this appears as a complete dissociation of atrial activity from ventricular activity (P waves are independent of QRS complexes). A common finding with this heart block is that the heart rate is usually less than 60 beats per minute. If the escape rhythm is junctional, the heart rate is between 40 and 60 beats per minute. However, if ventricular escape rhythm occurs, the heart rate can fall below 40 beats per minute and result in hemodynamic instability (hypotension). A hemodynamically unstable complete heart block is highly concerning because of the significant reduction in cardiac output. Immediate management includes providing supplemental oxygen if the client has decreased pulse oximetry, pharmacological therapy with atropine, preparing the client for temporary transcutaneous pacing, and admission to the critical care unit for close monitoring. The cure for an irreversible complete heart block would be the placement of a permanent pacemaker.

The nurse cares for a client with a complete (3rd-degree) heart block and hypotension. The nurse should take which appropriate action? A. prepare the client for temporary transcutaneous pacing B. obtain a prescription for an esmolol infusion C. begin chest compressions D. instruct the client to perform the Valsalva maneuver

Choice C is correct. Percutaneous coronary intervention (PCI) is cardiac catheterization that involves the insertion of a large catheter into the femoral or radial artery to access the coronary arteries. A stent may be placed to keep the lumen of the artery open. This test can diagnose narrowing in the coronary arteries and intervene with angioplasty and stenting, if necessary. If this is not available, the physician may order an intravenous thrombolytic to bust the clot in the coronary artery.

The nurse cares for a client with acute myocardial infarction (AMI). The nurse anticipates the physician will order an emergent A. exercise electrocardiography. B. computed tomography (CT) of the chest with contrast. C. percutaneous coronary intervention (PCI). D. echocardiogram.

Choice B is correct. Congestive Heart Failure (CHF) may be confirmed by an elevation of the B-type natriuretic peptide (BNP). This peptide is elevated when it is cleaved from the ventricle wall because of increased ventricular filling pressures.

The nurse cares for a client with suspected congestive heart failure (CHF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis? A. Basic metabolic panel (BMP) B. B-type natriuretic peptide (BNP) C. Complete Metabolic Profile (CMP) D. C-Reactive Protein (CRP)

Choice B is correct. This concerning tracing on the electrocardiogram is ventricular fibrillation. Ventricular fibrillation is electrical chaos in the ventricles that produces no cardiac output. The priority is to defibrillate the client immediately, according to ACLS protocol. If a defibrillator is not readily available, high-quality CPR must be initiated and continued until the defibrillator arrives. ➢ External electrical defibrillation remains the most successful treatment for ventricular fibrillation (VF) and is a priority treatment.

The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse. The nurse should take which priority action based on the tracing? A. Start cardiopulmonary resuscitation (CPR) B. Perform immediate defibrillation C. Initiate intravenous (IV) access D. Review the client's most recent electrolyte levels

Choice D is correct. Peripheral arterial disease is caused by conditions such as hypertension, hyperlipidemia, and diabetes mellitus which cause atherosclerosis of the peripheral arteries. This impeded blood flow may cause the client to experience intermittent claudication (pain with ambulation that is relieved with resting). The client should be educated on self-management strategies, including sleeping or resting with the legs dependent (below the heart) to facilitate blood flow and not wearing constrictive clothing that may further impede blood flow. This statement requires follow-up because the client's legs should be below the heart to facilitate blood flow.

The nurse has attended a staff education program about managing clients with peripheral arterial disease. Which of the following statements by the nurse would require follow-up? A. "The client should engage in a daily exercise regimen." B. "Smoking cessation is an essential treatment goal for clients who smoke." C. "Resting in a recliner with the legs dependent should be recommended." D. "Devices that elevate the legs above the heart should be provided at discharge."

Choice B is correct. A pulse deficit is a difference between the apical and peripheral pulses. This finding may signal that the client has a dysrhythmia, and the nurse should consider obtaining a 12-lead electrocardiogram and/or continuous telemetry monitoring.

The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as A. a widened pulse pressure. B. a pulse deficit. C. pulsus paradoxus. D. an expected finding.

Choices B and D are correct. These two statements indicate that the patient needs further follow-up education to correct the misconceptions. The client does not need to weigh themselves daily (Choice B) as that would be applicable for CHF and not for atrial fibrillation. Considering daily weight checks in CHF is useful to detect excess fluid retention, which may precede symptoms such as shortness of breath. Wearing a mask in public is unnecessary as an infection is not the concern here (Choice D).

The nurse has provided education to a client with atrial fibrillation. Which of the following statements by the client would require a follow-up? Select all that apply. "I have an increased risk for a stroke." "I should weigh myself daily at the same time." "I may be prescribed medications such as amiodarone." "I should wear a mask when I am in public." "I should follow-up with my primary healthcare provider (PHCP) if I develop shortness of breath."

- administer prescribed morphine sulfate - administer prescribed furosemide - administer supplemental oxygen - administer prescribed 3% saline - seizure precautions

The nurse has received orders from the physician and inserts a peripheral vascular access device. Which five (5) orders should the nurse prioritize? - give report to the nurse in the intensive care unit (ICU) - administer prescribed morphine sulfate - administer prescribed furosemide - administer supplemental oxygen - insert indwelling urinary catheter - administer prescribed 3% saline - call the lab and arrange for serum sodium collections every two hours - transport the client to the radiology department for a head computed tomography (CT) scan - seizure precautions

Choice D is correct. Perfusion refers to the continuous supply of blood through the blood vessels to vital organs. The client with hypotension is at the highest risk for impaired vascular perfusion. Hypotension can result from various causes such as adrenal insufficiency, dehydration, hemorrhage, septic shock, obstructive shock, and cardiogenic shock. A Mean Arterial Pressure (MAP) greater than 65 mmHg is essential to maintain perfusion to vital organs. Prolonged hypoperfusion may lead to end-organ damage, such as renal failure and ischemic hepatitis. Therefore, the cause of hypotension must be identified and treated right away.

The nurse has recently finished education about vascular perfusion. The nurse knows which of the following clients is at greatest risk for experiencing impaired vascular perfusion? A. A 76-year-old female client with a history of alcohol abuse. B. A 76-year-old female client with a history of radon gas exposure. C. A 64-year-old male client with a history of cigarette smoking. D. A 64-year-old male client with hypotension.

Choice B is correct. Ventricular tachycardia (VT) is an ominous dysrhythmia that may portend the client clinically deteriorating. Following a cardiac catheterization, the client is at risk for an array of complications, including hemorrhage, cardiac dysrhythmias, and reinfarction. Although brief, these two runs of VT need to be reported to the PHCP immediately, so prescribed medications such as amiodarone may be given to prevent further ventricular irritability.

The nurse in the medical-surgical unit is observing the telemetry monitor for assigned clients. Which client condition change requires immediate notification to the primary healthcare provider (PHCP)? A client A. with normal sinus rhythm (NSR), who has had three premature ventricular contractions (PVCs) in the past hour. B. recovering from cardiac catheterization and has had two brief runs of ventricular tachycardia (VT). C. with atrial fibrillation, whose heart rate decreased from 113 to 95 beats per minute. D. who has developed sinus tachycardia (ST) following the application of nitroglycerin paste.

Choice A is correct. Right-sided heart failure manifests with peripheral edema, hepatosplenomegaly, jugular venous distention, and oliguria. The client states that his swollen feet would be consistent with right-sided heart failure. This is because of the fluid backing up into the client's body.

The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis? A. "I notice that my feet are always swollen." B. "I can't seem to get rid of this wet cough." C. "I develop shortness of breath after I walk a few feet." D. "My legs start to burn if I walk long distances."

Choices A and B are correct. Peripheral arterial disease (PAD) is characterized by atherosclerosis in the lumen of the peripheral arteries. PAD symptoms include pain in the extremities that may be exacerbated by walking and are relieved by rest(claudication). Decreased peripheral pulses are a consistent manifestation of PAD.

The nurse is assessing a client with peripheral arterial disease (PAD). Which of the following findings would the nurse expect to observe? Select all that apply. - Decreased peripheral pulses - Pain with ambulation - Reddish-brown ankle discoloration - Bilateral dependent edema - Protruding veins in the leg

Choice A is correct. Ascites is a symptom of right-sided heart failure, not left-sided. Right-sided heart failure involves congestion in the systemic circulation. Clients with right-sided heart failure may also experience jugular vein distention, oliguria, weight gain, and peripheral edema.

The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure? A. ascites B. tachypnea C. cough D. orthopnea

Choices A and B are correct. Pain and swelling of the affected extremity are classic manifestations of venous thromboembolism. Other manifestations include warmth to the affected extremity and erythema.

The nurse is assessing a client with venous thromboembolism in the lower extremity. Which of the following assessment findings would be expected? Select all that apply Pain Swelling Paralysis Pulse deficit Dependent rubor

Choice D is correct. Upon seeing a sudden, noticeable drop in the client's heart rate, the nurse would notate a vasovagal response. Here, during the bronchoscopy, the involvement of a foreign object (i.e., the scope used in the bronchoscopy) in the client's pharynx likely caused vagus nerve stimulation. This stimulation resulted in a vasovagal response by the client, manifested by a sudden decrease in the client's heart rate.

The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidence by the client's A. hypertension. B. bronchodilation. C. increase in heart rate (HR). D. decrease in heart rate (HR).

Choices A, C, D, E, and F are correct. This client is experiencing a myocardial infarction (MI), a medical emergency. Starting a vascular access device and obtaining laboratory work such as troponin is especially crucial for the future administration of drugs and assessing the chemical damage done to the heart. The nurse should obtain prescriptions for chewable aspirin, sublingual nitroglycerin, and antiplatelet medications such as clopidogrel. Aspirin is used to exert its antiplatelet effects, and nitroglycerin promotes vasodilation of the coronary arteries. A client experiencing an MI would also get a chest radiograph (x-ray). This is useful in determining if the client is experiencing pulmonary edema due to the MI. Additionally, the radiograph will identify any other pathologies, such as cardiomegaly. Performing continuous cardiac monitoring is appropriate because the nurse needs to watch for the development of dysrhythmias closely.

The nurse is caring for a client experiencing a myocardial infarction. The nurse should prepare to take which action? Select all that apply. - Start a peripheral vascular access device (VAD) - Obtain a prescription for albuterol via nebulizer - Obtain a prescription for chewable aspirin - Obtain a prescription for nitroglycerin - Obtain an order for a chest radiograph (x-ray) - Establish continuous cardiac monitoring

Choice B is correct. B-type natriuretic peptide (BNP) is a commonly ordered test for clients who may have heart failure. Elevations indicate worsening of heart failure as it is indicative of fluid retention.

The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis? A. Basic metabolic panel (BMP) B. B-type natriuretic peptide (BNP) C. Lipid profile D. Troponin

Choice A is correct. Positive pressure ventilation (PPV) would be detrimental to a client experiencing cardiac tamponade. This order requires follow-up. PPV increases intrathoracic pressure, which decreases venous return to the heart. This reduction of venous return impairs ventricular filling and decreases cardiac output. This would be detrimental in a cardiac tamponade where the cardiac output is already impaired.

The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)? A. Positive pressure ventilation B. Pericardiocentesis C. Echocardiography D. 0.9% saline bolus

Choice B is correct. The initial treatment for acute pericarditis includes NSAIDs or colchicine. Pericarditis is an inflammatory condition of the pericardium that causes a client to experience chest pain, pericardial friction rub heard on auscultation and leukocytosis. Colchicine reduces the inflammation in the pericardium and may be prescribed for several weeks to achieve efficacy. Corticosteroids may be used as an adjunctive treatment.

The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Isoniazid B. Colchicine C. Allopurinol D. Warfarin

Choice B is correct. Troponin is the most specific iso-enzyme when evaluating a client's myocardial infarction (MI). Troponin levels will elevate within 3-4 hours of myocardial infarction and remain elevated for three weeks. This means that troponin is the most specific cardiac biomarker for an MI and is the most reliable test to run if the client does not seek care for some time after their symptoms begin.

The nurse is caring for a client who has sustained a myocardial infarction. Which cardiac enzyme should the nurse expect to be elevated in response to myocardial injury? A. CPK-MB B. Troponin C. Creatinine kinase D. Myoglobin

Choice C is correct. Arterial and venous blood flow impediments characterize Buerger's disease. This impediment is caused by inflammation and is significantly worsened by smoking. The nicotine causes vasoconstriction and worsens blood flow. A critical intervention for a client with this condition is discussing smoking cessation with this client.

The nurse is caring for a client with Buerger's disease. The nurse plans on suggesting that the client receive a referral for A. occupational therapy. B. speech therapy. C. smoking cessation. D. group psychotherapy.

Choice B is correct. A massive anterior acute myocardial infarction may result in left ventricular failure and flash pulmonary edema. In pulmonary edema, fluid (transudate) fills up the alveoli. Pulmonary edema presents with shortness of breath, tachypnea, and cough with pink frothy sputum. Physical exam may reveal crackles, elevated jugular venous pressure, and peripheral edema. Crackles indicate alveoli that are collapsed by fluid (transudate or exudate). Crackles are adventitious sounds produced when these small alveoli filled with fluid snap open on inspiration. Other causes of crackles include atelectasis, COPD, pneumonia, acute respiratory distress syndrome (ARDS), bronchitis, and bronchiectasis.

The nurse is caring for a client with a myocardial infarction experiencing tachycardia and coughing up frothy, pink-tinged sputum. Which finding would the nurse expect upon lung auscultation? A. Wheezing B. Crackles C. Rhonchi D. Diminished sounds

Choice C is correct. The essential action for a client with a femoral artery occlusion is to notify the PHCP or rapid response. This is a medical emergency! If untreated, this extremity may have to be amputated because of the interruption in distal perfusion.

The nurse is caring for a client with a suspected femoral artery occlusion. The nurse should take which action? A. Elevate the affected leg B. Apply a cold compress C. Notify the primary healthcare provider (PHCP) D. Perform passive range of motion to the affected leg

Choice D is correct. Blurred vision is an unexpected manifestation of atrial fibrillation and may signify that the client has had a stroke. Ischemic stroke is a significant complication of atrial fibrillation which explains why most clients with atrial fibrillation will be prescribed anticoagulants to prevent this life-threatening complication.

The nurse is caring for a client with atrial fibrillation. Which of the following client findings requires immediate follow-up by the nurse? A. Irregular QRS complexes on telemetry reading B. Irregular peripheral pulse C. Reports of intermittent palpitations D. Blurred vision

Choice A is correct. Classic manifestations of cardiac tamponade include tachycardia, tachypnea, jugular venous distention, and hypotension with a narrowed pulse pressure.

The nurse is caring for a client with cardiac tamponade. Which vital signs are expected? A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg

Choice A is correct. Congestive heart failure is a chronic illness that can be debilitating if not appropriately managed. Approximately 50% of individuals diagnosed with heart failure die within five years of the diagnosis. A local support group would be an appropriate recommendation for this client as the support group is a tertiary level of prevention. Support groups are effective because they enable an individual to be expressive and potentially develop social ties with others. All factors that may mitigate depression.

The nurse is caring for a client with congestive heart failure exhibiting signs of ineffective coping. The nurse should take which action based on the findings? A. Recommend a support group B. Review dietary items low in sodium C. Review the client's vaccination status D. Recommend the client take St. John's Wort

Choice D is correct. Even with small doses of nitroglycerin, clients are at risk of severe hypotension, particularly with position changes and when adjusting from a sitting to a standing position. Although all clients are at risk for this complication, elderly clients are more susceptible to nitroglycerin-induced hypotension, placing them at greater risk of falling when taking therapeutic doses of nitroglycerin. Therefore, the client should be educated to make position changes slowly to avoid a sudden drop in blood pressure.

The nurse is caring for a client with heart failure who has an order for a nitroglycerin patch. Which nursing action regarding the administration of a nitroglycerin patch is most relevant? A. Use a bare hand when placing the patch on the client. B. Place the patch in the same spot every day. C. Place the client supine with their feet elevated on a pillow. D. Instruct the client to rise slowly.

Choices A, B, C, and E are correct. Isometric exercise, which increases muscle tension or muscle work but does not shorten or actively move muscle, is ideal for clients who do not tolerate increased activity, such as a client who is immobilized in bed. The benefits include an increase in muscle mass, tone, and strength, thus decreasing the potential for muscle wasting; increased circulation to the involved body part; and increased osteoblastic activity. Reducing sodium intake is crucial in managing hypertension. High sodium consumption can lead to fluid retention and increased blood pressure. Smoking and exposure to secondhand smoke can significantly increase the risk of developing hypertension and cardiovascular diseases. Smoking cessation is strongly recommended to manage hypertension. Maintaining a healthy weight or achieving weight loss if overweight or obese is beneficial in managing hypertension. Losing excess weight can help lower blood pressure and reduce the strain on the cardiovascular system.

The nurse is caring for a client with hypertension. Which of the following lifestyle modifications are recommended for managing hypertension? Select all that apply. Isometric exercises Decreasing sodium intake Smoking cessation Use of herbal supplements Weight loss

Choice D is correct. The tracing in the exhibit shows irregularly irregular rhythm with no identifiable p-waves. This rhythm can be identified as "atrial fibrillation." Diltiazem is a calcium channel blocker (CCB) that controls the atrial fibrillation rate. Atrial fibrillation leads to increased ventricular rate and reduced ventricular diastolic filling. If the ventricular rate is uncontrolled, cardiac output is reduced, resulting in hypotension and congestive heart failure. Initial treatment in atrial fibrillation is aimed at ventricular rate control with calcium channel blockers (diltiazem, verapamil), a beta-blocker (atenolol, metoprolol), or digoxin. If the atrial fibrillation remains persistent, cardioversion is considered.

The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The nurse should anticipate which prescription from the primary healthcare provider (PHCP)? See the exhibit. View Exhibit A. captopril B. atropine C. adenosine D. diltiazem

Choices D and E are correct. Pulmonary edema secondary to acute decompensated heart failure (ADHF) is a medical emergency and requires rapid treatment. Vasodilators such as nitroglycerin help decrease preload and afterload, reducing the heart's workload. This medication is often combined with a loop diuretic such as furosemide or bumetanide to decrease volume. If vasodilators or loop diuretics are prescribed, close blood pressure monitoring is essential.

The nurse is caring for a client with the following clinical data. Based on the clinical data, which prescription would the nurse request from the primary healthcare provider (PHCP)? Select all that apply. See the image below.

Choice D is correct. The client's laboratory data shows a remarkably increased creatinine. This high creatinine level requires the nurse to review the client's current medications that could worsen the creatinine. Captopril is an ACE inhibitor used to manage heart failure and hypertension. While this medication may be nephroprotective, it can become nephrotoxic. While a client takes an ACE inhibitor, the creatinine and GFR must be watched closely. Elevations of the creatinine, especially of this level, requires reporting to the PHCP for further direction.

The nurse is caring for a client with the following clinical data. Based on the laboratory tests, which medication would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the images below. A. bupropion 150 mg XL PO Daily B. clonidine 0.1 mg PO Daily C. albuterol 2.5 mg via nebulizer Daily D. captopril 12.5 mg PO Daily

Choice D is correct. This tracing reflects atrial fibrillation. Atrial fibrillation characteristically has no definitive P-waves because fibrillatory waves replace them before each QRS.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). It would be correct for the nurse to document this tracing as See the tracing in the exhibit. View Exhibit A. sinus bradycardia. B. normal sinus rhythm with first degree block. C. atrial flutter. D. atrial fibrillation.

Choices A and E are correct. This reflects sinus tachycardia (ST). ST can be caused by various conditions, such as a febrile illness likely to induce dehydration. The appropriate action for the nurse is to obtain prescriptions for fluids to rehydrate the client and acetaminophen to mitigate the fever.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The client has an oral temperature of 101 o F (38.3o C). The nurse should be prepared to obtain which prescription from the primary healthcare provider (PHCP)? Select all that apply. See the image below. 0.9% saline bolus Enalapril Levothyroxine Metoclopramide Acetaminophen

Choice A is correct. The tracing reflects supraventricular tachycardia (SVT). The preferred medication for individuals experiencing SVT includes the rapid administration of adenosine followed by a rapid flush of 0.9% saline. Adenosine slows the electrical conduction time through the AV node.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse should anticipate a prescription for which medication? See the image below. A. Adenosine B. Atropine C. Labetalol D. Amiodarone

Choice A is correct. The client is presenting with signs of arterial insufficiency and an arterial ulcer. The application of compression (TED hose) to the extremities is contraindicated in cases of severe arterial insufficiency because the compression may further aggravate the ischemia. TED hose should not be applied until cleared by the primary healthcare provider (PHCP). The PHCP may want to ensure that the perfusion is adequate before clearance is given to apply a compression device.

The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated? A. Apply TED hose to bilateral legs B. Assess the need for smoking cessation C. Physical therapy consult D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler

Choices A, C, and D are correct. A is correct. It is not possible to eliminate sodium from the diet, nor would it be recommended. Sodium is a principal cation and it plays a role in driving the sodium-potassium pump as well as regulating water balance, so wholly eliminating sodium is not a good idea. C is correct. Canned vegetables do use a large amount of sodium to preserve flavor, so you should advise your client with hypertension to avoid them. D is correct. The body indeed needs some sodium as it plays a vital role in water balance, so this is an appropriate teaching point for your client.

The nurse is educating a client newly diagnosed with hypertension about sodium and its role in blood pressure. Which of the following statements about sodium are true? Select all that apply. Sodium cannot be completely eliminated from the diet. There is no sodium in fresh fruits and vegetables. Canned vegetables should be avoided. The body needs some sodium as it plays an important role in water balance. Reduce daily sodium intake to 2,000 mg

Choices A, B, C, and D are correct. A is correct. Stroke volume refers to the amount of blood ejected by the left ventricle during each contraction. An increase in stroke volume would directly increase cardiac output, as it is one of the two factors determining cardiac output (Workman, 2021). B is correct. An increase in blood volume can lead to an increase in cardiac output. More blood volume can stretch the heart muscle fibers, leading to a more muscular contraction and stroke volume, thereby increasing cardiac output (Frank-Starling law) (Workman, 2021). C is correct. Sympathetic stimulation increases both heart rate and the force of myocardial contraction, which can increase cardiac output. This is part of the body's 'fight or flight' response (Workman, 2021). D is correct. Positive inotropic drugs, such as digoxin, increase the force of myocardial contraction. This can lead to increased stroke volume and cardiac output (Workman, 2021).

The nurse is educating nursing students about factors that can influence cardiac output. Which of the following would cause an increase in cardiac output? Select all that apply. Increased stroke volume Increased blood volume Increased sympathetic stimulation Administration of positive inotropic drugs Increased systemic vascular resistance (SVR).

Choices A, B, C, E, and F are correct. Choice A is correct. Knowledge of the indications for pacemaker placement is essential for nurses caring for clients with pacemakers. By understanding the medical conditions or heart conditions that may necessitate a pacemaker, nurses can better assess and anticipate the needs of the client. Choice B is correct. Recognizing signs and symptoms of a malfunctioning pacemaker, such as dizziness, palpitations, or shortness of breath, enables nurses to respond promptly and seek appropriate medical intervention. Identifying potential issues with the pacemaker's functioning can prevent serious complications and improve client outcomes.

The nurse is educating the staff about caring for a client with a pacemaker. Which of the following teaching topics should the nurse prioritize? Select all that apply. - Understanding the indications for pacemaker placement. - Recognizing signs of pacemaker malfunction. - Explaining different types of pacemakers and how they function. - Advising clients with pacemakers to avoid all sources of electromagnetic fields (EMFs). - Discussing the importance of regular pacemaker check-ups and follow-up care. - Providing guidelines on safe physical activities and exercise after pacemaker placement

Choices A, B, C, and D are all correct. All rhythm changes will affect cardiac output. This is especially important to remember when administering antiarrhythmics to your client, as these medications and their effect will also change the cardiac output. There are two reasons that rhythm changes affect cardiac output. 1 - they break your heart rate. 2 - they change your stroke volume. Remember, CO = HR x SV, so any change to either heart rate or stroke volume subsequently affects your cardiac output. A - Supraventricular tachycardia (SVT) - There is an increase in heart rate but a decrease in stroke volume. This is because the heart is beating so fast that there is not enough time for diastole and, therefore, not enough time for the atriums to fill with blood. This decreases preload, which decreases contractility due to Starling's law, which reduces stroke volume. Clients with SVT have decreased cardiac output. B - Sinus bradycardia - The heart rate is lower due to bradycardia, so the cardiac output is lowered. Remember, CO = HR x SV. Decreased HR = decreased CO. C - Ventricular tachycardia - There is an increase in heart rate and a decrease in stroke volume. This is because the heart is

The nurse is reviewing an EKG strip for a client. Which of the following rhythm changes could impact the patient's cardiac output? Select all that apply. Supraventricular tachycardia Sinus bradycardia Ventricular tachycardia Mobitz type II heart block Isolated premature atrial contraction (PAC)

Choice A is correct. The nurse should assess the client first before implementing any intervention. Asking what the client means by his statement explores the client's feelings and provides information regarding his condition.

The nurse is taking care of a client that is 24 hours post-angioplasty. The client says, "I don't feel good today. I don't feel like eating." What is the nurse's best action? A. Ask what the statement means to the client. B. Delegate an LPN to assess the client. C. Notify the physician. D. Encourage the client to eat.

Choices A, C, and D are correct. Dietary recommendations for reducing CAD risk include increasing dietary complex carbohydrates and vegetable proteins; complex carbohydrates are dense in fiber and help reduce cholesterol. Reducing sodium intake is key as it assists with lowering blood pressure. Exercising at least 150 minutes a week is recommended. Exercising has many benefits, including weight loss, mood improvement, and vascular perfusion.

The nurse is teaching a group of individuals at a health fair regarding the prevention of heart disease. It would be correct for the nurse to recommend Select all that apply. increasing complex carbohydrates in the diet. a body mass index greater than 25. reducing dietary sodium. exercising at least 150 minutes per week. chewing tobacco instead of cigarettes.

Choice B is correct. Furosemide is a loop diuretic that should be dosed early in the day. This prevents the client from experiencing nocturia. This also reduces the risk of falls by the client as they will not have to wake up at night when there is reduced lighting.

The nurse is visiting a client who was recently prescribed antihypertensive medications. Which statement, if made by the client, requires follow-up? A. "My pulse decreases after taking my metoprolol." B. "I started taking my furosemide right before I went to sleep." C. "I am seasoning my foods with salt substitutes while taking my hydrochlorothiazide." D. "I wear my clonidine patch for seven days."

Choice A is correct. Tight postoperative glucose control is essential for optimal outcomes. Amongst the priorities of airway patency, ensuring appropriate hemodynamics, vital signs, and thermoregulation, the nurse will obtain frequent capillary blood glucose levels to ensure it is less than 180 mg/dL. Immediately postoperative, a continuous infusion of regular insulin is prescribed and is titrated based on the client's glucose level. The stress of this major surgery raises serum glucose levels and requires appropriate control via regular insulin. Choice D is correct. Grounding (connecting) the epicardial pacing wires to the pacemaker generator is appropriate. Epicardial pacing wires are placed on the heart to control postoperative cardiac dysrhythmias. Also, they are used to increase cardiac output by increasing the client's heart rate, if necessary. Choice E is correct. After a CABG, clients usually have two mediastinal chest tubes to drain fluid or blood around the heart. Clearing of this excess fluid and blood prevents hemodynamic compromise. These tubes are connected to a chest tube drainage system. The drainage should not exceed no more than 150 mL/hr.

The nurse plans care for a client immediately postoperative following a coronary artery bypass graft surgery (CABG). Which interventions are appropriate during this time? Select all that apply. - obtain the client's capillary blood glucose - provide tracheostomy care, as needed - teach the client about the driving restrictions after this procedure - ground the epicardial pacing wires to the pacemaker generator - ensure patency of the mediastinal chest tubes

supine; sitting; standing, keep the blood pressure cuff in the same position; 20mmHg; 10mmHg

The nurse prepares to obtain the client's orthostatic blood pressure (BP) by first positioning the client ___ then positioning the client ____ and finally repositioning the client _____ When obtaining the blood pressure, the nurse should _____ The nurse should be concerned for orthostatic hypotension if the systolic blood pressure decreases by _____ or the diastolic blood pressure decreases by ____

Choice B is correct. This client is being treated for hyperlipidemia and still has suboptimal values. The triglycerides are high, along with the LDL-C. The first step is to assess whether the client is taking the medication as prescribed. Side effects and adverse reactions commonly deter a client from adhering to prescribed medication, and this should be assessed before going further in the process, such as notifying the prescriber of a potential dosage adjustment.

The nurse reviews a client's lipid panel who is being treated for hyperlipidemia with simvastatin. Which of the following actions should the nurse take based on the results? Total cholesterol 235 mg/dl (6.07 mmol/l) [less than 200 mg/dl (<5.18 mmol/l)] High-density lipoprotein (HDL) 35 mg/dl (0.91 mmol/l) [more than 45 mm/dL (>0.75 mmol/L) for men; more than 55 mg/dL (>0.91 mmol/L) for women] Low-density lipoprotein (LDL) 135 mg/dl (3.49 mmol/l) [less than 130 mg/dL (< 3.36 mmo/l)] Triglycerides 169 mg/dL [Females: 35-135 mg/dL or 0.40-1.52 mmol/L; Males: 40-160 mg/dL or 0.45-1.81 mmol/L] A. Review the client's most recent creatinine B. Assess the client's adherence to the prescribed medication C. Determine if the client is adhering to a low salt diet D. Document the results as within normal limits

Choice D is correct. This tracing reflects sinus bradycardia. Verapamil is a calcium channel blocker, and a property unique to verapamil is that it decreases both blood pressure and heart rate. Verapamil may be indicated to prevent migraine headaches, hypertension, or vascular spasms.

The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely causing this tracing? See the image below. A. Losartan B. Nitroglycerin transdermal patch C. Enalapril D. Verapamil

Choice A is correct. Patients who have undergone cardiac surgery should have their exercise tolerance evaluated by a physician before resuming sexual activity. Many physicians agree that a patient may return to sexual activity if they can climb two flights of stairs without symptoms.

The patient recovering from cardiac surgery is wondering when he can resume sexual activity. The nurse would be most correct in stating that sexual intercourse may be returned at which point in time? A. After exercise tolerance is assessed B. One week after surgery C. When the patient can comfortably jog two miles D. Three months after surgery

Choice A is correct. This patient is presenting with early signs/symptoms consistent with compartment syndrome. Later signs of compartment syndrome include paralysis and the absence of pulses in the affected extremity. If not caught and treated early, compartment syndrome can result in permanent muscle and nerve damage

The patient with a right distal fibula fracture complains of pain and a tingling sensation in the right foot. Upon assessment, the nurse notes the right foot is cold to the touch with a weak dorsalis pedis pulse. Which potential complication should the nurse be most concerned about? A. Compartment syndrome B. Sepsis C. Peripheral neuropathy D. Pressure Injury

Choice D is correct. When assessing pulses, the strength, volume, and fullness of the peripheral pulses are categorized and documented as follows: 0: Absent pulses 1: Weak pulse 2: Normal pulse 3: Increased volume 4: Abounding pulse

What is the correct documentation of the patient's peripheral pulse when the finding is that the posterior tibial pulse is weak and thready? A. Grade C posterior tibial pulse B. Posterior tibial pulse is Grade B C. The client's posterior tibial is 2 D. Posterior tibial pulse is 1

- lung sounds - diminished deep tendon reflexes - pulse oximetry - confusion

Which of the following assessment findings require immediate follow-up? Select all that apply. lung sounds diminished deep tendon reflexes pulse oximetry temperature cardiac sounds confusion

Choice B is correct. The heart is a double pump with four chambers, four valves, and a conduction system with a pacemaker originating in the atrium.

Which of the following statements best describes the cardiovascular system? A. It has a heart with six chambers, strong vessels, and valves. B. It is a double-pump circulating blood out to the lungs and the body. C. It includes concepts of precontractility, postcontractility, and load. D. It functions with a conduction system and starts in the ventricles.

Choice C is correct. Bleeding is the priority concern for any patient who is taking a thrombolytic medication.

While monitoring a client with myocardial infarction, who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following? A. Observe for neurological changes B. Monitor for any signs of renal failure C. Observe for signs of bleeding D. Check the client's food diary

Choice B is correct. Epinephrine is necessary as this arrhythmia reflects asystole. Asystole (also known as ventricular standstill) requires an aggressive treatment consisting of high-quality cardiopulmonary resuscitation (CPR) and intravenous (IV) epinephrine. Epinephrine is necessary as this medication assists with restoring vascular tone.

he nurse assists the code team with an unresponsive and pulseless client. Which intervention does the nurse prepare for based on the electrocardiogram (ECG) tracing? See the image below. A. Prepare an infusion of sodium bicarbonate B. Administer epinephrine C. Defibrillation D. Cardioversion