ATI - cardiac

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness Manifestations of left-sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP). CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure.

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Exercise at least three times per week. The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Muffled heart sounds. Muffled heart sounds are a key indicator of cardiac tamponade because of the excess amount of fluid surrounding the heart.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness

A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings?

The client is experiencing premature atrial contractions. Pulse pressure devices require the presence of optimal arterial waveforms in order to capture accurate data. Therefore, a dysrhythmia, such as premature atrial contractions, will compromise the readings.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

Heart failure Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)

Hypercholesterolemia Hypertension Obesity Smoking Hypercholesterolemia is correct. Cholesterol levels outside the healthful range increase clients' risk for heart disease, and they can change these levels. Hypertension is correct. Although it may not always be possible to eliminate hypertension, clients can change their blood pressure levels and thus reduce their risk for atherosclerosis. Obesity is correct. Clients who are overweight or obese can reduce their risk for heart disease by losing weight. Smoking is correct. Clients who smoke can reduce their risk for heart disease by quitting smoking.

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Increased heart rate Increased blood pressure Increased respiratory rate Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify which of the following findings indicates that the medication is effective?

Increased urine output Dobutamine is administered to clients who have heart failure to improve their hemodynamic status. The nurse should identify an increase in client's urine output as an indication that the medication is effective.

A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action?

Oxygen saturation Blood pressure Breath sounds Weight Breath sounds are correct. The client's breath sounds indicate pulmonary congestion. The nurse should report this finding to the provider and prepare to administer a diuretic to promote excretion of pulmonary fluid. Weight is correct. The client has gained 2.1 kg (5 lb) within 1 week indicating fluid retention. The nurse should report this finding to the provider and prepare to administer a diuretic to promote excretion of pulmonary fluid. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating decreased gas exchange and placing the client at risk for dysrhythmias. Blood pressure is correct. The client's blood pressure is significantly increased indicating the presence of fluid overload.

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Perform neurovascular checks with vital signs. The nurse should assess color, temperature, and pulse in the affected extremity and monitor the client for neurovascular changes that can indicate a stroke, such as slurred speech and visual disturbances.

A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication?

Potassium Digoxin is a cardiac glycoside medication used to improve myocardial contractility, increasing stroke volume and cardiac output in a client who has heart failure. During therapy, the nurse should closely monitor the client's potassium level as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse should obtain a 12-lead ECG and administer an anticoagulant as prescribed because the client is most likely experiencing atrial fibrillation. Atrial fibrillation is characterized by manifestations of a fast, irregular heart rate that appears as a chaotic rhythm with unclear P waves. The nurse should monitor for manifestations of stroke as well as the client's PTT and INR because clients who have atrial fibrillation are at risk for the formation of clots.