Cardiac-NUR 211 (Cardiovascular.10 11/21)

The nurse cares for the client after a carotid endarterectomy. Which signs and symptoms does the nurse observe that indicate cranial nerve impairment?

facial drooping, tongue deviation, and dysphasia

The nurse cares for the client reporting substernal pain. The client's laboratory work revels an elevation in creatine phosphokinase (CP), CPK-MB (an isoenzyme), aspartate aminotransferase (AST), lactic dehydrogenase (LDH), and troponin. Which intervention does the nurse expect to carry out?

facilitate an admission to the coronary care unit

The nurse for the client diagnosed with myocardial infarction. Which would the nurse identify as the most important social support system when the client goes through treatment and rehabilitation?

family members

The nurse instructor instructs a class about myocardial infarction (MI). The instructor tells the class that oxygen is given to the client experiencing an MI to keep the heart muscle well-oxygenated. This is done to prevent which problem that the ischemic heart muscle is likely to develop?

fatal dysrhythmias

The nurse cares for a patient immediately after a femoral-to-popliteal bypass graft. The nurse is most concerned if which of the following is observed?

clammy skin

The nurse understands that the primary purpose of prompting rest following a myocardial infarction includes which rationale?

decrease the workload on the heart

The nurse prepares the client diagnosed with a myocardial infarction for a cardiac catheterization. The nurse recognizes that a history of allergy to which allergen is most closely associated with an allergic reaction to the dye?

oysters

The nurse cares for the client diagnosed with an acute anterior wall myocardial infarction (MI). Why does the nurse identify the administration of pain medication as a priority in this client's care?

pain will increase myocardial oxygen demand

The nurse cares for a client who has had coronary artery bypass graft surgery. Which intervention does the nurse include when planning care for the client?

prevent thrombophlebitis

The nurse cares for the client diagnosed with a recent myocardial infarction (MI) involving the anterior wall of the left ventricle. Which assessment data might alert the nurse that the client is developing left ventricular failure?

pulmonary crackles

An older man is admitted to the hospital with a diagnosis of heart failure (HF). Which of the following findings is most characteristic of heart failure?

pulse 110, respirations 24, blood pressure 100/60

The nurse cares for the client diagnosed with angina. Which question is essential for the nurse to ask the client before a cardiac catheterization?

"Are you allergic to anything?"

The nurse cares for the client diagnosed with myocardial infarction (MI). Which client statement indicates to the nurse an understanding of lifestyle changes required due to the MI?

"I guess I won't be playing volleyball with the guys for a while. I need to complete my cardiac rehabilitation program."

The nurse instructs a client diagnosed with atrial fibrillation receiving lisinopril. Which statement, if made by the client to the nurse, indicates the need for further teaching?

"I have switched to a salt substitute instead of iodized salt."

The client experiencing chest pain takes a nitroglycerin tablet sublingually. Five minutes later, the client calls the nurse and asks what to do since there has been no relief. Which is the nurse's best response?

"take two nitroglycerin tablets in 5-minute intervals as needed and seek medical attention is there is no relief."

Which nursing measure is most important immediately following cardiac catheterization?

check the extremities for pulses

The 6-month-old baby has a cyanotic congenital heart defect. The nurse knows that a cyanotic congenital heart defect is associated with which symptoms?

clubbing of the fingers

The nurse assesses the laboratory values of the client with a suspected acute myocardial infarction. What data does the nurse understand is the most important in determining myocardial tissue damage?

creatine kinase, isoenzyme MM (CK_MM)

The nurses cares for the client diagnosed with pulmonary fibrosis. The client tells the nurse, "My chest hurts." The nurse places the client on the electrocardiogram (ECG) monitor and observes a large amount of ventricular ectopy. The rhythm progresses into ventricular fibrillation. Which action does the nurse prepare to take immediately?

defibrillation

The nurse explains the purpose of ventricular defibrillation to the new graduate nurse. Which explanation does the nurse provide?

defibrillation allows the SA node to resume the role of pacemaker in the heart

The nurse cares for the client with a pulmonary artery catheter in place. Which step is essential when obtaining a pulmonary capillary wedge pressure (PCWP) reading?

deflate the balloon as soon as the PCWP reading is obtained

The nurse cares for the client diagnosed with coronary artery disease. Which instructions should the nurse include in the client's teaching plan?

follow a diet low in saturated fat, cholesterol, and salt

The nurse cares for the client 12 hours after aortofemoral bypass. It is most important for the nurse to place the client in which position?

full supine

Which reason does the nurse understand to be the purpose of a coronary artery bypass graft? (CABG)

insert the graft

The nurse cares for the client diagnosed with myocardial infarction (MI). The nurse understands that a stool softener is administered for which reason?

to avoid straining which may exacerbate the cardiac condition

The nurse administers a beta blocker and a calcium channel blocker to the client diagnosed with a myocardial infarction. The nurse is aware of which factors when planning to administer these medications together?

both medications can cause a decrease in heart rate, blood pressure, and a change in rhythm

The nurse recognizes that the type of edema related to cardiac failure is usually

dependent

The nurse cares for the client reporting shortness of breath and chest pain. The nurse assesses the client and finds a third heart sound known as an S3. The nurse identifies this sound as indicating which condition?

myocardial infarction

The nurse teaches the client diagnosed with hypertension about a low sodium diet. Which comment is most indicative that the client requires further instruction?

"I don't use any salt and I will season my foods with ketchup or mustard."

The nurse assesses capillary refill time on a middle-aged client. Which result is considered to be within the normal range?

1-3 seconds

The nurse cares for the client diagnosed with coronary artery disease (CAD). The client exercises three times per week, but now experiences shortness of breath and fatigue when exercising. The client asks the nurse, "Why can't I go to the gym any more without feeling tired within 5 minutes?" Which is the nurse's best response?

"Due to an inadequate blood supply to the heart, your heart is unable to meet your body's oxygen needs during exercise."

One week after discharge from the hospital , a client with heart failure (HF) comes to the cardiac clinic for a follow-up visit. Which of these statements, if made by the client to the nurse, indicates an improvement in the client's condition?

"I only sleep on one pillow"

The nurse prepares discharge teaching for the client diagnosed with a myocardial infarction (MI). Which client statement indicates to the nurse that the client understands the instructions?

"I will change my diet to reduce my fat intake to less than 30%."

The nurse performs dietary education for the client diagnosed with a myocardial infarction. Which client statement indicates to the nurse that there is an adequate understanding of the special dietary needs?

"I will eat more fresh fruit and vegetables"

The nurse instructs the client diagnosed with elevated total cholesterol levels. Which client statement indicates a need for further teaching?

"Medication is the best way to lower cholesterol"

The nurse prepares the client for a coronary artery bypass graft surgery. The client is crying and upset. The client tells the nurse, "The health care provider just told me about the surgery but I can't remember what was said." Which is the nurse's best response?

"The health care provider will use a blood vessel from the leg or chest to create a new blood supply by bypassing the obstructed coronary artery. This increased the blood supply to the heart."

The nurse teaches a class about cardioversion. The nursing student asks, "How does cardioversion differ from defibrillation?" Which is the best response for the nurse to give?

"The position of the synchronizer switch on the defibrillator is different."

The nurse instructs a client in the outpatient clinic about a cardiac stress test. Which statement by the nurse is best?

"The stress test will determine the amount that your heart can tolerate."

The nurse cares for the client diagnosed with coronary artery disease after experiencing a myocardial infarction. Which menu item chosen by the client indicates to the nurse that the client understands appropriate dietary needs?

"oatmeal and orange juice for breakfast, a salad for lunch, and grilled chicken with green vegetables for dinner

The nurse teaches the client diagnosed with coronary artery disease after a myocardial infarction. The information includes foods on a 2 gram sodium diet. Which client statement indicates to the nurse that the client understands the dietary education?

"sodium makes me hold fluid, and with my condition I can't hold too much fluid"

The nurse monitors the cardiac enzymes of the client who has severe chest pain. Which enzyme elevates and peaks most rapidly if the client experiences a myocardial infarction?

CK-MB (creatine kinase-MB)

One week following a myocardial infarction, a patient complains to the nurse of fatigue. The nurse notes that the patient is slightly short of breath and the pulse rate is 110 bpm. Which of the following actions by the nurse is best?

Check for any edema or weight gain

The nurse expects which of these laboratory test results to be elevated in a client following an acute myocardial infarction?

Creatine kinase (CK), troponin T and I, and myoglobin

Surgical repair of a congenital heart defect is performed on the 5-month-old infant. Which measure is most important for the nurse to include in the postoperative care plan?

Elevate the client's head to reduce respiratory effort.

The emergency department nurse cares for client experiencing a myocardial infarction with no dysrhythmias. Which orders does the nurse anticipate carrying out?

SATA: --adminster oxygen establish an IV line monitor the -electrocardigram (ECG) -adminster aspirin (ASA)

The nurse supervises the nursing student caring for the client who had a femoropopliteal bypass graft in the right leg 12 hours ago. The nurse intervenes if the nursing student performs which interventions?

SATA: -The nursing student places the client in a chair for 30 minutes. -The nursing student obtains a doppler evaluation of the client's right leg every two hours.

The nurse organizes care for a client who just had a carotid arteriorgram. Which interventions are important for the nurse to implement?

SATA: -check the puncture or cutdown site for bleeding and hematoma formation -assess vital signs frequently, including apical heart rate -assess urinary output and check for bladder distention

The nurse cares for a client after a coronary artery bypass graft (CABG). Which observation during the postoperative period most concerns the nurse?

The heavy chest tube drainage suddenly stops

A client receiving verapamil in the sustained-release form reports a headache. Which information does the nurse provide to the client?

This medication often causes headache

The nurse assesses the laboratory values of the client having an annual physical examination. Which laboratory value indicates that further assessment is necessary?

a blood cholesterol level of 260 mg/dL

The nurse cares for the client diagnosed with a myocardial infarction. The clients daughter asks the nurse, "What is a realistic goal for my cardiovascular health? Which is the best response by the nurse?

a blood cholesterol level of less than 160 mg/dL

The nurse cares for the client diagnosed with heart failure possibly due to cardiac valvular disease. Which is the most appropriate test to diagnose cardiac valvular disease?

a three-dimensional (3D) echocardiogram

The nurse cares for the client diagnosed with acute myocardial infarction. The client's skin is clammy, blood pressure is 85/50; client appears restless and anxious. Which action should the nurse take first?

administer analgesia as ordered

The nurse cares for the client diagnosed with acute myocardial infarction. Which intervention is priority?

administer oxygen

A client undergoes a cardiac catheterization. Following the procedure, the nurse discovers the client is bleeding from the cut-down site. Which action does the nurse take first?

applies pressure to the site

The nurse cares for the elderly client with systolic heart failure. The nurse is to administer a medication that decreased preload. Which best describes the desired effect of the medication for this client?

reduce venous return to the right heart

The health care provider prescribes captopril for a client diagnosed with hypertension. Before administering the first dose, it is most important for the nurse to make which statement?

remain in bed for the first three hours after taking the first dose of medication

The nurse performs diet teaching for a client diagnosed with a myocardial infarction. The nurse determines that teaching is effective if the client selects which of the following?

sliced turkey, green beans, pear

The nurse cares for the client diagnosed with heart failure (HF). The client has an ordered IV to run at 125 mL/hr. The nurse notes the client has increasing difficulty breathing, is coughing more, and has rhonchi in both lungs. Which nursing action is most appropriate for the nurse to take initially?

slow the IV to a keep open rate

The nurse cares for the client diagnosed with heart failure. The client has an intravenous (IV) infusion running at 60 drops per minute and receives 40 mg of furosemide intravenously daily. The clients complains, "I am more tired than usual." While the client sits in a chair, the nurse auscultates the lungs and notes crackles that were not present earlier. Which initial nursing action is most appropriate?

slow the IV to a keep open rate

A medical surgical unit is being converted into a cardiac unit due to increasing numbers of clients coming to the hospital with cardiac conditions. The nurse manager reviews with staff the differences between defibrillation and cardioversion. Which does the manager identify as characteristics these two procedures have in common?

intended action and paddle placement

The nurse cares for the client reporting numbness in the left arm and intermittent upper substernal pressure that radiates to the neck. The pressure is relieved by rest. The client states, "I can't explain it, but I feel like I'm about to die." Based on the available data, which nursing diagnosis does the nurse select as most important?

pain related to ischemia

The nurse teaches the client diagnosed with myocardial infarction. The client's choice of which cooking oil indicates that the nurse needs to review instructions for managing a diet low in saturated fat.

palm

The nurse provides care for an infant client diagnosed with a cyanotic congenital heart defect. The nurse understands that chronic hypoxia from this disorder can result in which finding?

polycythemia

The nurse cares for the client diagnosed with angina. The client is scheduled for a cardiac catheterization and tells the nurse, "I get a rash when I eat strawberries or shellfish." Which intervention does the nurse perform first?

stops preparations for the test

The nurse cares for the client diagnosed with heart failure. For which reason are the client's fluids restricted?

stroke volume is impaired and cardiac output is decreased

The nurse provides dietary education for the client diagnosed with a myocardial infarction. The client is on a 2-gram sodium diet. Which menu choice by the client indicates teaching is effective?

baked potato

The nurse on the medical unit cares for the client several hours following a cardiac catheterization. Which nursing intervention is necessary to ensure the client's safety?

immobilize the extremity into which the catheter was inserted