CARDIO- EXAM2
A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take? Assess the client's airway, breathing, pulses, and level of conciseness. Begin cardiopulmonary resuscitation (CPR). Defibrillate the client. Apply the external pacemaker.
Assess the client's airway, breathing, pulses, and level of conciseness. Explanation: If the client is experiencing ventricular tachycardia, the priority for the nurse is to assess the client's airway, breathing, and level of consciousness before any further action is taken.
A client in the emergency department has symptoms of anxiety, a 'racing heart,' and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse? Administer a beta blocker to slow the heart rate. Assess the client's vital signs and oxygen saturation. Obtain a stat 12 lead electrocardiogram (EKG) and tropin level. Administer diazepam 2.5 mg IV push for anxiety.
Assess the client's vital signs and oxygen saturation. Explanation: Sinus tachycardia has multiple causes; further assessment is needed before determining the treatment. Administration of beta blockers or diazepam may not be indicated depending on cause of the sinus tachycardia. A 12 lead EKG and tropin level might be appropriate following assessment of the client.
A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN), 100 mg/dL, serum creatinine 6.5 mg/dL, potassium 6.1 mEq/L, and lethargy. Which of the following is the priority nursing assessment? Blood pressure Arterial blood gases Cardiac rhythm Weight changes
Cardiac rhythm Explanation: Manifestations of CKD result from loss of the renal regulatory functions of filtering metabolic waste products and maintaining fluid and electrolyte balance. These laboratory results indicate CKD, but the most significant result is the potassium level. The normal range of potassium is between 3.5 and 5.0 mEq/L. A potassium level greater than 7 mEq/L may produce fatal cardiac dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal serum creatinine level ranges from 0.7 to 1.5 mg/dL.
A nurse is caring for a client admitted to the telemetry unit four days post coronary artery bypass graft (CABG) surgery. Which of the following should the nurse monitor? Select all that apply. Pain management V isitors entering the client's room BUN and serum creatinine Electrocardiogram (EKG) Level of consciousness
Electrocardiogram (EKG) Level of consciousness BUN and serum creatinine Pain management Explanation: Atrial fibrillation is a common occurrence after CABG (coronary artery bypass graft) surgery the nurse should monitor the EKG, assessment for level of consciousness in order to prevent a possible stroke, observe for signs of deep vein thrombosis (DVT) and pulmonary emboli (PE). Elevated BUN and Creatinine indicate potential acute renal failure and should be reported. Monitoring for other incidence of postoperative complications including the chest incision for symptoms of infection, management of pain and prevention of respiratory complications through the use of incentive spirometer is essential. There is no need to monitor visitors unless additional complications are present.
The nurse is assigned to a client in the ICU. During the initial assessment, the nurse notes jugular vein distention and recognizes that the plan of care will follow which disorder? Heart failure Abdominal aortic aneurysm Myocardial infarction (MI) Pneumothorax
Heart failure Explanation: Elevated venous pressure, exhibited as jugular vein distention, indicates the heart's failure to pump. Jugular vein distention is not a symptom of abdominal aortic aneurysm or pneumothorax. If severe enough, an MI can progress to heart failure, but an MI alone does not cause jugular vein distention.
The nurse should complete which of the following assessments on a client who has received tissue plasminogen activator or alteplase recombinant therapy? Neurologic signs frequently throughout the course of therapy. Arterial blood gas values. Excessive bleeding every hour for the first 8 hours. Blood glucose level.
Neurologic signs frequently throughout the course of therapy. Explanation: The nurse needs to assess neurologic status throughout the therapy. Altered sensorium or neurologic changes may indicate intracranial bleeding for the client who has received tissue plasminogen activator or alteplase. The nurse should carefully check for bleeding every 15 minutes during the first hour of therapy, every 15 to 30 minutes during the next 9 hours, and at least every 4 hours during the duration of therapy. Bleeding may occur from sites of invasive procedures or from body orifices. The blood glucose level does not need to be evaluated. Arterial blood gas values relate to acid base status and oxygenation and are avoided due to the invasiveness of arterial puncture at this time.
A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply. Orthopnea Cough Jugular vein distention Ascites Hepatomegaly Crackles
Orthopnea Cough Crackles Explanation: Left-sided heart failure produces primarily pulmonary signs and symptoms, such as orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and symptoms, such as ascites, jugular vein distention, and hepatomegaly.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? Prevent thrombophlebitis and blood clot formation. Promote urinary and intestinal elimination. Prepare the client for ambulation. Decrease the likelihood of pressure ulcer formation.
Prevent thrombophlebitis and blood clot formation. Explanation: Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? Monitor daily weights and urine output. Limit visitation by family and friends. Provide client education on medications and diet. Reduce pain and myocardial oxygen demand.
Reduce pain and myocardial oxygen demand. Explanation: Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
A client who has diabetes is taking metoprolol for hypertension. What should the nurse instruct the client to do? Select all that apply. Take the tablets with food at same time each day. Do not crush or chew the tablets. Report any fainting spells to the health care provider (HCP). Notify the health care provider (HCP) if pulse is 82 beats/minute. Use an appropriate decongestant if needed. Have a blood glucose level drawn every 6 to 12 months during therapy.
Take the tablets with food at same time each day. Do not crush or chew the tablets. Have a blood glucose level drawn every 6 to 12 months during therapy. Report any fainting spells to the health care provider (HCP). Explanation: Metoprolol is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The HCP should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, and tremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need to be reduced or discontinued
Automated external defibrillators (AEDs) are used in cardiac arrest situations for: early defibrillation in cases of atrial fibrillation. pacemaker placement. cardioversion in cases of atrial fibrillation. early defibrillation in cases of ventricular fibrillation.
early defibrillation in cases of ventricular fibrillation. Explanation: AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates.
A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about: right atrial blood flow. cardiac index. left end-diastolic pressure. cardiac output
left end-diastolic pressure. Explanation: When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area, and is considered a more accurate reflection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.
A client has atrial fibrillation. The nurse should monitor the client for: cerebrovascular accident. ventricular fibrillation. Heart block. cardiac arrest.
rebrovascular accident. Explanation: Because of the poor emptying of blood from the atrial chambers, there is an increased risk for clot formation around the valves. The clots become dislodged and travel through the circulatory system. As a result, cerebrovascular accident is a common complication of atrial fibrillation.
The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply: Serum myoglobin Serum troponin 24-hour creatinine clearance Electroencephalogram Urinalysis Serum bilirubin
serum troponin Serum myoglobin Explanation: Troponin and myoglobin are enzymes that are released when cardiac muscle is damaged. Serum troponin levels increase within 2 to 4 hours after MI. Serum myoglobin levels increase within ½ hour to 2 hours after MI. Serum bilirubin evaluates liver function and is not altered with cardiac damage. Urinalysis and 24-hour creatinine clearance reflect kidney—not cardiac—function. An electroencephalogram evaluates the electrical activity of the brain.
A client with an acute myocardial infarction is receiving nitroglycerin by continuous I.V. infusion. Which client statement indicates that this drug is producing its therapeutic effect? "My vision is blurred, so my blood pressure must be up." "I have a bad headache." "My chest pain is decreasing." "I feel a tingling sensation around my mouth."
"My chest pain is decreasing." Explanation: Nitroglycerin, a vasodilator, increases the arterial supply of oxygen-rich blood to the myocardium. This action produces the drug's intended effect: relief of chest pain. Headache is an adverse effect of nitroglycerin. The drug shouldn't cause a tingling sensation around the mouth and should lower, not raise, blood pressure.
A client hospitalized with a myocardial infarction (MI) has a blood glucose levels ranging from 12-28 mmol/L (216-504 mg/dL) asks the nurse why the readings are so high even though there are no added sweets on the diet tray. What is the best response by the nurse? "Your blood glucose levels must have been high before the MI and could have contributed to the MI." "The stress level in your body has increased with the MI, and more glucose is released during stressful times." "We will need to introduce stress management techniques to reduce the level of stress." "Your blood glucose levels are increased because of limited activity at this time."
"The stress level in your body has increased with the MI, and more glucose is released during stressful times." Explanation: The client is stating a reduction of food intake and has not eaten treats. This probably indicates that the increased stress levels are resulting in increased endogenous corticosteroid secretion. This will mobilize more glycogen and convert to glucose to provide a ready energy source. Glucose levels don't usually increase by reducing activity. Glucose levels probably didn't impact the MI. Stress management does not explain the reason for the hyperglycemia.
The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used. 1 Take vital signs. 2 Administer the prescribed dose of morphine. 3 Position electrodes on the chest. 4 Obtain a history of which drugs the client has used recently. SUBMIT ANSWER
Position electrodes on the chest. Take vital signs. Administer the prescribed dose of morphine. Obtain a history of which drugs the client has used recently. Explanation: The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide to treat pulmonary congestion and begins a nitroprusside drip as prescribed. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. The nurse should first assess: urine output. lung sounds. blood pressure. 12-lead EKG.
blood pressure. Explanation: The nurse should immediately assess the blood pressure since nitroprusside and furosemide can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the nitroprusside dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.
A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). In order to determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? "Did you take any nitroglycerine before coming to the emergency department?" "What time did your chest pain start?" "Is this the first time you experienced this type of pain?" "Do you have any allergies?"
"What time did your chest pain start?" Explanation: Thrombolytic therapy must be started within 6 hours of the onset of the myocardial infarction (MI). The time the chest pain started is the priority. The nurse can assess for allergies once the time is determined. Nitroglycerine will not impact the administration of thrombo threapy
The nurse is caring for a client following a myocardial infarction and is aware that complications can occur due to damage to the myocardium. Which of the following interventions would be appropriate for this client? Select all that apply. Electrocardiogram with any chest pain Auscultating apical pulse every 2 hours Maintaining bed rest for 72 hours Ambulating length of hall in first 24 hours Continuous cardiac monitoring via telemetry
Electrocardiogram with any chest pain Continuous cardiac monitoring via telemetry Auscultating apical pulse every 2 hours Explanation: After a myocardial infarction it is important to monitor the client carefully for complications. An EKG should be done with any chest pain to assess for any changes that would indicate additional damage to the heart muscle. Auscultating the apical pulse and continuous cardiac monitoring would identify a change in status. Bed rest would be maintained for 24 hours, and ambulation would be added gradually, not in the first 24 hours
The rapid response team arrives in the room of a client who has had a cardiac arrest. The nurse should first apply which piece of monitoring equipment? electrocardiogram (ECG) electrodes Doppler for pulse check blood pressure cuff pulse oximeter
electrocardiogram (ECG) electrodes Explanation: The nurse should first apply the ECG electrodes to the client's chest. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate the client. Pulse oximetry is not an immediate priority. The client's oxygenation is evaluated in a code situation using arterial blood gas analysis. The client's blood pressure is evaluated after the ECG rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of a pulse or to check the blood pressure in a code situation.
The nurse is caring for a client who was admitted to the hospital with severe nausea, vomiting, dyspnea, and substernal chest pain. Cardiac enzymes are positive for myocardial infarction (MI). Prior medical history includes an MI and diabetes. The nursing interventions for this client include the following. Place in order of priority. Use all options. 1 Decrease the anxiety and reduce the workload on the heart. 2 Monitor and manage potential complications. 3 Reduce the nausea and vomiting and stabilize the blood glucose. 4 Control the pain and support breathing and oxygenation. 5 Incorporate teaching about diet and health control.
Control the pain and support breathing and oxygenation. Reduce the nausea and vomiting and stabilize the blood glucose. Decrease the anxiety and reduce the workload on the heart. Monitor and manage potential complications. Incorporate teaching about diet and health control. Explanation: A client who is admitted with dyspnea and chest pain needs immediate assistance with breathing and pain to provide oxygen to the heart muscle. The priority is to prevent any further heart damage. Reducing the nausea and controlling the blood glucose is the next step. The client is likely to be very anxious, thus decreasing anxiety will also decrease the workload on the heart. Once the client is stabilized, then ongoing monitoring for complications would be appropriate, with teaching as the last priority.
A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider (HCP) suspects the client is experiencing a dissecting aortic aneurysm. The emergency supply cart is brought into the room because one complication of a dissecting aneurysm is: myocardial infarction. stroke. cardiac tamponade. pulmonary edema.
cardiac tamponade. Explanation: Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm. The sudden, painful "tearing" sensation is typically associated with the sudden release of blood, and the client may experience cardiac arrest. Stroke, pulmonary edema, and myocardial infarction are not common complications of a dissecting aneurysm.
A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because: the client is going into cardiogenic shock. the client is experiencing heart failure. the client is in the early stage of right-sided heart failure. the client shows signs of aneurysm rupture.
the client is going into cardiogenic shock. Explanation: This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.
