Cardio-Prep U
After teaching a patient about nutritional measures to improve heart health, the nurse determines that the patient requires additional teaching when he states which of the following?
"I can eat hot dogs but I need to stay away from fast foods." Explanation: A healthy diet low in fats, cholesterol, salt, and sugar and high in fiber helps fight cardiovascular disease. Hot dogs are processed foods and are high in salt; along with convenience or fast foods, they should be avoided.
A nurse is teaching a client with heart disease about exercising and signs of overexertion. The nurse determines that additional teaching is needed if the client states which of the following?
"I should stop exercising if my pulse is below my target zone." Explanation: For the client, the goal of the exercise program is to achieve the target heart rate. The client should stop exercising if his pulse rate exceeds his target zone. The client should call the physician if he feels that his pulse is racing, do warm-up exercises to prevent sudden demands on the heart, and wait at least an hour after eating to exercise.
A patient is scheduled for a cardiac catheterization. When explaining the purpose of this test to the patient, which of the following would be appropriate for the nurse to include in the teaching?
"The test can show any narrowing of the arteries in your heart." Explanation: Cardiac catheterization helps visualize the coronary arteries and identify possible narrowing of them. An echocardiogram can help to detect myocardial thickness and motion. Exercise testing assesses a person's response to cardiovascular stress. Electrophysiology determines if there are any problems with the electrical conduction in the heart.
A patient is scheduled for echocardiography. When explaining this test to patient, which statement by the nurse would be most appropriate?
"They will use an ultrasound device over your chest area to form patterns that will show how your heart is working." Explanation: Echocardiography uses ultrasonic waves to produce echoes that form a pattern to evalaute the heart's function. Chest radiography uses x-rays to determine the size and shape of the heart. Electrocardiography involves the use of electrodes attached to the chest and limbs to evaluate cardiac electrical activity. A cardiac catheterization involves the insertion of a catheter into a large vein or artery, which is threaded to the heart's chambers.
The nurse is preparing to apply warm compresses to the lower leg of a patient with chronic vascular disease. The nurse would ensure that the temperature of the compresses is below which of the following?
100.8 degrees F Explanation: For the patient with chronic vascular disease, hot soaks or compresses should not exceed 95.8 degrees to 100.8 degrees F to prevent burns.
The nurse is assessing the heart rate of a 2 1/2-year-old toddler who is sitting quietly in his mother's lap. Which finding would the nurse identify as problematic?
118 beats per minute Explanation: By the end of the toddler period, the heart rate has decreased to a resting rate of about 70 to 110 beats per minute. Findings outside this range would be a cause for concern.
A nurse is assessing the pulse rate of a 2-month old infant. Which of the following would the nurse document as a normal finding?
140 beats per minute Explanation: The normal pulse rate of a newborn and infant is 130 to 160 beats per minute. For school-age children, adolescents, and adults, a rate of 60 to 80 beats per minute is normal. In toddlers and preschoolers, a rate of 70 to 110 beats per minute is normal.
A nurse is working at a local clinic that provides care for families with young children. For a child of which age would the nurse be sure to obtain a blood pressure?
3 1/2 year old Explanation: The recommended practice is to measure the blood pressure annually in children older than 3 years.
A nurse is assessing a patient's capillary refill time. Which time would the nurse document as a normal finding?
3 seconds Explanation: The capillary refill time is usually less than 3 seconds. A longer time indicates narrowing of the blood vessesl, decreased circulating blood volume, or otherwise decreased cardiac output.
A nurse is providing care to several clients. Which client would the nurse determine as having the greatest risk for heart disease?
68-year-old African American male with diabetes Explanation: Of the clients listed, the 68-year-old African American male with diabetes has three risk factors for heart disease: increased age, race, and diabetes. The 35-year-old female has smoking as a risk factor. The 50-year-old male has increasing age and stress as risk factors. The 45-year-old female has gender (since she is most likely postmenopausal) as a risk factor.
A nurse is preparing a presentation for a local community group about risk factors for coronary heart disease. Which of the following would the nurse include as a nonmodifiable risk factor? Select all that apply.
African-American ethnicity • Gender Explanation: Nonmodifiable risk factors include family history of heart disease, gender, increased age, and African-American ethnicity. Cigarette smoking, physical inactivity, and diabetes are modifiable risk factors.
Which of the following accurately states a guideline for the use of an automated external defibrillator based on the American Heart Association (AHA) 2005 guidelines?
After the initial shock, deliver five cycles of chest compressions/ventilations. Explanation: After the initial shock, the AHA recommends delivering five cycles of chest compressions/ventilations (30/2), and then reanalyzing the cardiac rhythm. The AED should be applied as soon as it is available, and can be used for adults and children. Administering sets of one shock alternating with 2 minutes of CPR until the AED displays a "no shock indicated" message or until ACLS is available is recommended.
A nurse is reviewing the medication administration record for a client diagnosed with heart disease. The nurse demonstrates thorough understanding of medications that affect cardiac functioning by identifying which of the following as most likely being used to treat the client's irregular heart rhythm?
Amiodarone Explanation: Amiodarone is an antiarrhythmic that is used to correct irregular heart rhythms. Digoxin increases the heart's contractility and slows the heart rate. Captopril decreases blood pressure. Nitroglycerine causes peripheral vasodilation to relieve angina.
A nurse responds to a "code blue" in her healthcare facility. Which of the following interventions should be performed first in this situation?
Assess the patient. Explanation: The nurse should assess the patient first, activate the emergency response system, check for patient preference for resuscitation, and perform the ABCs of CPR (airway, breathing, and circulation) followed by the 'D' of defibrillation to manage sudden cardiac death.
The physician orders digoxin for a client with an irregular heart rate. Before administering this medication, which of the following would be most important for the nurse to do?
Auscultate the apical pulse for 1 full minute Explanation: The nurse should auscultate the apical pulse for 1 full minute before administering digoxin to the client. The apical pulse should be auscultated to establish its rate and character. This simple measurement is essential for complete assessment of the client who has a pulse that is difficult to palpate or an irregular heart rate. Determination of capillary refill time, edema, and engorged neck veins is not important before digoxin therapy. Capillary refill time and edema are determined to evaluate peripheral circulation. Neck veins are assessed to evaluate the status of right-heart pumping.
A patient is diagnosed with a cardiac dysrhythmia. The nurse interprets this condition as involving a problem reflecting which of the following?
Automaticity Explanation: A cardiac dysrhythmia involves the conduction system of the heart, which reflects automaticity, or the heart's ability to generate its own electrical impulse. Perfusion refers to the flow of blood through the body tissues. Contractility reflects the natural strength of the heart muscle. Systole refers to the contraction of the heart muscle, causing blood to be ejected from the ventricles.
While reviewing the assessment data of a male client, a nurse suspects that the client may have metabolic syndrome based on which of the following? Select all that apply.
Blood pressure of 160/92 mm Hg • Fasting blood glucose level of 130 mg/dL • Waist circumference of 48 inches Explanation: Metabolic syndrome in males is reflected by triglyceride levels over 150 mg/dL, blood pressure over 130/85 mm Hg, fasting blood glucose level over 110 mg/dL, HDL level less than 50 mg/dL, and a waist circumference over 40 inches.
The nurse is assessing a patient's edematous lower extremities and notes the absence of pitting. The area appears shiny, warm, and moist; it is hard on palpation. The nurse documents this finding as which type of edema?
Brawny Explanation: Brawny edema is characterized by fluid being no longer displaced secondary to excessive interstitial fluid accumulation. Pitting is absent and tissue palpation reveals firm or hard areas with skin surfaces appearing shiny, warm, and moist. Edema that is 2+ is characterized by a 4-mm depression with a fairly normal contour. Edema that is 3+ is characterized by a 6-mm depression that remains several seconds after pressing, with obvious skin swelling on inspection. Edema that is 4+ is characterized by a depression of 8 mm that remains for a prolonged time (possibly minutes) after pressing and frank swelling.
A nurse is preparing a teaching plan about substances that increase blood pressure for a patient with hypertension. Which of the following would the nurse most likely include?
Caffeine • Cold remedies • Asthma medications Explanation: Substances such as caffeine, cold remedies, and asthma medications can raise blood pressure. Diuretics decrease blood volume, which could lead to a decrease in blood pressure. Opioids can cause hypotension.
Students are reviewing information about cardiac output. They demonstrate an understanding of the concept when they state which of the following?
Changes in metabolic demand can change cardiac output. Explanation: Cardiac output is a function of heart rate and stroke volume, not blood pressure. An increase or decrease in either can change cardiac output. Tissue perfusion relies on several factors, one of which is adequate cardiac output. Adequate coronary perfusion is dependent on adequate cardiac output.
A nursing instructor is developing a class presentation about reasons people with cardiovascular problems seek medical care. Which of the following would the instructor include as the most common reason?
Chest pain Explanation: Although a person with cardiovascular dysfunction may have hypertension, lower extremity swelling, or cough, pain or discomfort in the chest is the most common reason people with cardiovascular dysfunction seek medical care.
During a home care visit, a nurse completes a physical assessment and supsects that the client is experiencing heart failure. Which of the following would lead the nurse to suspect this?
Dependent edema Explanation: Dependent edema and engorged neck veins suggest heart failure or inefficient pumping ability of the heart. Pink skin would be considered a normal finding. Engorged neck veins imply inefficient right-sided heart pumping. Clubbed fingers are associated with oxygenation problems resulting from respiratory or cardiovascular disease.
Which of the following is a noninvasive procedure assisting the nurse in cardiovascular care?
Electrocardiography Explanation: Noninvasive heart monitoring involves electrocardiography and cardiac monitoring. Invasive techniques, such as pulmonary artery monitoring, Swan-Ganz catheterization, cardiac output determination, and cardiac support via an intraaortic balloon pump (IABP), typically are used by trained critical care personnel to provide additional monitoring and support.
After reviewing information about the structure of the heart, nursing students demonstrate understanding of the information when they identify which of the following as the part that attaches the heart to the diaphragm and sternal wall?
Epicardium Explanation: The epicardium is a thin-walled sac that surrounds the heart and attaches it to the diaphragm and sternal wall of the thorax. The septum is the strong muscular wall that divides the heart into left and right halves. The endocardium is the innermost lining of the heart. The myocardium is the thick muscular layer that produces muscular contraction of the heart.
A nurse is preparing to administer a prescribed medication as prophylactic therapy for deep vein thrombosis. Which of the following would the nurse most likely give?
Heparin Explanation: Heparin is an anticoagulant that may be ordered as prophylaxis for deep vein thrombosis. Digoxin is a cardiac glycoside used to increase cardiac contractility and decrease heart rate. Nitroglycerine is a drug used to relieve angina pain. Amiodarone is a drug used to regulate heart rhythm.
A patient with cardiovascular disease says to the nurse, "I know that exercise is good for me, but how exactly does it help?" Which of the following would the nurse include when responding to the patient? Select all that apply.
Improved heart pumping efficiency • Raising of HDL cholesterol • Reduced triglyceride levels Explanation: Engaging in regular exerices improves the heart's pumping ability and efficiency, increases blood circulation (which prevents thrombi formation by decreasing platelet stickiness), raises the "good" (HDL) cholesterol level, and reduces triglyceride levels.
Nursing students are preparing a presentation for a health fair about the effects of cigarette smoking on cardiovascular health. Which of the following would the nurses include? Select all that apply.
Increased blood pressure • Enhanced atherosclerosis • Limited blood oxygen-carrying capacity Explanation: Cigarette smoking increases the heart rate, increases the blood pressure, constricts arterioles, and may cause irregular cardiac rhythm. It enhances the atherosclerotic process and is a major cause of peripheral vascular disease. Smoking also limits the blood's oxygen-carrying capacity by displacing oxygen with carbon monoxide.
Which of the following statements about bedside cardiac monitoring are true? Select all that apply.
It provides continuous observation of the heart's electrical activity. • It focuses on the detection of clinically significant dysrhythmias. • It is used for patients who have conduction disorders. • It is used to monitor patients who are at risk for developing life-threatening arrhythmias.
A nurse is preparing to apply a sequential compression device to a client's lower extremities. Before applying the sleeves, which of the following would be least appropriate for the nurse to apply to the client's legs?
Knee-high cotton socks Explanation: Before applying a sequential compression device, the nurse would apply antiembolism stockings or Stockinette or ace wraps to the client's legs to decrease the risk of diaphoresis and irritation under the plastic sleeves and to provide extra support. Knee-high cotton socks would be inappropriate to use because they would not provide extra support.
A patient with a history of cardiovascular disease has suffered an acute stroke. The nurse is assessing the patient's neurologic deficits to establish a baseline using the National Institutes of Health Stroke Scale. Which area would the nurse most likely assess? Select all that apply.
Level of consciousness • Vision • Movement • Sensation Explanation: The National Institutes of Health Stroke Scale assesses areas of patient function: level of consciousness (wakefulness), vision, movement, sensation, language, and speech.
A nurse is assigned to care for a client with a terminal cardiovascular illness. When developing the client's plan of care, which outcome would the nurse identify as most realistic for this client?
Maintenance of adequate comfort Explanation: The realistic outcome for a client with terminal cardiovascular disease is maintenance of adequate comfort and acceptance of impending death. Realistic outcomes for the client with chronic cardiovascular disease focus on helping the client to live within limitations imposed by the disease and to improve acceptance of changes in lifestyle and self-concept. Outcomes pertinent to the client who is admitted with an acute problem focus on recovery from the cardiovascular problem without residual complications.
Nurses are preparing a class presentation on the differences in cardiovascular function between men and women. Which of the following would the nurses include in the discussion? Select all that apply.
Male heart size is typically larger than female heart size. • Women typically develop hypertension later in life than men do. • The risk of death after a heart attack is significantly higher for women than for men. Explanation: Women generally have a smaller stature than men and therefore have smaller hearts and smaller blood vessels. Women also develop hypertension and cardiovascular disease later in life than men. There is a demonstrated link between the onset of menopause and cardiovascular events. A woman's risk for developing diabetes following a heart attack is three times higher than that of a man, and death following a heart attack is 50% higher in women than men.
The nurse is reviewing the medical record of a patient who returns to the clinic for a follow-up visit. On several previous visits, the patient's blood pressure readings were as follows: 124/80 mm Hg; 132/86 mm Hg; 130/88 mm Hg. The patient's blood pressure today is 128/82 mm Hg. The nurse would identify the patient as belonging to which blood pressure category?
Prehypertension Explanation: The patient's blood pressure readings fall within the prehypertension category, with a systolic blood pressure between 120 to 139 mm Hg and a diastolic blood pressure between 80 to 89 mm Hg. High BP stage 1 readings fall between 140 to 159 mm Hg for systolic pressure and 90 to 99 mm Hg for diastolic pressure. High BP stage 2 readings fall at systolic 160 mm Hg or higher and diastolic 100 mm Hg or higher. Hypertensive crisis is characterized by readings above 180 mm Hg systolic or 110 mm Hg diastolic.
A nurse is assessing a client's capillary refill. Which action would be most appropriate?
Press on the nail bed until it blanches Explanation: The nurse should perform capillary refill time test by pressing a nail bed until it blanches. Pressure is released, and the time it takes for the nail to return to its original color is noted. This capillary refill time is ordinarily less than 3 seconds. Localized skin colorations are assessed to determine bruises, redness, or mottling. Homan's sign is elicited by bending the client's foot upward toward the leg. Assessment of the apical and radial pulses is done simultaneously to determine whether all heartbeats are being perfused to distant pulse sites.
A patient is experiencing significant pitting edema of his lower extremities secondary to heart failure. Which of the following would the nurse include when developing this patient's plan of care? Select all that apply.
Raising the affected limbs • Reducing the patient's sodium intake Explanation: Care for the patient with lower extremity edema should include raising the affected limbs to assist venous return to the heart and help decrease venous pressure. Elevation should be such that it does not cause vessel constriction at the groin. Reducing sodium intake also is appropriate in helping to control edema. The hospital bed should not be elevated at the knees because doing so restricts venous flow behind the knee. Fluid intake may need to be restricted until fluid balance is restored. Having the patient get out of bed slowly would be appropriate if the patient were experiencing orthostatic hypotension.
A client is brought to the emergency department with complaints of chest pain. The physician orders electrocardiography (ECG) to be done. The nurse understands that an ECG helps to accomplish which of the following?
Record the heart's electrical impulse Explanation: Electrocardiography helps in recording the heart's electrical impulse. The various deflections of ECG tracing correspond to the individual events of the cardiac conduction cycle. Radiography of the heart helps establish the size and shape of the heart. Myocardial muscle thickness and presence of fluid around the heart is detected by echocardiography.
Nursing students are reviewing the functions of the cardiovascular system, specifically the blood. The students demonstrate understanding of the information when they identify which blood component as responsible for delivering oxygen to the tissues?
Red blood cells Explanation: The red blood cells are responsible for delivering oxygen, which is carried on the hemoglobin portion of the cell. Plasma carries electrolytes, trace minerals, and nutrients to the cells. White blood cells are involved with the inflammatory response; platelets are involved in coagulation.
A patient is admitted with a suspected myocardial infarction (MI). Which of the following laboratory tests would the nurse anticipate being ordered for this patient to help confim the MI? Select all that apply.
Serum myoglobin • Creatine kinase-MB • Troponin Explanation: Serum levels of specific biomarkers, such as myoglobin, creatine kinase-MB, and troponin are used to confirm a suspected MI. B-type natriuretic peptide is used to diagnose heart failure. Blood urea nitrogen is used to evaluate kidney function.
Upon entering a client's room, the client tells the nurse, "I'm having some really strong pain in my chest." The nurse intervenes immediately, placing the client in which position?
Sitting Explanation: The nurse should make the client comfortable in a sitting position. A supine position inhibits full chest expansion and limits gas exchange in the lung, so this position should be avoided. Since the heart works harder in the supine position than in the upright position, the supine position is not recommended. The hypotensive client is positioned with legs elevated 20 to 30 degrees.
A nurse is providing care to a client with high blood pressure who is at risk for decreased cerebral tissue perfusion. For which of the following would the nurse be alert?
Slowed speech Explanation: The nurse should look for slowed speech in the client, which indicates decreased tissue perfusion and decreased blood flow to the brain. Cognition is often the first indicator of decreased perfusion to be assessed because it is readily apparent in the nurse's first interactions with the client. People with normal cerebral perfusion usually speak in a normal cadence; they answer questions quickly and appropriately and are oriented to person, place, and time. They are able to follow directions.
An electrocardiogram (ECG) uses 10 electrodes/leads to assess the heart's electrical activity from 12 different views.
T
A group of nursing students are reviewing information about decreased tissue perfusion due to thrombus formation. The students demonstrate understanding of this information when they identify which of the following as increasing a client's risk for thrombus? Select all that apply
Use of oral contraceptives • Immobility • Post-operative status Explanation: Risk factors for thrombus formation include the use of oral contraceptives, immobility and surgery. Polycythemia, not anemia, is also a risk factor. Varicose veins lead to venous pooling.
When describing the normal cardiac cycle, which of the following would a nursing instructor describe as occurring during systole?
Ventricles eject blood. Explanation: The cardiac cycle begins with the generation of an impulse in the SA node. This impulse spreads throughout the heart, which then causes the muscle contraction and pumping motion. With each contrction during systole, the ventricles eject blood. During the diastole, the heart muscle relaxes and the chambers fill with blood.
Which of the following initial cardiac rhythms is most frequently found in patients who experience sudden cardiac arrest?
Ventricular fibrillation Explanation: This action will increase hematoma formation and prolong bleeding.
A nurse is developing a plan of care for a man with metabolic syndrome. Which of the following would the nurse expect to find?
Waist circumference of 44 inches Explanation: Metabolic syndrome is characterized by a waist circumference greater than 40 inches in men, triglyceride levels over 150 mg/dL, HDL levels less than 40 mg/dL for men, blood pressure greater than 130/85, and a fasting glucose greater than 110 mg/dL.
The nurse is reviewing the laboratory test results of a patient suspected of having had a myocardial infarction. Which of the following would the nurse identify as important in helping to confirm this diagnosis? Select all that apply.
• Creatine-kinase MB • Myoglobin • Troponin Explanation: Laboratory tests used to help confirm a myocardial infarction include myoglobin, creatine-kinase MB, and troponin. B-type natriuretic peptide is used to diagnose heart failure. Blood urea nitrogen reflects kidney function
