Cardiovascular

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1.The neurovascular status is normal because of increased blood flow through the leg. 2.The neurovascular status is moderately impaired, and the surgeon should be called. 3.The neurovascular status is slightly deteriorating and should be monitored for another hour. 4.The neurovascular status is adequate from an arterial approach, but venous complications are arising.

1 A bypass graft is a surgical procedure in which a graft (a vessel from another part of the body) is placed to connect the aorta to a femoral artery in the pelvis, bypassing a disease or occluded vessel. It is completed to increase blood flow to the legs. Warm, redness, and edema are expected after surgery, as blood flow has increased in the extremity. The pedal pulse is palpable, which ensures neurovascular status is intact.

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? 1.Chest pain 2.Urge to cough 3.Warm, flushed feeling 4.Pressure at the insertion site

1 A cardiac catheterization is a procedure in which a catheter is inserted into an artery and threaded to your heart. Various instruments can be attached to the tip of the catheter to measure pressure, view the interior of the heart, take blood samples, or remove tissues. If a dye is injected into the blood (coronary angiogram), it allows an x-ray to record a "movie" of your heart and arteries. The client will be asked to report any chest pain or unusual sensations during the procedure immediately. The contrast dye can cause a warm/flushing sensation, and pressure at the catheter insertion site is caused by the use of local anesthetic. The client may be asked to cough during the procedure.

A client is admitted to the hospital with a diagnosis of aortic regurgitation. The nurse plans care for the client, knowing that the failure of the aortic valve to close completely allows blood to flow retrograde through which structures? 1.Aorta to left ventricle 2.Left ventricle to left atrium 3.Right ventricle to right atrium 4.Pulmonary artery to right ventricle

1 A valve regurgitation is a condition in which a heart valve is faulty and doesn't close all the way, allowing blood to flow backwards, or regurgitate, back into the heart during contraction. The aortic valve is between the aorta and the left ventricle.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding? 1.Hypotension 2.Flat neck veins 3.Complaints of nausea 4.Complaints of headache

1 Atrial fibrillation is an irregular and often rapid heart rate that occurs when the atria experience chaotic electrical signals and beat out of coordination with the ventricles. If the heart rate is too high (>100 bpm), the lack of coordination becomes so extreme that the patient loses their atrial kick (the final squeeze of the atria pushing as much blood as possible into the ventricle during diastole). This causes decreased ventricular filling and low cardiac output. Option 1: Decreased cardiac output would lead to hypotension, as well as chest pain, palpitations, pulse deficit, fatigue, dizziness, syncope, SOB, and distended neck veins. Option 2: Afib causes distended neck veins, and blood cannot adequately fill the heart and gets backed up. Options 3: Nausea can be a sign of an MI. Option 4: Headache is not a symptom of afib.

A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse's response incorporates the information that bearing down or straining would trigger which physical response? 1.Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility 2.Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility 3.Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility 4.Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility

1 Bearing down can stimulate the vagus nerve, which decreases heart rate and cardiac contractility. A patient who had an MI already has a weakened heart that may not be adequately pumping, so any decrease in its ability to pump would further decrease tissue perfusion. Stimulation of the sympathetic NS would cause an increase in heart rate and contractility.

A nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? 1. 1+ edema 2. 2+ edema 3. 3+ edema 4. 4+ edema

1 Edema is accumulation of fluid in the intercellular spaces and is not normally present. Option 1: 1+ is mild pitting, indentation is slight and subsides rapidly, and leg does not look swollen. Option 2: 2+ is moderate pitting, indentation subsides rapidly, and leg may look a little swollen. Option 3: 3+ is deep pitting, indentation remains a short time, and leg looks swollen. Option 4: 4+ is very deep pitting, indentation remains a long time, and leg is very swollen.

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? 1."Where is the pain located?" 2."Are you having any nausea?" 3."Are you allergic to any medications?" 4."Do you have your nitroglycerin with you?"

1 If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality. Although options 2, 3, and 4 all may be components of the assessment, none of these questions would be the initial assessment question with this client.

A nursing student who is researching a medication at the nursing station asks the registered nurse (RN) what an α1-adrenergic receptor is. The RN responds by telling the student that these receptors are found primarily in which peripheral vascular structures and produce which actions? 1.The peripheral arteries and veins, and when stimulated cause vasoconstriction 2.Arterial and bronchial walls, and when stimulated cause vasodilation and bronchodilation 3.The heart, and when stimulated cause an increase in heart rate, atrioventricular (AV) node conduction, and contractility 4.Several tissues, and when stimulated cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation

1 Option 1: Alpha 1 receptors cause powerful vasoconstriction in vessels when stimulated. Option 2: Beta 1 receptors cause vasodilation in vessels and bronchi when stimulated (ex. long lasting beta agonists are used to treat asthma). Option 3: Beta 2 receptors cause increased contractility, conduction, and heart rate when stimulated.

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1."I will eat enough daily fiber to prevent straining at stool." 2."I will try to exercise vigorously to strengthen my heart muscle." 3."I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4."Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

1 Option 1: Dietary modifications required with heart failure include increasing fiber to prevent straining and constipation. Option 2: Vigorous exercise needs to be avoided with heart failure. Moderate exercise is encouraged to prevent atherosclerosis, increase circulation, and keep muscles and joints strong. Option 3: Clients with heart failure need to decrease fluid volume, as increased blood volume increases cardiac workload. Option 4: Alcohol increases blood pressure and can weaken and thin heart muscle; it needs to be avoided.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1.Listening to lung sounds 2.Monitoring for organomegaly 3.Assessing for jugular vein distention 4.Assessing for peripheral and sacral edema

1 Option 1: Left sided heart failure would cause blood to fail to pump adequately through the aorta and into the body. It would back up through the left atrium and ventricle, through the pulmonary veins, and into the lungs. Options 2, 3, 4: Organomegaly (enlarged organs), jugular vein distention, and edema are all signs of right sided heart failure, as the right atrium and ventricle fail to pump deoxygenated blood through the pulmonary artery, causing it to back up through the venae cavae and into the body.

A client with myocardial infarction is experiencing new, multiform premature ventricular contractions (PVCs). Knowing that the client is allergic to lidocaine hydrochloride, the nurse plans to have which medication available for immediate use? 1.Procainamide 2.Digoxin (Lanoxin) 3.Verapamil (Calan SR) 4.Metoprolol (Lopressor)

1 Option 1: Procainamide is an antidysrhythmic drug that can be used in lieu of lidocaine. Lidocaine is also used as an analgesic for nerve pain. Option 2: Digoxin is a cardiac glycoside and decreases contractility and HR to treat atrial fibrillation. Option 3: Verapamil is a calcium channel blocker and is used to treat hypertension and angina pectoris. Option 4: Metoprolol is a beta blocker and is used to treat hypertension.

The nurse is developing a plan of care for a client with pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? 1.Using a bedside commode 2.Sleeping in the supine position 3.Elevating the legs when in bed 4.Using seasonings to improve the taste of food

1 Option 1: Using a bedside commode decreases the distance the patient has to walk. Option 2: Sleeping in the supine position increases respiratory effort, as fluid is spread throughout the lobes rather than just being in the bases. This, in turn, decreases oxygenation. Option 3: Elevating the legs increases venous return and blood flowing to the heart, increasing cardiac workload. Option 4: Seasonings usually contain sodium, which increases water retention and increases cardiac workload.

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider will most likely prescribe which option?1.Maintain bed rest. 2.Maintain the affected leg in a dependent position. 3.Administer an opioid analgesic every 4 hours around the clock. 4.Apply cool packs to the affected leg for 20 minutes every 4 hours.

1 Standard management for the client with DVT includes bed rest; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Option 1: The patient should maintain bed rest. Ambulation can prevent DVT development, but is contraindicated if there is already a thrombi because it can cause it to dislodge and travel to a vital area. Option 2: Keeping the affected leg dependent (hanging) is no more effective than just keeping the leg immobile to prevent the clot from dislodging. Option 3: DVTs do not usually cause enough pain to warrant opioid use. Acetaminophen (Tylenol) is usually given to treat any pain. Option 4: Ice packs, heat, and compression can be used after the clot has been treated and broken up, but not before as they can cause vasoconstriction or vasodilation and dislodge the clot.

A nurse is caring for a client who has lost a significant amount of blood as a result of complications of a surgical procedure. The nurse understands that which client assessment will provide the earliest indication of new decreases in fluid volume? 1.Pulse rate 2.Blood pressure (BP) 3.Assessment for edema 4.Lung auscultation for crackles

1 The human body contains 4-6 liters of blood. The maximum allowable blood loss (ABL) is the amount of blood that can be lost before a transfusion is considered and is dependent on the patient's height, weight, age, and hematocrit percentage. Option 1: When fluid volume decreases, the heart will beat faster to compensate. Option 2: A decrease in blood pressure will occur with fluid volume deficit, but it's not the earliest indicator. Options 3, 4: Edema and crackles on auscultation are present in fluid volume overload.

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as the most likely indicator that the client is experiencing complications of this therapy? 1.Tarry stools 2.Nausea and vomiting 3.Orange-colored urine 4.Decreased urine output

1 Thrombolytic agents are used to dissolve existing thrombi and can cause excess bleeding. Tarry stools is a sign of an upper GI bleed.

A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1.Emotional stress 2.Atrial fibrillation 3.Nutritional anemia 4.Peptic ulcer disease 5.Recent upper respiratory infection

1, 2, 3, 5 Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's prescriptions? Select all that apply. 1.Elevation of the right leg 2.Ambulation in the hall every 4 hours 3.Application of moist heat to the right leg 4.Administration of acetaminophen (Tylenol) 5.Monitoring for signs of pulmonary embolism

1, 3, 4, 5 The nurse should provide comfort measures such as encouraging venous return (elevating the limb, providing heat), and treating pain. The nurse should monitor for signs of a pulmonary embolism (anxiety, dyspnea, chest pain). Ambulation is contraindicated, as it can increase the risk of the clot dislodging and traveling to a vital organ.

The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which interpretation about this finding?1.A normal finding2.Indicative of atrial flutter3.Indicative of atrial fibrillation4.Indicative of impending reinfarction

1.The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? 1.Stable angina 2.Variant angina 3.Unstable angina 4.Nonanginal pain

2 Angina is a type of chest discomfort caused by poor blood flow through the coronary vessels to the myocardium (heart muscle. Option 1: Stable angina occurs during physical activity and go away with rest. Option 2: Variant angina occurs at the same time each day and can be prolonged and severe. It is not precipitated by physical activity. It's occurrence is predictable. Option 3: Unstable angina occurs acutely, is unpredictable, and is often a precursor of a myocardial infarction. Option 4: The fact that this client has a history of angina, and that it occurs at the same time each day, indicates it's anginal pain.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? 1."I will avoid using table salt with meals." 2."It is best to exercise once a week for 1 hour." 3."I will take nitroglycerin whenever chest discomfort begins." 4."I will use muscle relaxation to cope with stressful situations."

2 Angina pectoris is chest pain caused by inadequate tissue perfusion of the myocardium (heart muscle) due to occluded coronary arteries. Option 1: A patient with angina will have a weakened heart due to poor perfusion. A weak heart cannot take the strain of high blood volume, so salt needs to be avoided to prevent increased water retention. Option 2: Exercise is most effective when it's done at least 3x a week for 20-30 minutes. Option 3: Nitroglycerin can be taken at the first signs of discomfort, but it's most effective if taken prior to an activity that the patient knows will cause chest pain. Option 4: Stress management techniques can prevent chest pain from angina.

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value came back elevated? 1.Myoglobin 2.Cardiac troponin 3.C-reactive protein 4.Creatine kinase (CK)

2 Cardiac troponin elevations indicate myocardial injury or infarction. Although the remaining options may also rise, they are not definitive enough to draw a conclusive diagnosis.

The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse? 1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

2 Cardioversion is a medical procedure that restores a normal heart rhythm in people with certain types of abnormal heartbeats (arrhythmias). It's usually done by sending electric shocks to your heart through electrodes placed on your chest, after the client is sedated. Remember ABCs: airway, breathing (O2 flow rate/administration), circulation (blood pressure/vital signs assessment), then LOC and dysrhythmia detection can be assessed.

A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgement of the pacing catheter? 1.Limiting both movement and abduction of the left arm 2.Limiting both movement and abduction of the right arm 3.Assisting the client to get out of bed and ambulate with a walker 4.Having the physical therapist do active range-of-motion exercises to the right arm

2 In the first several hours after insertion of a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site.

A hospitalized client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned and takes action, knowing that this level could ultimately lead to which complication? 1.Stroke 2.Cardiac arrest 3.High blood pressure 4.Urinary stone formation

2 Normal calcium is 8.6-10 mg/dL. Calcium is used by the heart to contract. Hypocalcemia can lead to dysrhythmias, prolonged QT interval, and cardiac arrest.

A nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin (Lanoxin) notes that the heart rate is 52 beats/min. The nurse should make which interpretation about this information? 1.Normal, because of the client's age 2.Abnormal, requiring further assessment 3.Normal, as a result of the effects of digoxin 4.Normal, because this is the reason the client is receiving digoxin

2 Normal heart rate is 60-100 bpm. Digoxin decreases heart rate and increases contractility and is used for patients with heart failure and atrial fibrillation. With a HR lower than 60 bpm, digoxin would be withheld.

The nurse is assessing the client's condition after cardioversion. Which observation should be of highest priority to the nurse? 1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

2 Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority.

The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client? 1.Use the knee-gatch on the bed. 2.Cover the legs lightly when sitting in a chair. 3.Encourage the client to cross legs when sitting in a chair. 4.Provide pillows for the client to place under the knees as desired.

2 Options 1, 3, 4: Crossing or angling the knees puts extra pressure on vessels and decrease perfusion to the lower extremities. Option 2: Lightly covering the legs will increase warmth and encourage vasodilation, promoting perfusion to the limbs. The nurse should also encourage ROM exercises and apply elastic stockings to prevent venous stasis.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1.Anterior chest pain 2.Pericardial friction rub 3.Weakness and irritability 4.Chest pain that worsens on inspiration

2 Pericarditis is inflammation of the pericardium (membrane that surrounds the heart) and can be caused by viral infections or autoimmune disorders such as lupus. Option 1: Anterior (front) chest pain can be caused by myocardial infarction or angina pectoris. Option 2: A pericardial friction rub in audible medical sign of pericarditis. Upon auscultation, an extra heart sound is heard: one sound for systolic and two for diastolic. Option 3: Weakness and irritability are very nonspecific symptoms and could be symptoms of many disorders. Option 4: Chest pain that worsens on inspiration can be both pericarditis or pleurisy (inflammation of the pleural cavity around lungs, which decreases lubrication).

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1.Sleep with the head of bed flat. 2.Weigh himself or herself on a daily basis. 3.Take a double dose of the diuretic if peripheral edema is noted. 4.Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs.

2 Pulmonary edema is usually caused by congestive (left sided) heart failure, which causes a back-up of fluid into the pulmonary vein and into the lungs. With heart failure, blood volume is not adequately pumped and therefore does not enter cells or filter through the kidneys adequately, resulting in fluid retention. An increase of 2-3 lb in 24 hours, or 5 lb in a week, needs to be reported to the HCP.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1.Use nail polish to protect the nail beds from injury. 2.Stop smoking because it causes cutaneous vasospasm. 3.Wear gloves for all activities involving use of both hands. 4.Always wear warm clothing even in warm climates to prevent vasoconstriction.

2 Raynaud's is a type of vascular disease of smaller arteries that causes abnormal, acute vasoconstriction in extremities in response to cold temperatures or stress. Without treatment, it can lead to loss of that extremity. Option 1: Clients with Raynaud's normally have sufficient blood flow and don't have decreased healing. Option 2: Smoking causes vasoconstriction and can exacerbate the condition. Option 3: Gloves are not necessary, unless the client is touching cold items. Option 4: Raynaud's phenomenon occurs in response to cold temperatures only.

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1."I'll need to become a strict vegetarian." 2."I should use polyunsaturated oils in my diet." 3."I need to substitute eggs and whole milk for meat." 4."I should eliminate all cholesterol and fat from my diet."

2 The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins

A nurse is assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. The nurse plans care with the understanding that the heart normally sends out how many liters of blood per minute to the body? 1. 2 L/min 2. 5 L/min 3. 10 L/min 4. 15 L/min

2 The heart ejects 5 L of blood per minute. 50-100 ml of blood is ejected with each pump of the heart (stroke volume).

A client is admitted to the hospital with a diagnosis of mitral stenosis. The narrowing of this valve will impede circulation of blood through which structures? 1.Left ventricle to aorta 2.Left atrium to left ventricle 3.Right atrium to right ventricle 4.Right ventricle to pulmonary artery

2 The mitral valve separates the left atrium from the left ventricle. A mitral stenosis is a narrowing of the mitral valve opening and can be caused by infection, such as rheumatic fever. A stenosed valve causes symptoms behind the valve, so a mitral stenosis would cause pulmonary congestion.

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? 1.Bilateral edema 2.Increased calf circumference 3.Diminished distal peripheral pulses 4.Coolness and pallor of the affected limb

2 Thrombophlebitis, also known as deep vein thrombosis (DVT) is a blood clot in the deep veins, usually in a lower extremity. Signs/symptoms include edema, warmth, redness, tenderness, low grade fever. Option 1: Edema will occur in the affected limb only. Option 2: Due to edema and swelling, calf circumference will increase in the affected limb. Option 3: DVT is a clot in a vein, so pulses will not be diminished. Option 4: Coolness and pallor occur with a clot in an artery, as there is decreased blood flow and tissue perfusion to the affected limb.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1.Keep the legs aligned with the heart. 2.Elevate the legs higher than the heart. 3.Clean the skin with alcohol every hour. 4.Position the client onto the side every shift.

2 Varicose veins are caused by faulty (weak or damaged) valves in veins, causing poor venous return and veins to swell with blood. Option 1: Keeping the legs aligned with the heart will not affect venous return. Option 2: Elevating the legs increases venous return. Option 3: Alcohol is very drying and irritating to the skin. It also will not affect varicose veins. Option 4: Turning the client every hour can prevent pressure ulcers and help circulation, but it's infrequent care and not the priority.

The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Place in Fowler's position for eating .2.Encourage coughing with deep breathing. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. 5.Place sequential compression boots on the client. 6.Encourage the intake of dark green, leafy vegetables.

2, 3, 4 Option 1: Hip flexion (which occurs with high fowler's) decreases venous return from the lower extremities. Venous stasis is a contributing factor to developing DVT. Option 2: Coughing and deep breathing will help prevent and clear secretions from the lungs, prevent pneumonia. Option 3: Fluids should be encouraged for hemodilution (↓ blood viscosity) and prevent further blood clots. Option 4: Compression stocking provide comfort by promoting venous return and reducing edema. Option 5: Sequential compression boots are only used to prevent DVT and are contraindicated if the patient currently has a DVT. Option 6: Vitamin K plays an essential role in forming blood clots, so foods high in vitamin K should be avoided.

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. 1.Soak the feet in hot water daily. 2.Be careful not to injure the legs or feet. 3.Use a heating pad on the legs to aid vasodilation. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet.

2, 4, 5 Options 1, 3: Although hot water may promote vasodilation, the client with PAD may have decreased sensation and is at risk for burns. Option 2: Decreased blood flow to the extremity will decrease healing ability and speed and increases the risk of infections. Option 4: Ambulation will increase circulation, especially collateral circulation (increased blood flow to other, non-occluded arteries). Option 5: Decreased fat intake can decrease cholesterol levels and lessen atherosclerosis, which occludes arteries.

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/min. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse interpret this rhythm?1.Sinus tachycardia2.Sinus dysrhythmia3.Sinus bradycardia4.Normal sinus rhythm

2.Sinus dysrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of firing of the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not affected.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1.Sinus dysrhythmia 2.Sinus tachycardia 3.Sinus bradycardia 4.Normal sinus rhythm

2.Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is experiencing which rhythm?1.Sinus tachycardia2.Ventricular fibrillation3.Ventricular tachycardia4.Premature ventricular contractions (PVCs)

2.Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Sinus tachycardia has a recognizable P wave and QRS. Ventricular tachycardia is a regular pattern of wide QRS complexes. PVCs appear as irregular beats within a rhythm. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.

A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? 1.Eat breakfast just before the procedure. 2.Wear firm, rigid shoes, such as work boots. 3.Wear loose clothing with a shirt that buttons in front. 4.Avoid cigarettes for 30 minutes before the procedure.

3 A diagnostic exercise test, also known as an exercise tolerance test, is used to assess the health of the heart. The client should remain NPO at least 2 hours before the procedure, wear rubber-soled shoes, avoid smoking and alcohol the day of the test (false positive risk), and wear loose clothing for easy ECG placement.

A nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site? 1.Bundle of His 2.Purkinje fibers 3.Sinoatrial (SA) node 4.Atrioventricular (AV) node

3 A heart block is an abnormal heart rhythm where the heart beats too slowly. It's caused by a dysfunction in the path of electrical signals/pacemaker of the heart. The SA node sets the natural pace of the heart (60-100 bpm). If the SA node is damaged, the AV node takes over as the pacemaker, but it is slower (40-60 bpm). Each pathway for electrical impulses is slower than the last. SA node → AV node → Bundle of His → Purkinje fibers

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? 1.Ad lib activities as tolerated 2.Strict bed rest for 24 hours after transfer 3.Bathroom privileges and self-care activities 4.Unsupervised hallway ambulation for distances up to 200 feet

3 Ad lib activities and strenuous exercise are contraindicated after an MI. Ambulation should be supervised and begin with brief distances.

A nurse employed in a cardiac unit determines that which client is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)? 1.A client with syncopal episodes related to ventricular tachycardia 2.A client with ventricular dysrhythmias despite medication therapy 3.A client with an episode of cardiac arrest related to myocardial infarction 4.A client with three episodes of cardiac arrest unrelated to myocardial infarction

3 An AICD detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have syncopal episodes related to ventricular tachycardia, those who are refractive to medication therapy, and those who have survived sudden cardiac death unrelated to myocardial infarction.

A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? 1."I need to cut down on cigarette smoking." 2."I am so relieved that my heart is repaired." 3."I need to adhere to my dietary restrictions." 4."I am so relieved that I can eat anything I want to now."

3 An angioplasty is a surgical procedure used to widen a blocked or narrowed artery using a balloon catheter. A stent (mesh, tubular structure) is usually placed inside the artery to prevent the artery from narrowing again. Option 1: Smoking causes vasoconstriction and needs to be stopped completely. Option 2: Angioplasty does not repair the heart. Options 3, 4: Angioplasty is usually required due to atherosclerosis, caused by hypertension and hyperlipidemia. Dietary changes need to occur to prevent the artery from becoming narrowed again.

The health care provider has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? 1.Questions the client about allergies to iodine or shellfish 2.Has the client sign an informed consent form for an invasive procedure 3.Tells the client that the procedure is painless and takes 30 to 60 minutes 4.Keeps the client on nothing-by-mouth (NPO) status for 2 hours before the procedure

3 An echocardiogram is a noninvasive procedure that tests the action of the heart using ultrasound waves to produce a visual display, used for the diagnosis or monitoring of heart disease. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client.

The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? 1.Walk for as long as possible each day. 2.Cross the legs at the ankle only, not at the knee. 3.Lie down with the legs elevated and avoid sitting. 4.Sit in a chair 3 times a day for 3 hours at a time.

3 Any activity that decreases venous return to the heart should be avoided, such as standing, sitting, and crossing the legs. The client should lie down whenever possible and elevate the legs to promote venous return.

A client who has been exercising in a gymnasium stops to measure his pulse and places his fingers over both carotid arteries simultaneously. A nurse exercising nearby is correct when the nurse cautions him to check the pulse on only one side, primarily for which reason? 1.It is unnecessary to use both hands. 2.The client could occlude the trachea. 3.The heart rate and blood pressure could drop. 4.Feeling dual pulsations may lead to an incorrect measurement.

3 Applying pressure to both carotid arteries at the same time is contraindicated because it causes excess pressure to the baroreceptors in the carotid vessels, which could cause the heart rate and blood pressure to drop reflexively. The manual pressure on both arteries also occludes blood flow to the brain.

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? 1.Flat neck veins 2.Nausea and vomiting 3.Hypotension and dizziness 4.Clubbed fingertips and headache

3 Atrial fibrillation is caused by disorganized electrical signals, causing the atria to beat irregularly. If heart rate is too high (>110 bpm), the coordination between the atria and ventricles becomes too uncoordinated and the heart can not longer effectively fill and pump. Option 1: Flat neck veins indicate hypovolemia and low blood pressure. Option 2: Nausea and vomiting are possible symptoms of an MI, not afib. Option 3: Hypotension can occur with uncontrolled afib due to ineffective pumping of the heart; when blood cannot adequately move through the heart, venous return is obstructed. Option 4: Clubbed fingers occur from chronically low blood oxygen levels and indicate lung or heart disorders.

The home health nurse is visiting a client who has had a prosthetic valve replacement for severe mitral valve stenosis. Which statement by the client reflects an understanding of specific postoperative care after this surgery? 1."I need to count my pulse every day." 2."I have to do deep breathing exercises every 2 hours." 3."I threw away my straight razor and bought an electric razor." 4."I have to go to the bathroom frequently because of my medication."

3 Blood clots like to form around foreign objects in the body, such as prosthetic valves. In order to decrease the risk of a blood clot, the client will need to be on life long anticoagulant therapy. Anticoagulant therapy increases bleeding risk.

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which question should best help a nurse discriminate pain caused by a noncardiac problem? 1."Can you describe the pain to me?" 2."Have you ever had this pain before?" 3."Does the pain get worse when you breathe in?" 4."Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

3 Determining the origin and cause of the pain will allow for proper treatment.

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1.Left atrium 2.Right atrium 3.Left ventricle 4.Right ventricle

3 Hypertension narrows vessels, causing an increased afterload. The left ventricle, which pumps blood out of the heart and into the body, has to overcome the increased pressure in the vessels and will begin to weaken.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1.A stage 1 ulcer 2.A vascular ulcer 3.An arterial ulcer 4.A venous stasis ulcer

3 Option 1: A stage 1 ulcer indicates the epidermis is intact. Option 2: A vascular ulcer is a general term to refer to damage caused by a vessel--venous or arterial. This is not a specific enough answer. Option 3: An arterial ulcer occurs when there is inadequate blood flow to the extremity. It causes increased pulse, pain, coolness, atrophy, dryness, and ischemia. Option 4: A venous stasis ulcer occurs when a vein does not adequately return blood to the heart, and it pools in the extremity. It causes increased pulse, redness, heat, edema, and weeping.

The nurse is instructing the post-cardiac surgery client about activity limitations for the first 6 weeks after hospital discharge. The nurse should include which item in the instructions? 1.Driving is permitted so long as the lap and shoulder seat belts are worn. 2.Lifting should be restricted to objects that do not weigh more than 25 pounds. 3.Use the arms for balance, not weight support, when getting out of bed or a chair. 4.Activities that involve straining may be resumed so long as they do not cause pain.

3 Option 1: Clients post-cardiac surgery should not drive at all. Option 2: Lifting needs to be restricted to 5 pounds. Option 3: The arms should not be used for weight support, as it puts pressure on the sternum. Option 4: The client needs to avoid any activities that cause straining, as this puts excess pressure on the heart.

A hospitalized client is experiencing a decrease in blood pressure. The nurse plans care for the client, knowing that this change will have which primary effect on his or her heart? 1.Decreased heart rate 2.Increased contractility 3.Decreased myocardial blood flow 4.Increased resistance to electrical stimulation

3 Option 1: When blood pressure is low, heart rate increases to compensate. Options 2, 4: Blood pressure does not affect contractility or electrical stimulation resistance. Option 3: Inadequately low blood pressure will decrease tissue perfusion. [Cardiac output = stroke volume x heart rate]

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? 1.The client is not experiencing dyspnea. 2.The client is not experiencing nausea or vomiting. 3.The pain has not been relieved by rest and nitroglycerin tablets. 4.The client says the pain began while she was trying to open a stuck dresser drawer.

3 Options 1, 2: Dyspnea, diaphoresis, N/V, and anxiety are possible, but not classical, symptoms of an MI. Option 3: With an MI, pain cannot be relieved by rest or nitroglycerin (unlike angina) and requires opioids. Classical symptoms of an MI is pain that radiates to the left arm, shoulder, jaw, and neck and begins spontaneously and lasts longer than 30 minutes. Option 4: Chest pain that occurs after exertion indicates stable angina pectoris.

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1.Flat neck veins 2.A pulse rate of 60 beats/min 3.Muffled or distant heart sounds 4.Wheezing on auscultation of the lungs

3 Pericarditis is inflammation of the pericardium (lining around the heart). Pericarditis can occur due to viral infections. Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). Option 1: Cardiac tamponade would cause distended neck veins, as blood is not pumping adequately through the body. Option 2: Cardiac tamponade would cause tachycardia, as the heart is trying to compensate from the low blood pressure. Option 3: Because heart cannot expand all the way, contractions are smaller and weaker. Option 4: Wheezing indicates a narrowing of the airway, which is not something a cardiac tamponade would cause. A cardiac tamponade may cause crackles (indicating fluid in the lungs) because blood gets backed up due to the heart not being able to expand, but not wheezing.

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? 1.Rhonchi 2.Wheezes 3.Crackles in the bases 4.Crackles throughout the lung fields

3 Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Crackles are caused by excess secretions in the alveoli. Option 1: Rhonchi are caused by obstruction or secretions in the bronchial airways. They are coarse, continuous low pitched rattling sounds that are heard on inspiration and expiration that sound very much like snoring. Option 2: Wheezes indicate a narrowed airway. Option 3: Crackles just in the bases indicates fluid just in the base lobes. Option 4: Crackles throughout the lungs indicates fluid in all lobes.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse? 1.Call a code. 2.Call the health care provider. 3.Check the client's status and lead placement. 4.Press the recorder button on the electrocardiogram console.

3 Sudden loss of electrocardiographic complexes can indicate ventricular asystole or just an electrode displacement. Regardless of the possible issue, the client should always be assessed first.

A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. Which action should the nurse take? 1. Adenosine is contraindicated for SVT. Verify the order with the health care provider 2. Administer medication only through a central venous access 3. Administer medication rapidly over 1-2 seconds followed by a saline flush 4. Mix medication in 50 mL normal saline and administer over 10 minutes

3 Supraventricular tachycardia is a rapid heart rhythm greater than 150 bpm; it slows impulse conduction through the AV node to slow down heart rate. The ECG should be monitored after administered, along with reporting any signs of flushing, dizziness, chest pain, and palpitations. Option 1: Adenosine is the first-line drug for SVT Option 2: Adenosine can be administered via a peripheral line or a central line; just ensure you're as close to the heart as possible (such as in the AC) Option 3: The half-life of adenosine is very short, so it needs to be administered rapidly and as close to the heart as possible Option 4: Adenosine should not be diluted

A client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. In formulating a response, the nurse understands that this effect occurs because of the client's primary need for which increased cardiac response? 1.Pulse rate 2.Cardiac index 3.Cardiac output 4.Stroke volume

3 The feeling of a pounding heart is the direct result of the body's attempt to meet the metabolic demands generated during exercise. An adequate cardiac output is necessary to maintain perfusion. With exercise, the heart will be faster (↑ HR) and harder (↑ stroke volume). Cardiac output = HR x SV Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a specific individual and takes into account body surface area.

A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? 1."Apply warm packs to the leg." 2."Keep the leg elevated as much as possible." 3."Contact your health care provider right away to report this problem." 4."This normally occurs after surgery and will subside when the edema goes down."

3 The sensation of pins and needles can indicate nerve damage, as some veins and nerves run close together.

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1.Bananas 2.Broccoli 3.Antacids 4.Cantaloupe

3 Toothpaste, mouthwash, mineral and softened water, and OTC meds such as analgesics, antacids, laxatives, and sedatives can increase sodium levels.

A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit? 1.Apples 2.Pears 3.Bananas 4.Cranberries

3 Triamterene is a potassium-sparing diuretic, so clients taking this drug can develop relative hyperkalemia as other electrolytes are lost through excretion. High potassium foods such as bananas, avocados, mangos, prunes, and oranges should be avoided.

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which condition? 1.Heart failure 2.Atrial fibrillation 3.Myocardial infarction 4.Ventricular tachycardia

3 Troponin is a protein found in the blood that indicates muscle damage. Troponin T and I are both released when the heart muscle has been damaged, but Troponin I is a more specific indicator of heart muscle damage than T (Troponin T is more broad/indicates general muscle damage). They are both used to diagnose an MI.

A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block?1.Presence of Q waves2.Tall, peaked T waves3.Prolonged PR interval4.Widened QRS complex

3.A prolonged PR interval indicates first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An ECG taken during a pain episode is intended to capture ischemic changes, which also include ST-segment elevation or depression.

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)?1.Chloride level of 98 mEq/L2.Sodium level of 135 mEq/L3.Potassium level of 6.8 mEq/L4.Magnesium level of 1.6 mEq/L

3.Hyperkalemia can cause tall, peaked or tented T waves on the ECG. Levels of potassium 5.0 mEq/L or greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels.

The nurse notes that a client's cardiac rhythm shows absent P waves and no PR interval. How should the nurse interpret this rhythm?1.Bradycardia2.Tachycardia3.Atrial fibrillation4.Normal sinus rhythm (NSR)

3.In atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration usually is normal and constant. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 seconds in duration, and the QRS interval is 0.06 to 0.10 seconds in duration.

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The P waves and QRS complexes are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse interprets the cardiac rhythm to be which rhythm?1.Sinus bradycardia2.Sick sinus syndrome3.Normal sinus rhythm4.First-degree heart block

3.Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? 1.Sinus bradycardia 2.Sick sinus syndrome 3.Normal sinus rhythm 4.First-degree heart block

3.Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

A nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The health care provider (HCP) tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the HCP is referring to which arteries? 1.Circumflex coronary artery 2.Right coronary artery (RCA) 3.Posterior descending coronary artery (PDA) 4.Left anterior descending coronary artery (LAD)

4

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? 1.Tea 2.Cola 3.Coffee 4.Raspberry juice

4 A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse immediately would assess which item based on priority? 1.Anxiety level of the client and family 2.Presence of a Medic-Alert card for the client to carry 3.Knowledge of restrictions of post-discharge physical activity 4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver

4 An automatic internal cardiovert-defibrillator (ICD) is an implanted device that performs cardioversion, defibrillation, or pacing of the heart. It sends a shock and causes contractions of the heart. When heart rate cut off is reached (i.e. tachycardia), it sends a shock to "reboot" the heart. The other interventions need to be addressed prior to the client leaving the hospital, but they are not the priority.

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Regular insulin 2. Glipizide (Glucotrol) 3. Repaglinide (Prandin) 4. Metformin (Glucophage)

4 Both the contract dye used in cardiac catheterization and metformin affect kidney function and increase the risk of lactic acidosis. Metformin would need to be withheld 24 hours, and 48 hours after, catheterization.

A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying measures to help the client cope with lifestyle changes needed to control the disease process. The nurse plans to refer the client to which member of the health care team? 1.Dietitian 2.Medical social worker 3.Pain management clinic 4.Smoking-cessation program

4 Buerger's disease is a vascular occlusive disease that affects the medium and small arteries and veins. Blood vessels swell, which can prevent blood flow, causing clots to form. This can lead to pain, tissue damage, and tissue necrosis. Smoking causes vasoconstriction, which can exacerbate the symptoms of the disease.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? 1.Rising blood pressure 2.Clearly audible heart sounds 3.Client expressions of relief 4.Rising central venous pressure

4 Cardiac tamponade is a condition in which blood or fluid fills the pericardial sac encasing the heart. This places extreme pressure on the heart and prevents the ventricles from expanding completely. A pericardiocentesis is a procedure in which excess fluid is drained from the pericardial sac using a needle. Option 1: If the pressure from fluid around the heart was still high, the heart would not be able to fully fill with blood (since it can't expand all the way) and blood pressure would be low. Option 2: Clearly audible heart sounds would indicate a successful procedure, as the heart can expand fully against and pump adequately. Option 3: The client may express relief, as signs of a cardiac tamponade include: dyspnea, discomfort, chest pain, lightheadedness. Option 4: Central venous pressure (CVP) is the blood pressure in the venae cavae right before blood returns from the body into the right atrium. The pressure would be increased here if the procedure failed, because the heart cannot expand and accept all the blood returning to the heart.

The nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse should address with the client which most important measure to ensure client safety? 1.Assessing pain 2.Administering vasodilators 3.Avoiding over-the-counter medications 4.Moving slowly from a sitting to a standing position

4 Cardiomyopathy is a chronic disease of the heart in which the heart muscle becomes enlarged and cannot adequately deliver blood to the body. This can lead to heart failure. The inability to pump will lead to an obstruction in venous return, which can cause hypotension, which puts the client at risk for falls due to orthostatic hypotension.

A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse should respond with which statement? 1."The work of breathing is increased when the client is anemic." 2."Blood flows more slowly when the hemoglobin or hematocrit is low." 3."The body has to work harder to fight infection in the presence of anemia." 4."Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."

4 Cells need oxygen to function properly and meet the metabolic needs of the body. With decreased hemoglobin (iron is a necessary component of hemoglobin that carries the oxygen), there will be decreased oxygen.

The home health nurse makes a home visit to a client who has an implantable cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? 1."If I feel an internal defibrillator shock, I should sit down." 2."I won't be able to have a magnetic resonance imaging test (MRI)." 3."My wife knows how to call the emergency medical services (EMS) if I need it." 4."I can stop taking my antidysrhythmic medicine now because I have a pacemaker."

4 Clients with an ICD usually continue to receive antidysrhythmic medications after discharge from the hospital. The nurse should stress the importance of continuing to take these medications as prescribed.

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? 1."I'm not supposed to eat cold cuts." 2."I can have most fresh fruits and vegetables." 3."I'm going to weigh myself daily to be sure I don't gain too much fluid." 4."I'm going to have a ham and cheese sandwich and potato chips for lunch."

4 Heart failure is a chronic condition in which the heart can no longer pump (systolic) or fill (diastolic) adequately. Causes of HF can include a previous MI, coronary artery disease (↓ blood to coronary arteries), hypertension, abnormal heart valves, etc. A major complication of HF is fluid accumulation, as increased fluid volume puts more strain on the heart. Reducing foods high in sodium (cold cuts, potato chips) will reduce fluid retention.

A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse anticipates that the client will exhibit which findings on assessment of vital signs? 1.Increased heart rate and increased blood pressure 2.Increased heart rate and decreased blood pressure 3.Decreased heart rate and increased blood pressure 4.Decreased heart rate and decreased blood pressure

4 In hypothermia, metabolic need is decreased and cells slow down. With fewer metabolic needs, the workload of the heart decreases and HR and BP will drop.

A client is being discharged from the hospital after being treated for infective endocarditis. The nurse should provide the client with which discharge instruction? 1.Take antibiotics until the chest pain is fully resolved. 2.Take acetaminophen (Tylenol) if the chest pain worsens. 3.Use a firm-bristle toothbrush and floss vigorously to prevent cavities. 4.Notify all health care providers (HCP) of the history of infective endocarditis before any invasive procedures.

4 Infective carditis (IE) is a bacterial infection in the heart valves or endocardium (interior lining of the heart). The bacteria of IE usually enters through wounds in the mouth, enters the blood stream, and infects the heart. Option 1: Antibiotics should always be taken until full course is completed, not until symptoms resolve. Option 2: If chest pain worsens with IE, the patient needs to contact their HCP. Pain should resolve with antibiotic therapy and not get worse. Option 3: A soft tooth brush should be used to prevent trauma to the gums, which can be a portal of entry for a bacterial infection. Option 4: Patients with a history of IE or congenital heart defects need to notify their HCP prior to dental or oral surgery because these surgeries provide a port of entry for bacteria that can further damage the heart. These patients will be put on prophylactic antibiotics prior to surgery to prevent bacteremia (presence of bacteria in the blood stream).

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL, and fasting blood glucose level of 184 mg/dL. The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? 1.Age 2.Hypertension 3.Hyperlipidemia 4.Glucose intolerance

4 Modifiable risk factors for CAD include: hypertension, obesity, hyperlipidemia (>200), glucose intolerance, cigarette smoking, and stress. >40 years old is a non-modifiable risk factor.

A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? 1."It will really hurt when the catheter is first put in." 2."I will receive general anesthesia for the procedure." 3."I will have to go to the operating room for this procedure." 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."

4 Option 1: A local anesthetic is used to insert the catheter into an artery, so there should be little to no pain. Option 2: General anesthesia is not used for this procedure. Option 3: The procedure is done in a cardiac catheterization room, not the OR. Option 4: The procedure can take 1-2 hours and can be physically uncomfortable.

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1. Apnea monitor 2.Oxygen flowmeter 3.Telemetry cardiac monitor 4.Oxygen saturation monitor

4 Option 1: An apnea monitor is used to detect apneic episodes (when breathing stops). Option 2: An oxygen flowmeter is used as part of a setup for oxygen delivery therapy and does not monitor anything. Option 3: Telemetry is used to detect dysrhythmias and has nothing to do with O2 monitoring. Option 4: An Oxygen saturation monitor detects changes in light absorption between oxygenated and deoxygenated hemoglobin. An SaO2 reading is used to detect for hypoxemia (Oxygenated tissues <90% in non-COPD patients).

The home health nurse visits a client recovering from cardiogenic shock secondary to an anterior myocardial infarction and provides home care instructions to the client. Which statement by the client indicates an understanding of these home care measures? 1."I exercise every day after breakfast." 2."I've gained 8 pounds since discharge." 3."I take an antacid when I experience epigastric pain." 4."I have planned periods of rest at 10:00 am and 3:00 pm daily."

4 Option 1: Eating decreases systemic circulation, as more blood flow goes to the digestive tract to aid in digestion. Exercise should be completed after a meal is settled. Option 2: An 8 pound increase is significant, as it can mean the heart is not adequately pumping blood and fluid retention is occurring. Option 3: Epigastric pain can be a sign of a complication and should be reported to the HCP. Option 4: After a myocardial infarction, the heart will require time to heal and will need recover periods. Activities should be paced with planned rest periods added.

A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if the client's PVCs continued to exhibit which finding? 1.Occur in pairs 2.Appear to be multifocal 3.Fall on the second half of the T wave 4.Decrease to a frequency of less than 6 per minute

4 PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client's cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly dysrhythmias.

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1."I need to be sure not to go barefoot around the house." 2."If I cut my toenails, I need to be sure that I cut them straight across." 3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4."I need to be sure that I elevate my leg above my heart level for at least an hour every day."

4 Peripheral arterial disease (PAD) is a condition in which arterial blood flow is compromised to an extremity, causing ischemia, pain, numbness, coldness, ulcers, hair loss, shiny dry skin, decreased pulse, and intermittent claudication (pain during walking). It is caused by arterial occlusion or damage. Options 1, 2: Because blood flow to the extremity is decreased, the patient is at an increased risk of injury (decreased feeling will lead to more injuries, decreased blood flow will lead to poor healing). Option 3: Lanolin is a lotion to prevent dried, cracked skin. It should not be applied between toes, as it increases moisture and can cause a fungal infection. Option 4: PAD causes poor blood flow to the extremity, so elevating the limb will just exacerbate this condition. Elevating the limb is done with peripheral venous disease, in which there is decreased venous return from the limb.

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1.Sensation of palpitations 2.Causative factors, such as caffeine 3.Precipitating factors, such as infection 4.Blood pressure and oxygen saturation

4 Premature ventricular contractions are extra heart beats in the ventricles and disrupt regular heart rhythm. They are benign if they happen infrequently, but can cause cause hemodynamic compromise if they occur often. The clients current status should always be assessed prior to any other action.

A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and asks the nurse to describe the procedure. Which response should the nurse make? 1."It involves tying off the veins so that circulation is redirected in another area." 2."It involves surgically removing the varicosity, so anesthesia will be required." 3."It involves tying off the veins to prevent sluggishness of blood from occurring." 4."It involves injecting an agent into the vein to damage the vein wall and close it off."

4 Sclerotherapy is the injection of an agent that causes sclerosis (hardening) of the vein, causing thrombosis and vein closure. With no blood flow through the vessel, vein distention will no longer occur. The surgical procedure of tying off a vein, and then removing it using a hook/wires through small incisions is called vein ligation and stripping.

A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1.Limiting oral and intravenous fluids 2.Measuring the client's pulse each shift 3.Providing the client with short, frequent walks 4.Eliminating sources of caffeine from meal trays

4 Sinus tachycardia is an elevated sinus rhythm characterized by an increase in the rate of electrical impulses arising from the sinoatrial node (>100 bpm). Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Option 1: Limiting fluids will decrease fluid volume and lead to a decrease in blood pressure, not heart rate. Option 2: The client's pulse should be measured more than once per shift. Option 3: Exercise will further increase the patient's heart rate, and is contraindicated. Option 4: Caffeine can cause sinus tachycardia.

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), which laboratory result should the nurse review as the priority? 1.Sodium level 2.Digoxin level 3.Creatinine level 4.Potassium level

4 The effects of digoxin are increased with hypokalemia, so potassium levels need to be monitored to ensure the correct dosage of digoxin is given. Hypokalemia can occur with non-potassium sparing diuretics like furosemide.

A nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which response by the student indicates a need for further research on the anatomy and physiology of the heart? 1."The coronary arteries branch from the aorta." 2."The coronary arteries supply the heart muscle with blood." 3."The left coronary artery provides blood for the left atrium and the left ventricle." 4."The left coronary artery supplies the right atrium and right ventricle with blood."

4 The left coronary arteries provides blood to the left atrium and left ventricle.

The nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse should provide which information to the client? 1.Oxygen has a calming effect. 2.Oxygen will prevent the development of any thrombus. 3.Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle. 4.The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.

4 The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.

A nurse is caring for a client with unstable ventricular tachycardia. The nurse should instruct the client to take which action, if prescribed, during an episode of ventricular tachycardia? 1.Lie down flat in bed. 2.Remove any metal jewelry. 3.Breathe deeply, regularly, and easily. 4.Inhale deeply and cough forcefully every 1 to 3 seconds.

4 The patient is in a dysrhythmia. Restorative coughing techniques are sometimes used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking? 1."None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 2."Because most of the damage has already been done, it will be all right to cut down a little at a time." 3."If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

4 The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries.

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What should the nurse plan to teach the client about this type of angina? 1.It is most effectively managed by β-blocking agents. 2.It has the same risk factors as stable and unstable angina. 3.It can be controlled with a low-sodium, high-potassium diet. 4.Generally it is treated with calcium-channel-blocking agents

4 Variant angina causes chest pain by coronary artery spasms of unknown cause. It usually occurs at rest and follows a pattern (i.e. same time each day). Option 1: Beta blockers are contraindicated for variant angina, as their vasodilating effects can increase artery spasms. Option 2: The risk factors for variant angina are unknown. The risk factors for stable and unstable angina, however, are things that cause heart damage such as hypertension, hyperlipidemia, and a previous myocardial infarction. Option 3: A low sodium diet can decrease fluid retention, which will alleviate symptoms of heart failure such as pulmonary edema, but it will not help angina. Option 4: Calcium causes the heart and arteries to contract more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open. Nitrates (vasodilators) are ineffective with this type of angina.

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? 1.Oxygen saturation decreased from 96% to 91%. 2.Pulse rate increased from 80 to 104 beats per minute. 3.Blood pressure decreased from 140/86 to 112/72 mm Hg. 4.Respiratory rate increased from 16 to 19 breaths per minute.

4 Vital signs that remain near baseline indicate good cardiac reserve*. Option 1: Left-sided heart failure causes blood to back up in the pulmonary vein and into the lungs, causing pulmonary edema and decreased ability to breathe. A decrease in O2 sat indicate decreased tissue perfusion. Option 2: An increase in HR above the norm with mild exercise indicates activity intolerance. Option 3: A drop in BP of greater than 10 mmHg during mild exercise indicates activity intolerance. Option 4: An RR of 19 breaths per min is still within the normal rage (12-20 breaths per min). An increase in RR is normal and expected with any exercises, as long as it's not excessive. *cardiac reserve: difference between the rate at which the heart pumps blood and its maximum capacity for pumping blood

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? 1.Before each P wave 2.Just after each P wave 3.Just after each T wave 4.Before each QRS complex

4.If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted. A demand pacemaker fires only when needed and should therefore discharge only when no electrical activity is occurring in the client's own heart.

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse most anticipate in this client if PVCs are occurring?1.A P wave preceding every QRS complex2.QRS complexes that are short and narrow3.Inverted P waves before the QRS complexes4.Premature beats followed by a compensatory pause

4.PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.