Cardiovascular Disorders

A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process? a. "I will have the transplant coordinator speak with you to answer your questions." b. "There is never contact between the donor's family and the recipient." c. "The recipient is allowed to ask questions about the donor and have them answered." d. "It is important that the recipient knows how to reach the family of the donor if health problems arise after the transplant."

a. "I will have the transplant coordinator speak with you to answer your questions." Explanation: The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation processes, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.

The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin. The client has had 2 previous episodes of coronary artery disease. At the onset of chest pain, what should the client do? a. Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. b. Call 911 when five nitroglycerin tablets taken every 5 minutes are not effective. c. Take one tablet and then immediately call 911. d. Go to the emergency department if two nitroglycerin tablets taken 5 minutes apart are not effective.

a. Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. Explanation: Nitroglycerin tablets should be taken 5 minutes apart for three doses; if this is ineffective, 911 should be called to obtain an ambulance to take the client to the emergency department. The client should not drive or have a family member drive the client to the hospital.

A client receiving digoxin has a serum magnesium level of 0.9 mg/dL (0.57 mmol/L). What is the nurse's best action? a. Notify the healthcare provider. b. Administer the digoxin as prescribed. c. Encourage the client to increase fluids. d. Administer calcium gluconate.

a. Notify the healthcare provider. Explanation: The decreased magnesium level can potentiate digoxin toxicity, and the healthcare provider should be notified. The digoxin should not be administered until the nurse receives clarification from the healthcare provider. Increasing fluids is not appropriate. Calcium gluconate is administered for hypermagnesemia.

A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priority action? a. Obtain an order for furosemide 80 mg I.V. push. b. Obtain an order for calcium gluconate 2 g I.V. push over 2-5 minutes. c. Increase the rate of the client's I.V. fluid to 150 ml/hour. d. Arrange for an emergency hemodialysis session.

b. Obtain an order for calcium gluconate 2 g I.V. push over 2-5 minutes. Explanation: All the actions listed will reduce the serum magnesium concentration. The calcium gluconate will react the quickest to reduce the critical level.

A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. What other sign should the nurse assess next? a. hyperkalemia. b. digoxin toxicity. c. fluid deficit. d. pulmonary edema.

b. digoxin toxicity. Explanation: Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation and the client becomes unresponsive. The nurse should anticipate which intervention? a. an I.V. push of digoxin b. an I.V. line for emergency medications c. immediate defibrillation d. synchronized cardioversion

c. immediate defibrillation Explanation: When ventricular fibrillation is verified, the first intervention is defibrillation, which is the only intervention that will terminate this lethal dysrhythmia. Digoxin is not indicated for V-fib. An I.V. will be one of the priorities, but not first. The client would need to have a functional rhythm for synchronized cardioversion to be performed.

The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye? a. iris b. cornea c. retina d. sclera

c. retina Explanation: The retina is especially susceptible to damage in a client with chronic hypertension. The arterioles supplying the retina are damaged. Such damage can lead to vision loss. The iris, cornea, and sclera are not affected by hypertension.

A nurse is monitoring a client on the telemetry unit. The electrocardiogram tracing shows a PR interval of 0.22 seconds. What is the appropriate action of the nurse? a. Document the findings and continue to monitor the client. b. Contact the healthcare provider. c. Administer epinephrine. d. Administer oxygen via nasal cannula.

a. Document the findings and continue to monitor the client. Explanation: The PR interval normally ranges from 0.12 to 0.20 seconds. A reading of 0.22 seconds is first-degree heart block. The nurse should monitor the client and document the findings. The other interventions are not necessary at this time.

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. What should the nurse instruct the client to do? a. Climb the steps early in the day. b. Rest for at least an hour before climbing the stairs. c. Take a nitroglycerin tablet before climbing the stairs. d. Lie down after climbing the stairs.

c. Take a nitroglycerin tablet before climbing the stairs. Explanation: Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

A client with Raynaud's phenomenon is prescribed diltiazem. The nurse should assess the client for which intended outcome of this drug? a. increased heart rate b. less pain in extremities c. fewer episodes of numbness in the fingers d. lower serum calcium levels

c. fewer episodes of numbness in the fingers Explanation: Calcium channel blockers are first-line drug therapy for the treatment of vasospasms with Raynaud's phenomenon when other therapies are ineffective. Diltiazem relaxes smooth muscles and improves peripheral perfusion, thereby reducing finger numbness. Diltiazem reduces the heart rate; it does not increase it. Diltiazem does not directly reduce pain, but it does improve circulation. The intended outcome of diltiazem is not to decrease calcium levels.

An older adult takes two 81-mg aspirin tablets daily to prevent a heart attack. The client reports having a constant "ringing" in both ears. How should the nurse respond to the client's comment? a. Tell the client that "ringing" in the ears is associated with the aging process. b. Refer the client to have a Weber test. c. Schedule the client for audiometric testing. d. Explain to the client that the "ringing" may be related to the aspirin.

d. Explain to the client that the "ringing" may be related to the aspirin. Explanation: Tinnitus (ringing in the ears) is an adverse effect of aspirin. Aspirin contains salicylate, which is an ototoxic drug that can induce reversible hearing loss and tinnitus. The nurse should explain this to the client and then encourage the client to inform the health care provider (HCP) of the symptom. Tinnitus is not a function of aging. The Weber test and audiometric testing are useful for determining hearing loss but are not necessarily helpful in the management or diagnosis of drug-induced tinnitus.

The nurse is evaluating a client who received tissue plasminogen activator (t-PA) following a myocardial infarction (MI). What is the expected outcome of this drug? a. Control chest pain. b. Reduce coronary artery vasospasm. c. Control the arrhythmias associated with MI. d. Revascularize the blocked coronary artery.

d. Revascularize the blocked coronary artery. Explanation: The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.

The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client reports anxiety because of receiving less monitoring than in the CCU. How can the nurse allay the client's fears? a. Assign the same nurse to the client when possible. b. Obtain an order for an antianxiety medication. c. State that the client would not have been moved out of CCU in an unstable condition. d. Move the client to a room far from the nurses' station to reduce exposure to noise.

a. Assign the same nurse to the client when possible. Explanation: Assigning the same nurse when possible provides continuity of care and stability, thereby reducing the client's anxiety. An anxiolytic might be counterproductive and "overkill;" the client needs reassurance first. The client might have been the "most stable" choice in the event of an urgent need for a CCU bed. A room close to nurses' station would provide this client with a sense of security because the nurses are close by in the event of an emergency.

The nurse is assigned a client who is postoperative from a permanent pacemaker insertion. Which intervention would be important in prevention of dislodgement of the pacing electrode? a. Restricting activity of the client's left side. b. Restricting oral fluid intake. c. Measuring vital signs and urine output hourly. d. Administering pain medication routinely.

a. Restricting activity of the client's left side. Explanation: In the postoperative period, dislodgement of the pacing electrode is the most common complication. The intervention that will help prevent dislodgement of the pacing electrode is restricting activity of the client's left side; this minimizes activity and many clients wear a sling to immobilize the left arm and shoulder. Fluid intake may be needed if the client has been NPO for the procedure and decreasing fluid does not have an impact. The client will have vital signs and urine output monitored in the post-anesthesia care unit, but will likely go home as this is an outpatient procedure if done electively. The client will need pain medication but should take it on an as-needed basis for comfort after the procedure.

A nurse assigns beds to four new clients admitted to the cardiac telemetry floor. Which client should the nurse assign to the bed farthest from the nurses' station? a. a 24-year-old client with unstable hyperthyroidism and sinus tachycardia b. a 38-year-old client with mitral valve prolapse in sinus rhythm who is newly diagnosed with diabetes c. a 48-year-old client in sinus rhythm transferring from intensive care unit 3 days after coronary artery bypass grafting (CABG) d. an 80-year-old client with sinus tachycardia who is confused and agitated 2 days after a prostatectomy

a. a 24-year-old client with unstable hyperthyroidism and sinus tachycardia Explanation: The client with hyperthyroidism is probably irritable and anxious and needs uninterrupted rest. The nurse should assign this client to a quiet room away from the noise at the nurses' station. The client who had a CABG is most likely to develop an arrhythmia on the third postoperative day. The unstable client with diabetes mellitus could experience hypoglycemia or hyperglycemia and requires frequent monitoring of blood glucose levels. The elderly client is confused and agitated. The nurse should assign these three clients to beds as close to the nurses' station as possible.

The nurse is preparing the client newly diagnosed with peripheral arterial disease for discharge with the medication atorvastatin. What laboratory work should the nurse obtain to establish a baseline before starting the medication? a. creatinine level and liver function tests b. white blood cell count and blood sugar c. hemoglobin and hematocrit levels d. platelet count and urinalysis

a. creatinine level and liver function tests Explanation: Atorvastatin has serious adverse reactions of hepatotoxicity and acute renal failure, so it is recommended that creatinine level and liver function tests be performed at baseline as a monitoring parameter. Diabetes, upper respiratory infections, urinary tract infections, anemia, and thrombocytopenia can also be adverse reactions, but these are not included in recommendations for baseline safety monitoring.

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first? a. the client with heart failure who is having some difficulty breathing b. the anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today c. the coronary bypass client asking for pain medication for "11 of 10" pain in the donor site d. the client admitted during the previous shift with new-onset controlled atrial fibrillation, who has a call light on

a. the client with heart failure who is having some difficulty breathing Explanation: The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs an analgesic, but that does not take priority over a client with difficulty breathing.

A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral arterial disease. The health care provider (HCP) started the client on pentoxifylline once daily. Approximately 1 hour after receiving the initial dose of pentoxifylline, the client reports having chest pain. The nurse should first: a. advise the client to rest. b. Inform the HCP. c. have the client rest in bed. d. start an intravenous infusion of normal saline.

b. Inform the HCP. Explanation: Angina is an adverse reaction to pentoxifylline, which should be used cautiously in clients with CAD. The nurse should report the client's symptoms to the HCP , who may prescribe nitroglycerin and possibly discontinue the pentoxifylline. The client should rest until the chest pain subsides. It is not necessary at this point to initiate the rapid response team or start an intravenous infusion. The client's reports of symptoms should never be dismissed.

A client with end-stage heart failure is preparing for discharge. The client and their caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave the client feeling isolated. Which suggestion by the home care nurse best addresses this concern? a. Place a chair in the bedroom so guests can visit with the client. b. Set up the hospital bed in the family room so the client can be part of household activities. c. Set up the hospital bed in the bedroom so the client can rest in a quiet environment. d. Set up the hospital bed in the bedroom so the client can be assessed in a quiet environment.

b. Set up the hospital bed in the family room so the client can be part of household activities. Explanation: The client should be kept actively involved in the household to prevent feelings of isolation. This can be accomplished by setting up the hospital bed in the family room. Placing a chair in the bedroom allows the client periods of isolation when visitors aren't present. It's important for the client to have periods of rest; however, rest can be accomplished without keeping the client isolated in a bedroom. The needs of the client should be considered before the needs of the nurse who assesses the client during an occasional visit.

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as a. a first heart sound (S1). b. a third heart sound (S3). c. a fourth heart sound (S4). d. a murmur.

b. a third heart sound (S3). Explanation: An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.

Which assessment finding supports the administration of protamine sulfate? a. RBCs of 5.4 million/mm3 b. aPTT 3.5-5 times normal c. platelets of 152 d. INR 8

b. aPTT 3.5-5 times normal Explanation: Protamine sulfate is the antidote specific to heparin. The RBC, and platelet levels are normal. Normal aPTT in heparinized clients is 2-2.5 times normal. INR measurement relates to therapy with warfarin, not heparin. An INR value of 8 is abnormally high and would likely require administration of vitamin K, the antidote for warfarin.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? a. phytonadione (vitamin K) b. protamine sulfate c. thrombin d. plasma protein fraction

b. protamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

A client with migraine headaches and a history of angina asks the nurse why the health care provider does not prescribe one of the newer medications for migraine, such as sumatriptan. The nurse responds that: a. these drugs are very expensive. b. sumatriptan is contraindicated in clients with angina. c. sumatriptan is used only for prophylactic treatment of migraines. d. sumatriptan is used only for migraines with an aura.

b. sumatriptan is contraindicated in clients with angina. Explanation: Sumatriptan is contraindicated in clients with ischemic heart disease, such as angina, myocardial infarction, or coronary artery disease, because it is a vasoconstrictor.The cost of the medication is not the concern at this time; the drugs are contraindicated because of the client's history of angina.Sumatriptan is used for the abortive treatment of migraines, not prophylactic treatment, and it is effective in treating acute migraines with or without aura.

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because a. the client is experiencing heart failure. b. the client is going into cardiogenic shock. c. the client shows signs of aneurysm rupture. d. the client is in the early stage of right-sided heart failure.

b. the client is going into cardiogenic shock. Explanation: This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following their therapeutic regimen? a. Total cholesterol level increases from 250 mg/dl to 275 mg/dl (6.48 mmol/L to 7.12 mmol/L). b. Low density lipoproteins (LDL) increase from 180 mg/dl (4.66 mmol/L to 190 mg/dl (4.92 mmol/L). c. High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). d. Triglycerides increase from 225 mg/dl (5.83 mmol/L) to 250 mg/dl (6.47 mmol/L).

c. High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). Explanation: The goal of treating hyperlipidemia is to decrease total cholesterol and LDL levels while increasing HDL levels. HDL levels should be greater than 35 mg/dl. This client's increased HDL levels indicate that the client followed the therapeutic regimen. Recommended total cholesterol levels are below 200 mg/dl. LDL levels should be less than 160 mg/dl, or, in clients with known coronary artery disease (CAD) or diabetes mellitus, less than 70 mg/dl. Triglyceride levels should be between 100 and 200 mg/d.

The nurse is caring for a group of clients. Which client should the nurse see first? a. a client with a history of sinus tachycardia who is to receive a beta-blocker b. a client with stable angina who took one sublingual nitroglycerine 30 minutes ago c. a client with a placement of a coronary artery stent 30 minutes ago d. a client with new onset of atrial fibrillation who has a heart rate of 95

c. a client with a placement of a coronary artery stent 30 minutes ago Explanation: The client who has just returned from having a stent placed in a coronary artery should be seen first. The nurse should assess this client to establish a baseline. Risks associated with a stent placement include a reocclusion, cardiac tamponade, dysrhythmias, bleeding, and thrombosis. While a new onset of atrial fibrillation is a concern, this client's heart rate is less than 100 bpm and is not showing signs of being hemodynamically unstable. A client with a history of sinus rhythm who will receive a beta-blocker is not a higher priority. While a client with stable angina who took a sublingual nitroglycerine 30 minutes ago will need to be assessed frequently, there is no evidence to suggest this client is currently experiencing chest pain.

A client develops atrial fibrillation following an acute myocardial infarction. The physician orders digoxin, 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to a. an increased serum creatinine level. b. a decreased serum digoxin level. c. an increased serum creatine kinase (CK) level. d. a decreased serum CK level.

c. an increased serum creatine kinase (CK) level. Explanation: I.M. administration of digoxin isn't recommended because it causes severe pain at the injection site and increases serum CK, which complicates interpretation of enzyme levels. Regardless of the route of administration, digoxin doesn't increase the serum creatinine level. When digoxin is administered, the serum digoxin level will rise from zero, not decrease.

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? a. prolonged PR interval b. absent Q wave c. elevated ST segment d. widened QRS complex

c. elevated ST segment Explanation: Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should a. place a heating pad around the affected calf. b. elevate the affected leg as high as possible. c. keep the affected leg level or slightly dependent. d. shave the affected leg in anticipation of surgery.

c. keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review? a. reducing the intake of unsaturated fats, participating regularly in anaerobic burst training activity, and increasing fluid intake b. reducing the intake of calcium and increasing the intake of sodium, and incorporating rest periods c. reducing cholesterol levels, increasing activity levels progressively, and coping strategies d. increasing homocysteine levels, reducing weight, and a sedentary lifestyle

c. reducing cholesterol levels, increasing activity levels progressively, and coping strategies Explanation: Cardiac rehabilitation is designed to assist the client in regaining functioning gradually. It also includes heart-healthy information such as dietary changes, a progressive increase in activity, and effective coping strategies for stress reduction. The emphasis is on lifestyle changes and reducing the risk of recurrence. The information related to unsaturated fats and participation in burst training is inaccurate. There is no need to reduce calcium intake and sodium is not increased. Homocysteine levels should be decreased, not increased.

A client who requested a do-not-resuscitate (DNR) order upon admission to the hospital now states a desire for the medical team to do everything possible to help the client get better. The client is concerned about the DNR order. Which response by the nurse is best? a. "Do you want to rescind the DNR, or just change it?" b. "You know that we will do everything needed to keep you comfortable even though you have the DNR in place." c. "Have you talked this over with your family?" d. "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."

d. "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." Explanation: Telling the client that it is not a problem to rescind the order is the best response. The client is allowed to rescind a DNR order at any time. The client makes the decision about a DNR order with input from the physician and does not need to talk to family members. The nurse should not imply with a question that perhaps revising the DNR would be more appropriate than rescinding it. The client has not expressed concern about feeling discomfort, so it would be inappropriate for the nurse to address that concern.

A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Immediately following surgery, what should the nurse do as a priority to prevent infection? a. Assess the temperature in the right arm. b. Monitor the radial pulse in the right arm. c. Protect the extremity from cold. d. Avoid using the arm for a venipuncture.

d. Avoid using the arm for a venipuncture. Explanation: If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.

The client has had a myocardial infarction, and the nurse has instructed the client to prevent Valsalva's maneuver. The nurse determines the client is following the instructions when the client: a. assumes a side-lying position. b. clenches the teeth while moving in bed. c. drinks fluids through a straw. d. avoids holding the breath during activity.

d. avoids holding the breath during activity. Explanation: Valsalva's maneuver, or bearing down against a closed glottis, can best be prevented by instructing the client to exhale during activities such as having a bowel movement or moving around in bed.Valsalva's maneuver is not prevented by having the client assume a side-lying position.Clenching the teeth will likely contribute to Valsalva's maneuver, not inhibit it.Drinking fluids through a straw has no effect on preventing or causing Valsalva's maneuver.

The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should: a. apply a half-leg pneumatic compression device. b. suggest the client contact her health care provider. c. assess the client for foot ulcers. d. encourage the client to avoid standing in one position for long periods of time.

d. encourage the client to avoid standing in one position for long periods of time. Explanation: The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distended veins, but there is no indication that the client should contact the health care provider at this point in time. The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time.

What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? a. cardiac pacemaker b. hypothermia-hyperthermia machine c. defibrillator d. intra-aortic balloon pump

d. intra-aortic balloon pump Explanation: Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.

Which client has a need for prophylactic antibiotic therapy prior to dental manipulations? a. the client who had a TKR (total knee replacement) one year ago b. the client who had a left THR (total hip replacement) 3 months ago c. the client who had an in ICD (implantable cardiac defibrillator) 2 weeks ago d. the client who had an aortic valve replacement 5 years ago

d. the client who had an aortic valve replacement 5 years ago Explanation: A heart valve prosthesis such as an aortic valve replacement is a major risk factor for the development of infective endocarditis. Preventative measures include antibiotic prophylaxis prior to dental work. Other implanted devices (hip, knee, ICD) can increase the risk of infection, but the client with the greatest risk is the one with the valve replacement.

When teaching the client with hypertension to avoid orthostatic hypotension, the nurse should provide which instructions? Select all that apply. - Plan regular times for taking medications. - Arise slowly from bed. - Avoid standing still for long periods. - Avoid excessive alcohol intake. - Avoid hot baths.

- Arise slowly from bed. - Avoid standing still for long periods. Explanation: Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management, but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.

The nurse is assessing a client who is at risk for cardiac tamponade from chest trauma sustained in a motorcycle accident. What is the client's pulse pressure if the blood pressure is 108/82 mm Hg? Record your answer using a whole number.

26 Explanation: Pulse pressure is the difference between systolic and diastolic pressures. Normally, systolic pressure exceeds diastolic pressure by approximately 40 mm Hg. Narrowed pulse pressure, a difference of less than 30 mm Hg, is a sign of cardiac tamponade.

A client is receiving cilostazol for intermittent claudication. What should the nurse ask the client to determine the effectiveness of the drug? a. "Do you have less pain in the legs?" b. "Can you wiggle your toes?" c. "Are you urinating more frequently?" d. "Do you experience less dizziness?"

a. "Do you have less pain in the legs?" Explanation: Cilostazol improves blood flow, and the client should have improved circulation in the legs as evident by less pain. The client does not have nerve impairment and should be able to wiggle the toes. Urination is not improved by taking cilostazol. Dizziness is a side effect of the drug, not an intended outcome.

A client with chest pain is prescribed intravenous nitroglycerin. Which finding is of greatestconcern for the nurse initiating the nitroglycerin drip? a. Serum potassium is 3.5 mEq/L (3.5 mmol/L). b. Blood pressure is 88/46 mm Hg. c. ST elevation is present on the electrocardiogram. d. Heart rate is 61 bpm.

b. Blood pressure is 88/46 mm Hg. Explanation: Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain, and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of: a. cerebral bleeding. b. I.M. injection. c. myocardial necrosis. d. skeletal muscle damage due to a recent fall.

c. myocardial necrosis. Explanation: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

A physician has scheduled a client with mitral stenosis for mitral valve replacement. Which condition may arise as a complication of mitral stenosis? a. left-sided heart failure b. myocardial ischemia c. pulmonary hypertension d. left ventricular hypertrophy

c. pulmonary hypertension Explanation: Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include mural thrombi, pulmonary hemorrhage, and embolism to vital organs. Myocardial ischemia may occur in a client with coronary artery disease. Left ventricular hypertrophy is a potential complication of aortic stenosis.

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect? a. left-sided heart failure b. aortic regurgitation c. complete heart block d. pericardial tamponade

d. pericardial tamponade Explanation: A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (a pulse amplitude alteration from beat to beat, with a regular rhythm). Aortic regurgitation may cause a bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm? a. The blood pressure and pulse are within normal limits, but the client's skin color is pale and slightly diaphoretic. b. The client reports feeling nauseated. c. The client has been taking an antihypertensive for the past 3 years but forgot to take it today. d. The client reports increasing severe back pain.

d. The client reports increasing severe back pain. Explanation: Increased severe back pain and increased irritation to nerves are indicative of a potential rupture of an aneurysm. The client would be hypertensive and present with tachycardia, so the other choices are not correct. Nausea, although possible, or a missed dose of medication, do not indicate potential rupture.

Which client statement should the nurse evaluate as indicating the client's correct understanding of the causes of coronary artery disease (CAD)? a. "The leading cause of CAD is atherosclerosis." b. "There are many causes of CAD." c. "Cigarette smoking is the most common cause of CAD." d. "I will need to ask my healthcare provider about the causes of CAD."

a. "The leading cause of CAD is atherosclerosis." Explanation: Atherosclerosis (plaque formation) is the leading cause of CAD. Cigarette smoking is the leading cause of lung cancer. Telling the client to ask the healthcare provider is not appropriate.

A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. The nurse suspects that these assessment findings are most probably due to the client experiencing a specific type of MI known as a. anterior. b. posterior. c. lateral. d. inferior.

a. anterior. Explanation: An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. Posterior, lateral, and inferior MI aren't usually associated with heart failure.

A client with angina shows the nurse the nitroglycerin tablets that the client carries in a plastic bag in a pocket. Where should the nurse teach the client to keep the nitroglycerin tablets? a. in the refrigerator b. in a cool, moist place c. in a dark container to shield from light d. in a plastic pill container where it is readily available

c. in a dark container to shield from light Explanation: Nitroglycerin in all dosage forms (sublingual, transdermal, or intravenous) should be shielded from light to prevent deterioration. The client should be instructed to keep the nitroglycerin in the dark container that is supplied by the pharmacy, and it should not be removed or placed in another container.

The nurse evaluates the client's understanding of nutritional modifications to manage hypertension. The nurse knows the teaching was successful when the client makes what statement? a. "A glass of red wine each day will lower my blood pressure." b. "I should eliminate caffeine from my diet to lower my blood pressure." c. "If I include less fat in my diet, I'll lower my blood pressure." d. "Limiting my salt intake to 2 grams per day will lower my blood pressure."

d. "Limiting my salt intake to 2 grams per day will lower my blood pressure." Explanation: To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Chronic, moderate caffeine intake and fat intake do not affect blood pressure.

A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply. - Provide oxygen. - Administer nitroglycerin. - Administer aspirin. - Insert a Foley catheter. - Administer morphine. - Administer acetaminophen

- Provide oxygen. - Administer nitroglycerin. - Administer aspirin. - Administer morphine. Explanation: When emergently managing chest pain, the nurse can use the memory mnemonic MONA to plan care: morphine, oxygen, nitroglycerin, and aspirin. A Foley catheter is not included in the emergent management of chest pain and can be inserted when the pain has been relieved and the client is stable. Acetaminophen is not used to manage chest pain.

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a. brachial artery b. radial artery c. aorta d. right ventricular wall

c. aorta Explanation: Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall.

A client taking newly prescribed metoprolol asks the nurse what medication to take for a headache. What is the nurse's best response? a. aspirin b. ibuprofen c. acetaminophen d. indomethacin

c. acetaminophen Explanation: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) counteract the blood pressure reducing effects of beta blockers by reducing the effects of prostaglandins. Acetaminophen is the best medicine for this client to take for a headache.

A client with a ventricular dysrhythmia is receiving intravenous lidocaine. For which assessment finding should the nurse suspect the client is experiencing toxicity from the medication? a. nausea and vomiting b. pupillary changes c. confusion and restlessness d. hypertension

c. confusion and restlessness Explanation: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine or tocainide — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.

A client's electrocardiogram (EKG) tracing shows normal sinus rhythm followed by three premature ventricular contractions (PVCs) and a return to normal sinus rhythm. What is the priority action of the nurse? a. Assess the client's apical-radial pulse rate. b. Assess the client's blood pressure. c. Administer oxygen. d. Administer amiodarone.

a. Assess the client's apical-radial pulse rate. Explanation: Nonsustained ventricular tachycardia is several consecutive PVCs followed by the return to normal sinus rhythm. PVCs may reduce the CO and lead to angina and heart failure depending on frequency. Because PVCs in CAD or acute MI indicate ventricular irritability the nurse should first assess the client's physiologic response to PVCs by obtaining the client's apical-radial pulse rate, since PVCs often do not generate a sufficient ventricular contraction to result in a peripheral pulse. This can lead to a pulse deficit. Assessment of the client's hemodynamic status is important to determine if treatment with drug therapy is needed. Treatment relates to the cause of the PVCs such as oxygen therapy for hypoxia, electrolyte replacement, and drug therapy includes beta-adrenergic blockers, procainamide, or amiodarone.

The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? a. dopamine b. enalapril c. furosemide d. metoprolol

a. dopamine Explanation: Cardiogenic shock is when the heart has been significantly damaged and is unable to supply enough blood to the organs of the body. Dopamine, a sympathomimetic drug, improves myocardial contractility and blood flow through vital organs by increasing perfusion pressure. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and does not have a direct effect on contractility or tissue perfusion. Metoprolol is a adrenergic blocker that slows heart rate and lowers blood pressure; neither is a desired effect in the treatment of cardiogenic shock.

The nurse is evaluating arterial wave formation from an arterial line and notes a slow upstroke. What is the best action by the nurse? a. Auscultate heart sounds. b. Auscultate lung sounds. c. Assess wrist for hyperextension. d. Assess capillary refill time.

a. Auscultate heart sounds. Explanation: A slow upstroke can be indicative of aortic stenosis. The nurse should auscultate heart sounds for signs and symptoms of aortic stenosis such as prolonged systolic ejection murmur and paradoxical splitting of S2 heart sound. Auscultating lung sounds will not provide information relevant to stenosis of the aorta. Assessment of the wrist for hyperextension would be appropriate if the client were exhibiting tingling or numbness in the fingers. Assessing capillary refill time would be appropriate if the client were exhibiting signs/symptoms of decreased perfusion to the hand.

An older adult is admitted to the hospital with sudden onset of severe pain in the back, flank, and abdomen. The client reports feeling weak; the blood pressure is 68/31 mm Hg. There has been no urine output. Bilateral leg pulses are weak, although bruit and pulsation are noted at the umbilicus. What should the nurse do first? a. Obtain consent for emergency surgery. b. Assess leg pulses with a Doppler test. c. Palpate the abdomen for presence of a mass. d. Start an IV infusion.

d. Start an IV infusion. Explanation: The symptoms noted are classic symptoms of leaking abdominal aneurysm and shock; the client needs immediate fluid volume replacement. Assessing the pulses with a Doppler will be of no additional diagnostic value. Palpating the abdomen on a client with a suspected abdominal aneurysm is contraindicated and could lead to rupture. After emergency fluid resuscitation, consent for surgery is needed.