Cardiovascular Disorders

A nurse administers the first dose of nadolol to a client with a blood pressure of 180/96. During an assessment 4 hours later, which information indicates that the client needs immediate intervention? The client's heart rate has decreased from 88 to 76 beats/minute. The client has cool fingers and toes bilaterally. The client has wheezing throughout the lung fields. The client's blood pressure (BP) is 142/90 mm Hg.

The client has wheezing throughout the lung fields. Explanation: Wheezing indicates the client is experiencing bronchospasms, which are a common adverse effect of a noncardioselective beta blocker. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the healthcare provider. The other symptoms are all expected effects of nadolol.

A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client? "You'll continue to take your medications until the morning of the test." "During the procedure, the health care provider will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms." "The test is a noninvasive method of determining the effectiveness of your medication regimen." "You might be sedated during the procedure and won't remember what's happened."

"During the procedure, the health care provider will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms." Explanation: The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce arrhythmia. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antiarrhythmic medications are held for at least 24 hours before the test to study the arrhythmia without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.

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 glass of red wine each day will lower my blood pressure." "I should eliminate caffeine from my diet to lower my blood pressure." "Limiting my salt intake to 2 grams per day will lower my blood pressure." "If I include less fat in my diet, I'll lower my blood pressure."

"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 scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client? "PTCA involves passing a catheter through the coronary arteries to find blocked arteries." "PTCA involves inserting grafts to divert blood from blocked coronary arteries." "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." "PTCA involves cutting away blockages with a special catheter."

"PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." Explanation: PTCA is best described as the insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. Cutting away blockages with a special catheter is an atherectomy. Passing a catheter through the coronary arteries to find blocked arteries is a cardiac catheterization. Inserting grafts to divert blood from blocked arteries describes coronary artery bypass graft surgery.

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

"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.

The nurse is providing discharge instructions to a client with peripheral venous disease. The nurse should include which information in the discussion with this client? Select all that apply. Keep extremities elevated on pillows. Limit walking so as not to activate the "muscle pump." Keep the legs in a dependent position. Use a heating pad to promote vasodilation. Avoid prolonged standing and sitting.

Avoid prolonged standing and sitting. Keep extremities elevated on pillows. Explanation: Elevating the extremities counteracts the forces of gravity, promotes venous return, and reduces venous stasis, so the client would not be encouraged to keep the legs in a dependent position. Walking is encouraged to activate the muscle pump and promote collateral circulation. Prolonged sitting and standing lead to venous stasis and should be avoided. Although heat promotes vasodilation, the use of a heating pad is to be avoided to reduce the risk for thermal injury secondary to diminished sensation.

A visiting nurse is teaching a client with heart failure about taking their medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? Come to the client's house each morning to prepare the daily allotment of medications. Ask the client's family to take turns coming to the house at each administration time to assist the client with their medications. Ask the physician if the client can take fewer pills each day. Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications.

Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications. Explanation: The nurse should intervene by asking a family member to fill a compliance aid each week with the client's weekly supply of medications in the appropriate time slots. Family members can't be expected to come to the client's house four times each day to administer medications. The physician shouldn't change the dosing regimen just for convenience. The home care nurse can't visit the client each morning to prepare the daily medication regimen.

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? The client reports increasing severe back pain. The client reports feeling nauseated. The client has been taking an antihypertensive for the past 3 years but forgot to take it today. The blood pressure and pulse are within normal limits, but the client's skin color is pale and slightly diaphoretic.

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.

A nurse is caring for a client returning from cardiac catheterization. The nurse helps transfer the client back to bed. Which transfer technique uses appropriate ergonomic principles? The nurse maintains a narrow base of support during transfer and encourages the client to hold onto the staff members if the client is frightened. The nurse explains the procedure to the client and grabs the client under the arms to pull them over to the bed. The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room. The nurse lowers the bed for transfer. The nurse raises the bed before leaving the room, making sure to place the call light within reach.

The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room. Explanation: The nurse should raise the bed for transfer, maintain a wide base of support during transfer, and lower the bed before leaving the room. Lowering the bed for a transfer places the nurse at risk for injury. Raising the bed before leaving the room places the client at risk for injury. The nurse should maintain a wide base of support for transfers and shouldn't encourage the client to grab or hold onto staff members during transfers. Although the nurse should explain the procedure to the client, the nurse shouldn't grab the client under the arms. This action could cause shoulder injury or nerve damage. The nurse shouldn't pull a client during transfers; doing so places the client at risk for skin-shear injuries.

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute kidney failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is: a decrease in the blood flow through the kidneys." an obstruction of urine flow from the kidneys." a blood clot that formed in the kidneys." structural damage to the kidney."

a decrease in the blood flow through the kidneys." Explanation: There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.

After evaluating a client for hypertension, a physician orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have? decreased blood pressure with reflex tachycardia decreased peripheral vascular resistance decreased cardiac output and decreased systolic and diastolic blood pressure increased cardiac output and increased systolic and diastolic blood pressure

decreased cardiac output and decreased systolic and diastolic blood pressure Explanation: As a long-acting, selective beta1-adrenergic blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blockers, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.

Which signs and symptoms accompany a diagnosis of pericarditis? fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) lethargy, anorexia, and heart failure pitting edema, chest discomfort, and nonspecific ST-segment elevation low urine output secondary to left ventricular dysfunction

fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) Explanation: The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction lethargy, anorexia, heart failure and pitting edema do not result from acute renal failure.

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level? respiratory rate blood pressure pulse rate body temperature

pulse rate Explanation: The client who is on a progressive exercise program at home after a myocardial infarction should be taught to monitor the pulse rate. The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The client should also be taught to discontinue exercise if chest pain occurs.

While transferring a load of firewood from the front driveway to the backyard woodpile at 11 a.m., the client experienced a heaviness in the chest and dyspnea. The client stopped working and rested, and the pain subsided. At noon, the pain returned. At 12:30 p.m., the client's spouse took the client to the emergency department. Around 1:30 p.m., the health care provider diagnosed an anterior myocardial infarction (MI). The nurse should anticipate which orders by the health care provider? morphine administration, stress testing, and admission to the cardiac care unit serial liver enzyme testing, telemetry, and a lidocaine infusion sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry streptokinase, aspirin, and morphine administration

sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry Explanation: The nurse should anticipate an order for sublingual nitroglycerin, tPA, and telemetry. The tPA is appropriate because the client's chest pain began less than 3 hours before diagnosis. The tPA is more specific for cardiac tissue than streptokinase. Stress testing should not be performed during an MI. The client does not exhibit symptoms that indicate the use of lidocaine. Lidocaine is usually used as an anesthetic and is also used for acute treatment of ventricular arrhythmia, but anterior myocardial infarction results from reduction in blood supply to the anterior wall of the heart due to coronary artery occlusion.

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

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.

The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client who is inquiring about the purpose of the new diet? to address the fluctuation in blood sugar to improve the gastric acidity of the stomach to reduce the metabolic workload of digestion to reduce the amount of fecal elimination

to reduce the metabolic workload of digestion Explanation: Acute care of the client with an MI is aimed at reducing the cardiac workload. Clear liquids are easily digested to help reduce this workload. Sympathetic nervous system involvement causes decreased peristalsis and gastric secretion, so limiting food intake helps prevent gastric distension and cardiac workload. A clear diet will not reduce gastric acidity or blood glucose, and fecal elimination will still occur, so these are incorrect choices.

A client is to have a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory value to the health care provider (HCP) before the stress test? prothrombin time troponin level cholesterol level erythrocyte sedimentation rate

troponin level Explanation: The elevated troponin level should be reported to the HCP before the stress test because this change indicates myocardial damage. Sending the client to walk on a treadmill for stress testing would be contraindicated with evidence of recent myocardial injury and could further extend the damage. The other blood levels are helpful but not critical to this client's welfare at this point in time.

A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The health care provider (HCP) has prescribed 60 mg of enoxaparin subcutaneously. Before administering the drug, the nurse checks the client's laboratory results. (See image.) Based on these results, what should the nurse do? Assess the client for signs of bruising on the extremities. Withhold the dose of the medication, and contact the HCP. Administer the medication as prescribed. Contact the pharmacist for a lower dose of the medication.

Withhold the dose of the medication, and contact the HCP. Explanation: Based on the laboratory findings, the prothrombin time and the INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should contact the HCP before administering the next dose. The nurse should not administer the drug until the HCP has been contacted. The HCP, not the pharmacist, will decide the dose of the enoxaparin. The decision about administering the drug will be based on laboratory results, not evidence of bruising or bleeding.

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

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 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? Document the findings and continue to monitor the client. Administer epinephrine. Contact the healthcare provider. Administer oxygen via nasal cannula.

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.

The nurse observes that an older female client has small-to-moderate, distended, and tortuous veins running along the inner aspect of their lower legs. What should the nurse do? Assess the client for foot ulcers. Apply a half-leg pneumatic compression device. Encourage the client to avoid standing in one position for long periods of time. Suggest the client contact her health care provider.

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 they stand 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.

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include? "Client will verbalize the intention to avoid exercise." "Client will verbalize the intention to stop smoking." "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol." "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours."

"Client will verbalize the intention to stop smoking." Explanation: A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).

A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take? Defibrillate the client. Assess the client's airway, breathing, pulses, and level of conciseness. Apply the external pacemaker. Begin cardiopulmonary resuscitation (CPR).

Assess the client's airway, breathing, pulses, and level of conciseness. Explanation: If the client is experiencing ventricular tachycardia, the priority for the nurse is to assess the client's airway, breathing, and level of consciousness before any further action is taken.

A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client? Contact a surgeon to perform a femoral-popliteal bypass graft. Keep the legs elevated when sitting or lying down. Undergo sclerotherapy for cosmetic improvement. Avoid walking to reduce the discomfort.

Keep the legs elevated when sitting or lying down. Explanation: The nurse instructs the client to elevate the legs to improve venous return and alleviate discomfort. Walking is encouraged to increase venous return. Sclerotherapy or laser treatment is done for cosmetic reasons, but it does not improve circulation. Surgery may be performed for severe venous insufficiency or recurrent thrombophlebitis in the varicosities. A femoral-popliteal bypass graft is a surgical intervention for arterial disease.

The nurse reviews the morning laboratory results from a female client admitted with deep vein thrombosis. The client is receiving intravenous heparin. Based on the client's current laboratory values, what should the nurse do? Encourage the client to drink 3500 mL of fluids daily. Maintain the current rate of the heparin infusion. Monitor oxygen saturation levels every 4 hours. Notify the health care provider (HCP) about the increased liver enzymes.

Maintain the current rate of the heparin infusion. Explanation: An aPTT of 65 seconds is considered therapeutic with a control of 30 seconds. Therapeutic levels for heparin are 1.5 to 2.5 times the control, which would make the therapeutic level between 45 and 75 seconds. The nurse should continue the infusion at the current rate and continue to monitor the client. The liver enzymes (AST, ALT) are within normal range; it is not necessary to notify the HCP. The BUN and creatinine levels are within normal limits; the client does not need to increase fluid intake beyond 3000 mL. The hemoglobin and hematocrit are within normal limits; it is not necessary to obtain frequent oxygen saturation levels.

The client has had hypertension for 20 years. The nurse should assess the client for? Peptic ulcer disease. Renal insufficiency and failure. Endocarditis. Valvular heart disease.

Renal insufficiency and failure. Explanation: Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.

The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hours ago. Which finding warrants further evaluation? a blood urea nitrogen (BUN) level of 26 mg/dL (26 mmol/L) and a creatinine level of 1.2 mg/dL (1.2 μmol/L) an arterial blood pressure of 80/50 mm Hg absent bowel sounds and mild abdominal distention +1 pedal pulses in the bilateral lower extremities

an arterial blood pressure of 80/50 mm Hg Explanation: A blood pressure of 80/50 mm Hg in a client who has just had surgical repair of an abdominal aortic aneurysm warrants further evaluation as this indicates decreased perfusion to the brain, heart, and kidneys. A BUN level of 26 mg/dL (26 mmol/L) and a creatinine level of 1.2 mg/dL (1.2 μmol/L) are normal findings. While +1 pedal pulses may be an abnormal finding, it is not uncommon, and it is important to compare this finding with previous assessments and note any change in the strength of the pedal pulses. Absent bowel sounds and mild abdominal distention are expected for a client immediately following surgery. However, this finding should be monitored as it could indicate a paralytic ileus.

The nurse is assessing a client with irreversible shock. The nurse should document the progression of which expected finding? increased alertness circulatory collapse diuresis hypertension

circulatory collapse Explanation: Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.

A client has undergone an amputation of three toes and a femoral-popliteal bypass. The nurse should teach the client that, after surgery, which leg position is contraindicated while sitting in a chair? crossing the legs extending the knees elevating the legs flexing the ankles

crossing the legs Explanation: Leg crossing is contraindicated because it causes adduction of the hips and decreases the flow of blood into the lower extremities. This may result in increased pressure in the graft in the affected leg. Elevating the legs, flexing the ankles, and extending the knees are not necessarily contraindicated.

The nurse is planning the care for a client with risk factors for atherosclerosis. What should the nurse include in the teaching plan for this client as modifiable risk factors? Select all that apply. genetics gender stress hypertension e-cigarette use

e-cigarette use hypertension stress Explanation: Nicotine use (e-cigarettes), hypertension, and stress are modifiable risk factors for atherosclerosis. Gender and genetics are nonmodifiable risk factors for atherosclerosis.

A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances? pacemaker placement early defibrillation in cases of atrial fibrillation cardioversion in cases of atrial fibrillation early defibrillation in cases of ventricular fibrillation

early defibrillation in cases of ventricular fibrillation Explanation: AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and the Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and the use of the AED as a tool to increase sudden cardiac arrest survival rates.

The nurse is caring for a client with venous thrombosis of the left lower extremity. To prevent further tissue damage, the nurse should observe the client for which finding? metabolic acidosis swelling in the left lower extremity gradual or acute loss of sensory and motor function blood pressure and heart rate changes

gradual or acute loss of sensory and motor function Explanation: Acute arterial occlusion is a sudden interruption of blood flow. The interruption can be the result of complete or partial obstruction. Acute pain; loss of sensory and motor function; and a pale, mottled, numb extremity are the most dramatic and observable changes that indicate a life-threatening interruption of tissue perfusion. Blood pressure and heart rate changes may be associated with the acute pain episode. Metabolic acidosis is a complication of irreversible ischemia. Swelling may result but may also indicate venous stasis or arterial insufficiency.

The nurse is monitoring a client postoperatively after a permanent pacemaker insertion. Which finding would be most concerning to the nurse? heart rate of 48 beats/minute reports of left chest soreness urine output of 30 mL over 1 hour blood pressure of 160/91 mm Hg

heart rate of 48 beats/minute Explanation: The client experiencing bradycardia would be the most serious report postoperatively because it likely indicates pacemaker malfunction. The blood pressure, while elevated, is not at a dangerous level at this time and only needs to be monitored. The urine output is normal over 1 hour and would be monitored and gauged against the client's intake. The client would be expected to have soreness in the left chest and should be given pain medication as needed.

A client with neutropenia has an absolute neutrophil count (ANC) of 900/µL (0.9 × 109/L). The nurse teaches the client to prevent which risk for neutropenia? bleeding hemorrhagic stroke infection sickle cell crisis

infection Explanation: A client is at moderate risk for infection when the ANC is less than 1000/µL (1 × 109/L). The client does not have a platelet disorder and is not at risk for bleeding or hemorrhagic stroke. The client does not have sickle cell anemia and is not at risk for a crisis.

left fifth intercostal space, midclavicular line. left fifth intercostal space, midaxillary line. left second intercostal space, midclavicular line. left seventh intercostal space, midclavicular line.

left fifth intercostal space, midclavicular line. Explanation: The correct landmark for obtaining an apical pulse is the left fifth intercostal space in the midclavicular line. This area is the point of maximum impulse and the location of the left ventricular apex. The left second intercostal space in the midclavicular line is where the nurse auscultates pulmonic sounds. The apical pulse isn't obtained at the midaxillary line or the seventh intercostal space in the midclavicular line.

A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 1200 hours 2 days after surgery, the client has abdominal distention. The nurse checks the progress notes in the client's medical record, as shown. What is most likely contributing to the client's abdominal distention? morphine intravenous (IV) fluid intake nasogastric (NG) tube ice chips

morphine Explanation: The client is experiencing paralytic ileus. One of the adverse effects of morphine used to manage pain is decreased gastrointestinal motility. Bowel manipulation and immobility also contribute to a postoperative ileus. Insertion of an NG tube generally prevents a postoperative ileus. The ice chips and IV fluids will not affect the ileus.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should have the client take deep breaths and cough. place the client in high Fowler's position. administer oxygen. perform chest physiotherapy.

place the client in high Fowler's position. Explanation: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

A nurse is caring for a client who is on a continuous cardiac monitor. When evaluating the client's rhythm strip, the nurse notes that the QRS interval has increased from 0.08 second to 0.14 second. Based on this finding, the nurse should withhold continued administration of which drug? propafenone procainamide metoprolol verapamil

procainamide Explanation: Procainamide may cause an increased QRS complexes and QT intervals. If the QRS duration increases by more than 50%, then the nurse should withhold the drug and notify the physician of the nurse's finding. Metoprolol may cause increased PR interval and bradycardia. Propafenone and verapamil may cause bradycardia and atrioventricular blocks.

The nurse is planning care for a client in the first 24 hours after admission for a thrombotic stroke. Which assessment is a priority for the nurse to make during this time? cholesterol level bowel sounds pupil size and response echocardiogram

pupil size and response Explanation: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, though it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for a client with a thrombotic stroke without heart problems.

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? retina sclera cornea iris

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 client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by doing which action? using ultrasound to estimate the velocity changes in the blood vessels showing the location of the obstruction and the collateral circulation determining how long the client can walk scanning the affected extremity and identifying the areas of volume changes

showing the location of the obstruction and the collateral circulation Explanation: An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client's ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise.

A client who has a history of bacterial endocarditis is scheduled to have oral surgery to remove a tooth. What should the nurse instruct the client to do? Rinse with mouthwash the night before and the day of the surgery. Be sure the dentist prescribes a prophylactic antibiotic before the oral surgery. Gargle with a saline solution before the appointment. Contact the health provider (HCP) to request a sedative.

Be sure the dentist prescribes a prophylactic antibiotic before the oral surgery. Explanation: Clients who are at risk for developing infective endocarditis due to cardiac conditions such as a history of bacterial endocarditis must take prophylactic antibiotics before any dental procedure that may cause bleeding. Gargling with saline or using mouthwash is not sufficient to prevent infection. The client will not need a sedative prior to the surgery.

The nurse is preparing the client for cardioversion. What should the nurse do? Select all that apply. Explain the procedure to the client. Place a self-adhesive patch between the skin and the paddles. Record the delivered energy and the resulting rhythm. Place the paddles over the client's clothing. Call "clear" before discharging the electrical current.

Explain the procedure to the client. Place a self-adhesive patch between the skin and the paddles. Call "clear" before discharging the electrical current. Record the delivered energy and the resulting rhythm. Explanation: The nurse should first explain the procedure to the client and then place the patch electrodes per agency procedure. The nurse must make sure to call "clear" before discharging the electrical current to prevent injury to others who may be helping with the procedure. After the procedure, the nurse must record the amount of electrical current delivered and the resulting rhythm. The paddles are placed on the patch adhered to the client's skin, not over the client's clothing.

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: Inform the HCP. advise the client to rest. start an intravenous infusion of normal saline. have the client rest in bed.

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.

An adult with hypertension is taking propranolol hydrochloride. What should the nurse instruct the client to do? Notify the health care provider of an irregular or slowed pulse rate. Monitor blood pressure every week, and adjust the medication dose accordingly. Measure partial thromboplastin time weekly to evaluate blood clotting status. Discontinue the drug if nausea occurs.

Notify the health care provider of an irregular or slowed pulse rate. Explanation: Propranolol hydrochloride is a beta-adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other arrhythmias. The nurse should instruct the client not to discontinue medication because sudden withdrawal of propranolol hydrochloride may cause rebound hypertension. Propranolol dosage is not adjusted based on weekly blood pressure readings. Measurement of partial thromboplastin time values is not a factor in the treatment of hypertension.

The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best action? Document the finding in the medical record. Notify the healthcare provider. Teach the client about risks for coronary artery disease. Determine whether the rhythm is irregular, coinciding with inspiration and expiration

Notify the healthcare provider. Explanation: Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle; elevated ST segments indicate that the client is experiencing a myocardial infarction. The healthcare provider should be notified. Teaching should be delayed until the client is stable. An irregular heart rhythm that varies with respiration-sinus arrhythmia-is a normal variation of sinus rhythm; there is no intervention needed.

The nurse is evaluating client understanding of discharge teaching about Prinzmetal's variant angina (PVA). Which statement by the client requires further instruction? "I will limit my level of physical exertion." "I will take prophylactic beta blockers." "I will begin a tobacco cessation plan." "I will use nitroglycerin during an attack."

"I will take prophylactic beta blockers." Explanation: PVA is a variety of angina caused by vasospasm. It is commonly experienced by clients with migraine headaches and Raynaud's disease. Although migraines may be treated with prophylactic beta blockers, these drugs are contraindicated for PVA due to an increased frequency of attacks. Physical activity is not a direct cause of PVA and may help relieve it in some clients. Heavy tobacco use has been associated with PVA. Clients are encouraged to stop use of tobacco products. Nitrates are effective in treating PVA attacks.

A client is taking verapamil hydrochloride as an antihypertensive. Which statement made by the nurse instructs the client about an adverse effect of verapamil? "Restrict your fluid intake to decrease the chance of developing fluid retention." "A low-residue diet will help prevent the occurrence of diarrhea." "Take your pulse and report any irregular heartbeats." "You should obtain a complete blood count routinely to monitor for potential bone marrow depression."

"Take your pulse and report any irregular heartbeats." Explanation: Verapamil can cause irregular cardiac rhythms. Clients should be taught to take their pulse and report any irregular heartbeats to their health care provider.Diarrhea is not a problem; constipation is the most common adverse effect of verapamil.Verapamil does not cause bone marrow depression.The client does not need to restrict fluids. Instead, a normal fluid intake is encouraged to prevent constipation.

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching? Impaired memory Risk for infection Chronic pain Impaired gas exchange

Risk for infection Explanation: Endocarditis is infection of the endocardium, heart valves, or a cardiac prosthesis, and clients are at high risk for relapse if they are not compliant with treatment or if they have invasive procedures. Therefore, clients with endocarditis have a Risk for infection. The nurse should stress to the client that they will need to continue antibiotics for a minimum of 5 years and that they will need to take prophylactic antibiotics before invasive procedures for life. There is no indication that the client has Chronic pain or Impaired memory. Because the client doesn't have valvular damage, Impaired gas exchange doesn't apply.

While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. What should the nurse do next? Administer nitroglycerin. Stop and assess the client further. Obtain the client's blood pressure and heart rate. Call for help, and place the client in a wheelchair.

Stop and assess the client further. Explanation: The nurse should stop and assess the client further. A chair should be available for the client to sit down. Obtaining the client's blood pressure and heart rate is important when the client is exercising. These values can be used to predict when the oxygen demand becomes greater than the oxygen supply. Calling for help is not necessary for the midsternal burning. If the health care provider has prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen balance.

Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's: troponin level. blood pressure. electrocardiogram (ECG). lidocaine level.

electrocardiogram (ECG). Explanation: Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Lidocaine level will be monitored but it is not the primary focus; troponin level monitors myocardial damage. Blood pressure, which can drop on lidocaine, does need to be monitored but the focus should be the ECG to evaluate the effectiveness of the medication.

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? absent Q wave elevated ST segment prolonged PR interval widened QRS complex

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.

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

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 client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client makes which statement? "I'll limit exercise that involves walking." "I'll try to lose weight by following a reduced-calorie, balanced diet." "I'll wear knee-high stockings, rolled at the top to hold the stockings up." "I'll perform leg lifts every 4 hours to strengthen hamstring muscles."

"I'll try to lose weight by following a reduced-calorie, balanced diet." Explanation: The client is at risk for the development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining an ideal body weight is the goal. To achieve this, the client should consume a balanced diet and participate in a regular exercise program. Performing leg lifts improves muscle strength, but it is more important for the client to increase exercise by walking. Wearing support stockings is helpful to promote circulation, but the client should not roll the stockings at the top to hold the stockings up as this will decrease circulation at the knees.

The nurse is caring for an older adult with mild dementia who has been admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply. Limit the client's visitors. Arrange for familiar pictures or special items at the bedside. Reorient frequently to time, place and situation. Put the client in a quiet room furthest from the nursing station. Spend time with the client, establishing a trusting relationship. Perform necessary procedures quickly.

Reorient frequently to time, place and situation. Arrange for familiar pictures or special items at the bedside. Spend time with the client, establishing a trusting relationship. Explanation: It is not unusual for the older adult client to become somewhat confused when "relocated" to the hospital, and this may be more difficult for those with known dementia. Frequent reorientation delivered patiently and calmly and placing familiar items nearby (so the client can see them) may help decrease confusion related to hospitalization. Establishing a trusting relationship is important with every client but may be more so with this client. Putting the client in a room farther from the nursing station may decrease extra noise for the client but will also make it more difficult to observe the client and maintain a safe environment. Procedures should be explained to the client prior to proceeding and should not be rushed. Visits by family and friends may help keep the client oriented.

A client has acute arterial occlusion. The health care provider has prescribed intravenous (IV) heparin. What should the nurse do before starting the medication? Test the client's stools for occult blood. Check the 24-hour urine output record. Count the client's apical pulse for 1 minute. Review the blood coagulation laboratory values.

Review the blood coagulation laboratory values. Explanation: Before starting a heparin infusion, the nurse needs to know the client's baseline blood coagulation values (hematocrit, hemoglobin, red blood cell count, and platelet count). In addition, the partial thromboplastin time should be monitored closely during the process. The client's stools would be tested only if internal bleeding is suspected. Although monitoring vital signs such as apical pulse is important in assessing potential signs and symptoms of hemorrhage or potential adverse reactions to the medication, vital signs are not the most important data to collect before administering the heparin. Intake and output are not important assessments for heparin administration unless the client has fluid and volume problems or kidney disease.