Cardiovascular Disorders - ML8

A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction? "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." "Client walks 4 miles (6.4 kilometers) in 1 hour every day." "Client performs relaxation exercises three times per day to reduce stress." "Client verbalizes an understanding of the need to seek emergency help if his heart rate increases markedly while at rest."

"Client walks 4 miles (6.4 kilometers) in 1 hour every day." Four weeks after an MI, a client's walking program should aim for a goal of 2 miles (3.2 kilometers) in less than 1 hour. Walking 4 miles (6.4 kilometers) in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. Performing relaxation exercises; following a low-fat, low-cholesterol diet; and seeking emergency help if the heart rate increases markedly at rest indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.

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 an understanding of the need to call the physician if acute pain lasts more than 2 hours." "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol." "Client will verbalize the intention to stop smoking." "Client will verbalize the intention to avoid exercise."

"Client will verbalize the intention to stop smoking." 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 receiving cilostazol for intermittent claudication. What should the nurse ask the client to determine the effectiveness of the drug? "Can you wiggle your toes?" "Are you urinating more frequently?" "Do you have less pain in the legs?" "Do you experience less dizziness?"

"Do you have less pain in the legs?" 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 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." "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 used to increase the heart rate and produce the irregular beats that caused your signs and symptoms."

"During the procedure, the health care provider will insert a special wire used to increase the heart rate and produce the irregular beats that caused your signs and symptoms." 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 dysrhythmia. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antiarrhythmics are held for at least 24 hours before the test in order to study the dysrhythmia without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.

Which statement would lead the nurse to determine that a client lacks understanding of the client's acute cardiac illness and the ability to make lifestyle changes? "No more working 10 hours a day for me unless it's an emergency." "I already have my airline ticket, so I won't miss my meeting tomorrow." "I talked with my spouse yesterday about working on a new budget together." "These relaxation tapes sound okay; I'll see if they help me."

"I already have my airline ticket, so I won't miss my meeting tomorrow." Leaving the hospital and immediately flying to a meeting indicate poor judgment by the client and little understanding of what lifestyle changes the client needs to make. The other statements show that the client understands some of the changes that need to be made in order to decrease stress and lead a healthier lifestyle.

A client is receiving cilostazol for peripheral artery disease causing intermittent claudication. Which statement by the client indicates to the nurse that this medication is effective? "I am having fewer aches and pains." "I am able to walk further without leg pain." "My toes are turning grayish black in color." "I do not have headaches anymore."

"I am able to walk further without leg pain." Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider (HCP) . Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body.

The nurse is caring for a client admitted for a quadruple coronary artery bypass graft. Which statements by the client indicate that preoperative teaching has not been effective? Select all that apply. "I had stopped smoking a month before the surgery; however, I will be able to start again once I have recovered." "I will be relieved to have this surgery over with; I have a very busy schedule at work right now." "I understand that I need to change my eating habits and activity levels to keep my heart healthy." "I know that I will have to perform deep breathing and coughing exercises to prevent complications." "I will be on a heart monitor and a respirator to help me breathe."

"I had stopped smoking a month before the surgery; however, I will be able to start again once I have recovered." "I will be relieved to have this surgery over with; I have a very busy schedule at work right now." Both of these statements indicate that the client believes the surgery will solve the problem and lifestyle changes are not necessary. There is no demonstration of understanding of preoperative teaching. "I know that I will have to perform deep breathing and coughing exercises to prevent complications," "I will be on a heart monitor and a respirator to help me breathe," and "I understand that I need to change my eating habits and activity levels to keep my heart healthy" are all positive statements that indicate a good understanding of the teaching, indicating the client is an active participant and is following guidelines to help in recovery after the surgery and promote heart health.

The nurse instructs a client on the use of transdermal nitroglycerin 0.2 mg/hour patch for angina pectoris. Which client statement indicates that teaching was effective? "I should store the supply of transdermal pads in the refrigerator." "I should report any skin irritation to the healthcare provider." "I should apply the patch to the same area every day." "I should touch the medication pad before applying to my skin."

"I should report any skin irritation to the healthcare provider." Because transdermal nitroglycerin can cause skin irritation, this should be reported to the healthcare provider. The site to apply the patch should be rotated every day to prevent sensitization and tolerance. The medication pad should not be touched, because this could cause the drug to be absorbed through the fingers. The medication should be stored away from temperature and humidity extremes because this may inactivate the drug.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? "I sleep on three pillows each night." "I don't have the same appetite I used to." "My pants don't fit around my waist." "My feet are bigger than normal."

"I sleep on three pillows each night." Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

The nurse has been instructing the client about how to prepare meals that are low in fat. Which of these comments would indicate the client needs additional teaching? "I will use a nonstick-coated pan when cooking." "I will avoid using steak sauce and catsup." "I will eat more liver with onions." "I'll eat water-packed tuna."

"I will eat more liver with onions." Liver and organ meats are high in cholesterol and saturated fat and should be limited.Water-packed tuna is one of the leanest types of fish available.Using a nonstick pan when cooking reduces the need for shortening or oil.Steak sauce and catsup are high in sodium and would likely accompany meals that include beef and other higher-fat meats.

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? "It is important that the recipient knows how to reach the family of the donor if health problems arise after the transplant." "I will have the transplant coordinator speak with you to answer your questions." "The recipient is allowed to ask questions about the donor and have them answered." "There is never contact between the donor's family and the recipient."

"I will have the transplant coordinator speak with you to answer your questions." 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 is teaching a client how to apply nitroglycerin topical ointment. Which statement indicates that the client needs additional clarification of the instructions? "It's important that I rotate the application sites to avoid skin irritation." "I should remove any remaining old ointment with a tissue before applying a new dose." "I'll use the applicator paper to measure the amount of ointment I should use." "I'll carefully massage the ointment into the skin."

"I'll carefully massage the ointment into the skin." The client should not rub or massage the ointment into the skin. The ointment should be allowed to absorb slowly. The client should use the applicator paper to measure the amount of ointment to apply. The client should rotate the application sites to avoid skin irritation. The client should remove any remaining ointment with a tissue before applying a new dose.

A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching? "I can't wait to get back to my football league." "I have an appointment for magnetic resonance imaging of my knee scheduled for next week." "I need to stay at least 10? away from the microwave." "I'll keep a log of each time my ICD discharges."

"I'll keep a log of each time my ICD discharges." The client stating that they should keep a log of all ICD discharges indicates effective teaching. This log helps the client and physician identify activities that may cause the arrhythmias that make the ICD discharge. The client should also record the events right before the discharge. Clients with ICDs should avoid contact sports such as football. They must also avoid magnetic fields, which could permanently damage the ICD. Household appliances don't interfere with the ICD.

A client takes isosorbide dinitrate as an antianginal medication. Which statement indicates that the client understands the adverse effects of the drug? "I should take isosorbide dinitrate with food." "I should take my pulse before taking the medication." "I'll need to change positions slowly so I won't get dizzy." "It's important that I report any swelling in my ankles."

"I'll need to change positions slowly so I won't get dizzy." Common adverse effects of isosorbide are light-headedness, dizziness, and orthostatic hypotension. Clients should be instructed to change positions slowly to prevent these adverse effects and to avoid fainting. Ankle swelling is not related to isosorbide administration. The client does not need to take his pulse before taking the medication. The client does not need to take the medication with food.

A client diagnosed with primary (essential) hypertension is taking chlorothiazide. The nurse determines teaching about this medication is effective when the client makes which statement? Select all that apply. "I won't drink alcoholic beverages while on this medication." "I'll reduce salt intake in my diet." "If I have severe dizziness, I'll reduce my dosage." "I'll take the drug before I go to bed." "I'll weigh myself at the same time each day." "If I have prolonged exposure to sunlight, I'll use sunscreen."

"I'll weigh myself at the same time each day." "I won't drink alcoholic beverages while on this medication." "I'll reduce salt intake in my diet." "If I have prolonged exposure to sunlight, I'll use sunscreen." Chlorothiazide causes increased urination and decreased swelling (if there is edema) and weight loss. It is important to check and record weight two to three times per week at same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or take other medications without the approval of the health care provider (HCP). Reducing sodium intake in the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses are less likely to cause adverse effects, and therefore excessive table salt as well as salty foods should be avoided. Chlorothiazide is a diuretic that is prescribed for lower blood pressure and may cause dizziness and faintness when the client stands up suddenly. This can be prevented or decreased by changing positions slowly. If dizziness is severe, the HCP must be notified. Diuretics may cause sensitivity to sunlight, hence the need to avoid prolonged exposure to sunlight, use sunscreens, and wear protective clothing. Chlorothiazide causes increased urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer bathroom trips mean less interference with sleep and less risk of falls. The client should not change the dosage without consulting the HCP.

A group has asked the nurse to discuss how lifestyle factors affect heart health. Which statements by members of the group would indicate that the teaching was effective? Select all that apply. "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "Gradually increasing my exercise levels will help enhance circulation through the heart." "Walking is excellent exercise to strengthen my heart." "Chewing tobacco rather than smoking it lessens the negative effect on the heart."

"If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "Gradually increasing my exercise levels will help enhance circulation through the heart." "Walking is excellent exercise to strengthen my heart." Increasing exercise levels, diet changes, losing weight, and walking are all important elements of heart health. Chewing tobacco is still harmful to the body.

A client with unstable angina has been prescribed sublingual nitroglycerin tablets. What statement should the nurse include in client teaching? "As soon as you feel chest pain, take one tablet every 5 minutes until the pain stops." "If the first dose doesn't work, you can take a second 5 minutes later and, if necessary, a third 5 minutes after that." "If chest pain persists 5 minutes after you take the first tablet, take 2 more tablets." "If the medication doesn't alleviate your chest pain, call your health care provider."

"If the first dose doesn't work, you can take a second 5 minutes later and, if necessary, a third 5 minutes after that." The nurse should instruct the client that the correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved, the client can take an additional dose every 5 minutes up to a maximum of 3 doses. If pain is not relieved after the third dose, the client should call 911. The client should take no more than one dose at a time. Since this is an emergency situation, the client should be directed to call 911 rather than the HCP's office.

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? "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." "A glass of red wine each 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." 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 newly admitted client reports taking digoxin and warfarin. Which statement would the nurse include in the discharge instructions? "Limit foods high in potassium, such as bananas." "Increase your calorie intake if your appetite decreases." "Report your morning and afternoon heart rates to your healthcare provider." "Notify your healthcare provider if you experiences visual changes."

"Notify your healthcare provider if you experiences visual changes." Hypokalemia can exacerbate digoxin toxicity so potassium should not be limited. The client will be taught the signs and symptoms of digoxin toxicity and what needs to be reported to the healthcare provider. Visual changes and anorexia are signs of digoxin toxicity and should be reported. The heart rate will not need to be verified twice a day. Anorexia is a symptom of digoxin toxicity so if the client is anorexic that should be reported to the healthcare provider.

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 opening a blocked artery with an inflatable balloon located on the end of a catheter." "PTCA involves passing a catheter through the coronary arteries to find blocked arteries." "PTCA involves cutting away blockages with a special catheter." "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 is best described as 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.

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." "You should obtain a complete blood count routinely to monitor for potential bone marrow depression." "Take your pulse and report any irregular heartbeats."

"Take your pulse and report any irregular heartbeats."

A client says to the nurse, "My father died of a heart attack when he was 60, and I suppose I will, too." The nurse should respond by saying to the client: "You have a fine doctor. Everything will be all right soon, I'm sure." "Would you agree that this would be very unlikely?" "Tell me more about what you're feeling." "Are you thinking that you won't recover from this illness?"

"Tell me more about what you're feeling." When a client makes a comment about death, it is best for the nurse to help the client express his or her feelings. Asking a question that requires no more than a yes or no answer is unlikely to elicit how the client really feels and offers no support.Trying to explain away the client's feelings will be of no help to the client and ignores the way the client feels.Clichés such as "everything will be all right soon" are not helpful because they ignore the client's feelings.Because the client has just made a statement about dying at 60, it is unlikely that the client will agree to the nurse's version of what is likely or unlikely.

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

"The leading cause of CAD is atherosclerosis." 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 history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." "You are experiencing leg pain because of venous congestion." "You are experiencing pain due to inadequate removal of carbon dioxide from the tissues in the legs." "The pain is related to atherosclerosis, which is the same problem causing your angina."

"The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." When there is a history of atherosclerosis affecting the heart and resulting in intermittent claudication, there is arterial insufficiency. This results in inadequate provision of oxygenated blood to the muscles when there is an increase in muscle demand. This results in the pain of intermittent claudication. Thus, the nurse's response should explain there is inadequate oxygen reaching the leg muscles. The choices that mention "venous congestion" and "inadequate removal of carbon dioxide" refer to problems with venous congestion rather than arterial perfusion and do not directly address the reason for the pain. Stating that the pain is related to atherosclerosis does not explain why the client feels pain in the legs.

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? "The pain lasted about 45 minutes." "The pain occurred while I was mowing the lawn." "The pain got worse when I took a deep breath." "The pain resolved after I ate a sandwich."

"The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.

The nurse instructs a client recovering from a myocardial infarction (MI) about cardiac rehabilitation. The client states, "I will not be able to do rehabilitation because I have very bad knees." What is the nurse's best response? "We can ensure you are prescribed pain control medications prior to discharge so you can participate." "Before discharge, we will send in a consult to an orthopedic specialist to get your knee issue addressed." "There are other physical activities you can do at home that are also beneficial for your recovery." "The rehabilitation team will assess you and recommend activities that accommodate for your knee problems."

"The rehabilitation team will assess you and recommend activities that accommodate for your knee problems." Cardiac rehabilitation is used to help the client recovering from a cardiac event improve tolerance to physical activity and also includes education about healthy lifestyle choices. Because it is a comprehensive program that does not only focus on increasing physical activity, encouraging activities at home is not as beneficial for the client. The activities can be adjusted to accommodate the client's knee condition. Though analgesics or a consult may be prescribed, these are not the best responses as the nurse should inform the client about the adaptability of the rehabilitation program even if the knee issue persists.

A client hospitalized with a myocardial infarction (MI) who has a blood glucose level ranging from 12-28 mmol/L (216-504 mg/dL) asks the nurse why the readings are so high even though there are no added sweets on the diet tray. What is the best response by the nurse? "We will need to introduce stress management techniques to reduce the level of stress." "Your blood glucose levels must have been high before the MI and could have contributed to the MI." "The stress level in your body has increased with the MI, and more glucose is released during stressful times." "Your blood glucose levels are increased because of limited activity at this time."

"The stress level in your body has increased with the MI, and more glucose is released during stressful times." The client is stating a reduction of food intake and has not eaten treats. This probably indicates that the increased stress levels are resulting in increased endogenous corticosteroid secretion. This will mobilize more glycogen and convert to glucose to provide a ready energy source. Glucose levels don't usually increase by reducing activity. Glucose levels probably didn't impact the MI. Stress management does not explain the reason for the hyperglycemia.

The recipient of a donated organ asks the nurse, "What did the donor die from?" Which response by the nurse is most appropriate? "The transplant coordinator can give you information about the donor's medical history." "Did you want to send the donor family a thank you card?" "Contact between the donor and the recipient is prohibited." "I will have the surgeon speak with you."

"The transplant coordinator can give you information about the donor's medical history." Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers; however, medical history, such as history or hepatitis or HIV infection, is permitted. The transplant coordinator is the liaison for information regarding the donor.

Which statement indicates that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? "This device decreases the blood flow in the heart." "This device increases how hard the heart has to work." "This device helps stop life-threatening heart rhythms." "This device decreases the heart's need for oxygen."

"This device decreases the heart's need for oxygen." An intra-aortic balloon pump increases coronary perfusion and cardiac output, and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock. A defibrillator is commonly used for termination of life-threatening ventricular rhythms.

Which statement indicates that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? "This device decreases the heart's need for oxygen." "This device decreases the blood flow in the heart." "This device helps stop life-threatening heart rhythms." "This device increases how hard the heart has to work."

"This device decreases the heart's need for oxygen." An intra-aortic balloon pump increases coronary perfusion and cardiac output, and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock. A defibrillator is commonly used for termination of life-threatening ventricular rhythms.

The client with heart failure asks the nurse about the reason for taking enalapril maleate. The nurse should tell the client: "This drug will constrict your blood vessels and keep your blood pressure from getting too low." "This drug helps your heart beat more forcefully." "This drug will slow your heart rate down." "This drug will dilate your blood vessels and lower your blood pressure."

"This drug will dilate your blood vessels and lower your blood pressure." Enalapril maleate is an angiotensin-converting enzyme inhibitor that prevents conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor and also contributes to aldosterone secretion. Thus, enalapril decreases blood pressure through systemic vasodilation.

An anxious client who suffered an acute myocardial infarction is transferred from the coronary care unit to the telemetry unit. The client asks the charge nurse if they can have the same nurse care for them every day. How should the charge nurse respond? "It's important for you to receive care from a variety of nurses so you can evaluate your care." "We will try to assign you the same nurse as often as possible." "Different nurses will be assigned to you each day to avoid your becoming dependent on one nurse." "It's our policy to rotate client care assignments to ensure quality care for everyone."

"We will try to assign you the same nurse as often as possible." The charge nurse should try to accommodate the client's wishes by assigning a familiar nurse whenever possible. Doing so should help decrease the client's anxiety. Preventing dependency shouldn't be a concern; allaying the client's anxiety should. The client shouldn't be concerned with evaluating the quality of care rendered by multiple nurses. Providing continuity of care helps ensure quality care.

A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? "Are you more tired now than you used to be?" "Have you been able to keep up with all your usual activities?" "What daily activities were you able to do 6 months ago compared with the present?" "How long have you had this problem?"

"What daily activities were you able to do 6 months ago compared with the present?" It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client about being more tired now than usual does not address activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.

A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in their left chest. The client tells the nurse how excited they are because the client's planning to go rifle hunting with a grandson. How should the nurse respond? "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." "Being that close to a rifle might make your ICD fire." "You'll need to take an extra dose of your antiarrhythmic before you shoot." "Enjoy your time with your grandson."

"You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." The recoil from the rifle can damage the ICD, so the client should be warned against shooting a rifle with the left hand. Close proximity to a rifle won't cause the ICD to fire inadvertently. The client shouldn't take an extra dose of antiarrhythmic.

The nurse is preparing to administer 0.1 mg of digoxin intravenously. Digoxin comes in a concentration of 0.5 mg/2 ml. How many milliliters should the nurse administer? Record your answer using one decimal place.

0.4 The nurse should administer 0.4 ml to administer 0.1 mg of digoxin I.V. if it comes in a concentration of 0.5 mg/2 ml, or 0.25 mg/ml.

A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride, an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within 10 to 15 minutes after I.V. bolus administration. 10 to 15 minutes after continuous I.V. infusion. 1 to 2 minutes after continuous I.V. infusion. 1 to 2 minutes after I.V. bolus administration.

1 to 2 minutes after I.V. bolus administration. Lidocaine exerts its antiarrhythmic effect in 1 to 2 minutes after I.V. bolus administration. A continuous I.V. infusion will maintain lidocaine's antiarrhythmic effect for as long as the drip is used. Lidocaine provides antiarrhythmic effects for only 15 minutes after the I.V. infusion is stopped.

The nurse is caring for a client prescribed IV heparin for treatment of thromboembolism. The client is prescribed 18 units/kg/hr. The client weighs 145 lb (66 kg). The heparin comes from the pharmacy as 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round to the nearest whole number.

12 The recommended dose of 18 units/kg should be obtained by multiplying the weight in kilograms by 18 units. 66 kg × 18 units = 1188 units/hr. Concentration for the medication is 25,000 units/250 mL. Use the formula Desired/Have × Volume: 1188 units/25,000 units × 250 mL = 11.88 mL/hr or 12 mL/hr.

When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum? 0.5 in (1 cm) 1 in (2.5 cm) 1.5 in (4 cm) 2 in (5 cm)

2 in (5 cm) An adult's sternum must be depressed 2 inches (5 cm) with each compression to ensure adequate heart compression.

How long after oral administration should a nurse expect to see digoxin's peak effect? 10 to 20 minutes 2 to 6 hours 30 minutes to 2 hours 2 to 5 minutes

2 to 6 hours The peak effect of digoxin occurs 2 to 6 hours after administration of an oral dose and 1 to 4 hours after an I.V. dose. Digoxin's onset of action ranges from 30 minutes to 2 hours after administration of an oral dose and from 5 to 30 minutes after an I.V. dose.

A client with heart failure is receiving furosemide, 40 mg I.V. The physician orders [40 mEq (40 mmol/L)] of potassium chloride in 100 ml of dextrose 5% in water to infuse over 4 hours. The client's most recent serum potassium level is [3.0 mEq/L (3.0 mmol/L)]. At what infusion rate should the nurse set the I.V. pump? 25 ml/hour 100 ml/hour 50 ml/hour 10 ml/hour

25 ml/hour The nurse should use the following formula to determine the infusion rate:ml/hour = (total volume (in ml) to be infused/total time of infusion in hours)ml/hour = (100 ml/4 hours) ml/hour = 25

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to safely remove the femoral sheath when the partial thromboplastin time (PTT) is: 50 seconds or less. 75 seconds or less. 100 seconds or less. 125 seconds or less.

50 seconds or less. Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 50 seconds or less before the sheath is removed. Removing the sheath before the PTT drops below 50 seconds can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.

A client with sepsis and hypotension is being treated with dopamine. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine in 250 ml, the infusion pump is running at 23 mL/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using two decimal places.

7.71 First, calculate how many micrograms per milliliter of dopamine are in the bag: 400 mg/250 mL = 1.6 mg/mL. Next, convert milligrams to micrograms: 1.6 mg/mL × 1,000 mcg/mg = 1,600 mcg/ml. Lastly, calculate the dose: 1,600 mcg/mL × 23 mL/hour/79.5 kg 79.5 kg/60 minutes/hour = 7.71 mcg/kg/minute

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client? Chronic obstructive pulmonary disease (COPD) Acute respiratory distress syndrome (ARDS) Mitral valve prolapse Anaphylaxis

Acute respiratory distress syndrome (ARDS) ARDS is a complication associated with sepsis. ARDS causes respiratory failure and may lead to death, even after the client has recovered from sepsis. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial air flow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.

A nurse is caring for a client who has had gastric bypass surgery. The health care provider encourages the client to increase mobility as soon as possible. The nurse notes edema to the right leg with skin color changes to the right lower extremity. The client reports pain at the incision site as 3 on a 0- to 10-point scale and pain to the right calf as 7 on a 0- to 10-point scale. The nurse reports the findings to the health care provider and suspects that the client has a deep vein thrombosis. Which intervention should the nurse include in the plan of care? Select all that apply. Prepare the client for evacuation of the thrombus. Administer heparin infusion. Apply ice to the right calf. Ambulate as tolerated. Elevate the right lower extremity.

Administer heparin infusion. Elevate the right lower extremity. Ambulate as tolerated. The plan of care for clients diagnosed with a deep vein thrombosis include anticoagulant therapy, elevation of affected extremity when sitting or lying down, application of moist heat to the affected extremity, and ambulation as tolerated. The traditional approach was to keep clients on bed rest, but that is a component of Virchow's triad. There is no evidence that ambulation is contraindicated or that surgery would be included in the plan of care.

A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which prescription from the health care provider should the nurse verify before implementing? Prepare for a pulmonary artery catheter insertion. Call for urine output less than 30 mL/h for 2 consecutive hours. Administer metoprolol 5 mg IV push. Titrate dobutamine to keep systolic blood pressure greater than 100 mm Hg.

Administer metoprolol 5 mg IV push. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.

A client with stage IV heart failure documents in an advance directive that no ventilatory support should be provided. What should the nurse do when the client begins experiencing severe dyspnea? Ask the healthcare provider to prescribe bilevel positive airway pressure (BIPAP). Coach the client to take slow deep breaths. Ask the client's family to consent to ventilator placement. Administer oxygen, morphine, and a bronchodilator for comfort.

Administer oxygen, morphine, and a bronchodilator for comfort. An advance directive identifies a client's wishes in the event that a life-threatening illness or injury occurs. The client's comfort should be paramount and the nurse should respect the client's wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will make breathing easier. The client will need more than coaching to take slow deep breaths. It is a violation of the client's advance directive to ask the family to consent to a ventilator. BIPAP is used to treat sleep apnea and not acute shortness of breath.

The nurse is preparing to defibrillate a client on a cardiac monitor who is in ventricular fibrillation (see photo). What should the nurse do? Move the paddle in the nurse's left hand to the midline. Move the paddle in the nurse's right hand to above the client's nipple. After pressing the charge button and calling "all clear," push the shock button. Grasp the handles of the paddles to allow visibility of the black markings on the paddle.

After pressing the charge button and calling "all clear," push the shock button. The paddles are in the correct position. The nurse can push the shock button to defibrillate the client.

The nurse is caring for an older adult with mild dementia 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. Arrange for familiar pictures or special items at bedside. Put the client in a quiet room furthest from the nursing station. Limit the client's visitors. Perform necessary procedures quickly. Spend time with the client, establishing a trusting relationship. Reorient frequently to time, place and situation.

Arrange for familiar pictures or special items at bedside. Spend time with the client, establishing a trusting relationship. Reorient frequently to time, place and situation. It is not unusual for the elderly 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 along with 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 maybe more so with this client. Putting the client in a room further 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 to keep the client oriented.

A middle-aged man collapses in the emergency department waiting room. What should the nurse do first? Ask the client to state his name. Watch the victim's chest for respirations. Perform the chin-tilt to open the victim's airway. Feel for any air movement from the victim's nose or mouth.

Ask the client to state his name Calling the victim's name and gently shaking the victim is used to establish unresponsiveness. The head-tilt, chin-lift maneuver is used to open the victim's airway. Feeling for any air movement from the victim's nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victim's chest for respirations to see if the victim is breathing.

While auscultating the apical heart rate, the nurse notes an irregular heart rhythm at a rate of 120 beats/min. What is the nurse's next action? Ask the client to hold the breath and bear down. Assess for a pulse deficit. Administer atropine. Auscultate the apical pulse with the client on the left side.

Assess for a pulse deficit. The correct landmark for obtaining the apical pulse is the left fifth intercostal space in the midclavicular line. The nurse measures the apical-radial pulse for a deficit; apical rate minus radial rate. A deficit is present during atrial fibrillation, and premature ventricular contractions because some heart beats do not perfuse to distal areas. The client should not perform the Valsalva maneuver without electrocardiographic monitoring and the healthcare provider at the bedside; assessment of the underlying disorder should be made first to direct the proper intervention. Prior to calling healthcare providers, the nurse should report vital signs and presence of pulse deficit.

The nurse observes a sudden dampening of the arterial waveform. What is the priority action by the nurse? Flush the line. Assess the client's blood pressure. Contact the healthcare provider. Change the tubing.

Assess the client's blood pressure. The priority action is to assess the client. A hypotensive crisis can look like dampened waveform and be life threatening if not treated appropriately. After the client is assessed, the healthcare provider can be contacted for additional interventions including a fluid challenge. Changing the tubing and flushing the line can be completed after the client is assessed.

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first? Administer a bolus of lidocaine. Call the health care provider (HCP). Assess the client's orientation and vital signs. Activate the rapid response team.

Assess the client's orientation and vital signs. The priority action is to assess the client and determine whether the rhythm is life threatening. More information, including vital signs, should be obtained and the nurse should notify the HCP. A bolus of lidocaine may be prescribed to treat this arrhythmia. This is not a code-type situation unless the client has been determined to be in a life-threatening situation.

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown. At 1030, the client has sharp mid-chest pain after having a bowel movement. What should the nurse do first? Contact the health care provider (HCP). Assess the client's vital signs. Assess the client's neurologic status. Administer pain medication as prescribed.

Assess the client's vital signs. The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the HCP.

During a shift report for a client with heart failure, the nurse going off shift reports that the client had sinus bradycardia during the shift and a creatinine of 3.5 mg/dL. Which action does the nurse perform when administering digoxin to this client? Monitor the radial pulse. Evaluate the B-type natriuretic peptide level (BNP). Measure the urine output. Assess the digoxin level.

Assess the digoxin level. After digoxin is metabolized, the kidneys eliminate the remaining digoxin. Kidney disease will prevent elimination of digoxin causing potential toxicity; measuring the digoxin level, especially in the presence of bradycardia, a side effect of digoxin, is indicated. The nurse monitors the apical pulse when administering digoxin, as atrial fibrillation or other dysrhythmia that causes a pulse deficit may lead the nurse to hold the medication when the true pulse is above 60 beats/min. Renal impairment does not always decrease urine output; therefore, monitoring for toxicity is the priority. Although the BNP level will correlate to the client's heart failure, the most important assessment is for digoxin toxicity.

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

Auscultate heart sounds. 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.

A client admitted to the telemetry unit with newly diagnosed atrial fibrillation has been started on warfarin. What should the nurse instruct the client to do when taking this medication? Select all that apply. Avoid injury to prevent bruising. Floss the teeth deep into the gums. Be careful using a razor or fingernail clippers. Report any change in color of urine or stool. Not take the medication if the pulse is below 60.

Avoid injury to prevent bruising. Be careful using a razor or fingernail clippers. Report any change in color of urine or stool. Warfarin is an anticoagulant used in clients with atrial fibrillation to reduce the risk of stroke or systemic embolization and, therefore, will put the client at risk for bleeding. The nurse should instruct the client to watch for signs of bleeding and prevent bruising. While good oral hygiene remains important, the nurse would advise against vigorous flossing and irritating the gums as it may increase the risk of bleeding. Warfarin does not affect the heart rate.

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? bed rest with the affected extremity in the dependent position Bed rest with the affected extremity elevated bed rest with the affected extremity flat bed rest with all normal activities as long as there no increased pain on the affected site

Bed rest with the affected extremity elevated Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.

A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the client is admitted to the coronary care unit? Obtain a health history. Auscultate heart sounds. Evaluate the client's pain. Begin telemetry monitoring.

Begin telemetry monitoring Telemetry monitoring should be started as soon as possible. Life-threatening arrhythmias are the leading cause of death in the first hours after MI. The other options are secondary in importance to assessing abnormal, life-threatening rhythms.

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? Take one tablet and then immediately call 911. Go to the emergency department if two nitroglycerin tablets taken 5 minutes apart are not effective. Call 911 when five nitroglycerin tablets taken every 5 minutes are not effective. Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective.

Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. 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 nurse is teaching a client how to take nitroglycerin to treat angina pectoris. What should the nurse include in the instructions? Call emergency medical services immediately if chest pain does not subside within 15 minutes. If the medication causes headache, dizziness, or flushing, call your primary healthcare provider immediately. Take up to 5 nitroglycerine tablets at 5 minute intervals. Side effects of dry, hacking cough are to be expected

Call emergency medical services immediately if chest pain does not subside within 15 minutes. Nitroglycerine given for treatment of angina should be taken in 5 minute intervals for up to 3 doses. If the pain does not subside after three doses, the patient should seek emergency care immediately. Expected side effects of nitroglycerine include headache that should decrease over time, dizziness, and flushing. A dry cough is a side effect of an angiotensin converting enzyme (ACE) inhibitor.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? Increase the flow rate of intravenous fluids. Administer a sedative. Call the rapid response team. Try to elicit a positive Homans' sign.

Call the rapid response team. Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client's change in mental status, tachypnea, and tachycardia indicate a possible pulmonary embolism. The nurse should promptly call the rapid response team. Administering a sedative without further evaluation of the client's condition is not appropriate. There is no need to elicit a positive Homans' sign; the client is already diagnosed with deep vein thrombosis. Increasing the IV flow rate may be an appropriate action but not without first notifying the HCP.

The nurse observes the cardiac rhythm (see above) for a client who is being admitted with a myocardial infarction. Which should the nurse do first? Prepare for immediate cardioversion. Begin cardiopulmonary resuscitation (CPR). Check for a pulse. Prepare for immediate defibrillation.

Check for a pulse. This ECG strip indicates the client has ventricular tachycardia. The nurse should first check the client for the presence of a pulse. The presence of a pulse determines the treatment for ventricular tachycardia. It is also important to assess the client's heart rate and level of consciousness. Cardioversion may be used to treat hemodynamically unstable tachycardias. Assessment of instability is required before cardioversion. It is not appropriate to begin CPR unless the pulse is absent. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia.

A postoperative client has exhibited decreased urine output, hypotension, and tachycardia. Which nursing assessment is the priority? Palpate the radial pulse Assess the I.V. rate Obtain a bladder scan Check the dressing

Check the dressing Although all are assessments that may be indicated for this client, the priority is the dressing. The client is exhibiting signs of shock. Shock in a postoperative client typically results from bleeding.

A child with heart disease starts on oral digoxin. When preparing to administer the medication, what should the nurse do first? Teach the mother how to measure the child's heart rate. Verify the dosage with the pharmacist. Ask the mother if she is willing to administer the medication. Check the last serum electrolyte results for the child.

Check the last serum electrolyte results for the child. It is most important to know the child's serum potassium level when administering digoxin. Digoxin increases contractility of the heart and increases renal perfusion, resulting in a diuretic effect with increased loss of potassium and sodium. Hypokalemia increases the risk of digoxin toxicity. Verifying the dosage is specified by facility policy and varies among facilities. Although the child may take the medication better from the mother than from the nurse, asking the mother to give the medication is not necessary. In addition, this would be done after the nurse has checked the electrolyte levels. Teaching the parent how to measure the child's heart rate can be done at any time, not necessarily when preparing to give digoxin.

A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. Start a dopamine drip for a systolic BP less than 100 mm Hg. Check the postoperative CBC, INR, PTT, and platelet levels. Administer warfarin. Monitor the mediastinal chest tube drainage. Confirm availability of blood products.

Check the postoperative CBC, INR, PTT, and platelet levels. Confirm availability of blood products. Monitor the mediastinal chest tube drainage. The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding; therefore, availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should not be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.

During a home visit, the nurse assesses a client who is taking hydrochlorothiazide and lisinopril for the treatment of hypertension. Which finding would indicate the nurse should inform the health care provider of a possible need to change medication therapy? Blood pressure is 132/80 mm Hg. Potassium level is 4.1 mEq/L. Client is experiencing nocturia. Client has a persistent cough.

Client has a persistent cough. A persistent cough is a side effect of the ACE inhibitor that may warrant a change to another antihypertensive medication.BP and potassium are within normal limits. The nurse assesses when the drug is taken and changes to an earlier time of administration.

A client with sepsis has continued to deteriorate and has become unresponsive. The nurse has inserted an intravenous line and assisted with the initiation of mechanical ventilation. Which is the highest priority for the nurse at this time? Confirm the placement of the endotracheal tube. Assess the surgical dressing for infection. Assess urine output. Administer intravenous fluids.

Confirm the placement of the endotracheal tube. Confirming the placement of the endotracheal tube ensures oxygenation. Oxygen is essential for life, so this action takes priority. Intravenous fluid resuscitation is the next priority based on client unresponsiveness. Assessing for the source of the infection should be explored by assessing the surgical site, blood, urine, and sputum culture studies. Urine output should be monitored to assess perfusion and for potential acute renal failure.

A nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that they think they are going to die before a donor heart is found. The client also tells the nurse that they have not been attending a church but wants to talk with a priest. What action should the nurse take? Contact the nurse's priest to see if they will see the client. Tell the client that it doesn't matter if they attend a church or not. Reassure the client that they have nothing to worry about because donors are usually found in time. Contact the clergy member who is assigned to the transplant team.

Contact the clergy member who is assigned to the transplant team. Each multidisciplinary transplant team has a clergy person assigned. The nurse should contact that person and request that the assigned clergy visit the client. It isn't appropriate for the nurse to ask their own priest to see the client. Telling the client that they have nothing to worry about because donors are typically found offers false reassurance. Telling the client that it doesn't matter if they attend a church invalidates the client's concern.

The nurse is evaluating a hemodynamically unstable client with an arterial line and notes that the client has tachycardia, cool and clammy skin, a pericardial friction rub, and the arterial waveform shows an inspiratory systolic pressure that is 15 mm Hg less than the expiratory systolic pressure. What is the priority intervention by the nurse? Auscultate heart sounds. Contact the health care provider. Assess manual blood pressure. Perform square wave test.

Contact the health care provider. The priority action is to contact the health care provider because these symptoms are indicative of cardiac tamponade. Assessing the heart sounds is not indicated at this time. The square wave test would be performed to check for accuracy of the arterial readings and optimal wave formation. There is no indication for performing a manual blood pressure at this time.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention? Reduce the nausea and vomiting and stabilize the blood glucose. Monitor and manage potential complications. Control the pain and support breathing and oxygenation. Decrease the anxiety and reduce the workload on the heart.

Control the pain and support breathing and oxygenation. Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.

A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states "I am so tired. Even my vision is blurry." What is the nurse's best action? Cluster activities to allow the client uninterrupted rest time. Administer zolpidem. Decrease the lidocaine infusion rate. Ask the client the date of the most recent eye exam.

Decrease the lidocaine infusion rate. Side effects of lidocaine include lightheaded, euphoria, shaking, low blood pressure, drowsiness, confusion, weakness, blurry or double vision, and dizziness. Serious reactions such as seizures, bradycardia, and heart block are possible if lidocaine reaches toxic levels. The nurse should recognize these potential adverse effects and the lidocaine infusion should be decreased while lidocaine blood levels are checked to determine if the cause of the tiredness and blurred vision is a lidocaine toxicity. Knowing when the client's most recent eye examination was completed and allowing the client to rest or administering zolpidem will not address the problem of potential lidocaine toxicity and may lead to the more serious toxic reactions.

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: Crackles. Dependent edema. Dyspnea. Intermittent claudication.

Dependent edema. Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.

After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine, 5 mcg/kg/minute I.V. Which classification best describes dobutamine? Direct-acting alpha-active agent Indirect-acting beta-active agent Indirect-acting dual-active agent Direct-acting beta-active agent

Direct-acting beta-active agent Adrenergic agents are classified according to their method of action and the type of receptor on which they act. Direct-acting agents act on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual-acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors. Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent.

When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, which is the expected outcome of the drug? Treat dysrhythmias. Prevent kidney failure. Promote hydration. Dissolve clots.

Dissolve clots. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.

A client with a cerebral embolus is receiving IV recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy? Improved cerebral vascularization Dissolved emboli Decreased vascular permeability Prevention of cerebral hemorrhage

Dissolved emboli Thrombolytic agents such as alteplase are used for clients with a history of thrombus formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic agents act by dissolving emboli. Thrombolytic agents do not directly improve perfusion or improve cerebral vascularization, nor do they prevent cerebral hemorrhage.

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. What should the nurse should advise the client to do during the 2-hour car ride? Take an ambulance. Do ankle pumps. Perform arm circles. Elevate the legs.

Do ankle pumps. Performing active ankle and foot range-of-motion exercises periodically during the ride home will promote muscular contraction and provide support to the venous system. It is the muscular action that facilitates return of the blood from the lower extremities, especially when in the dependent position. Arm circle exercises will not promote circulation in the leg. It is not necessary for the client to elevate the legs as long as the client does not occlude blood flow to the legs and does the leg exercises. It is not necessary to take an ambulance because the client is able to sit in the car safely.

A nurse notes that the client's PR interval is .17 and the QRS complex is .10. What action should the nurse take next? Administer the ordered nitroglycerin paste. Document the findings. Request a 12-lead electrocardiogram. Give 2 liters of oxygen via nasal cannula.

Document the findings. These are normal findings. The nurse should document the findings. A 12-lead ECG would be ordered if the client needs further evaluation in the event of an abnormal finding. Administering nitroglycerin is a routine intervention and not related to the measured PR and QRS intervals. Oxygen administration is not indicated in the presence of normal findings.

The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1,000 units per hour. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. What should the nurse do first? Notify the health care provider (HCP). Prepare protamine sulfate for intravenous administration. Observe and document the bleeding. Don gloves and apply direct pressure over the site.

Don gloves and apply direct pressure over the site. The nurse should first don gloves and apply direct pressure over the site to stop blood loss from the femoral artery. While the nurse will later observe the site for further bleeding and record the extent of bleeding, this is not the first action that is needed. If the bleeding cannot be controlled, the HCP who performed the procedure should be contacted, but first an attempt to manually stop the bleeding with direct pressure is warranted. Protamine sulfate is the antidote for heparin sodium, but this is not an initial action to control the bleeding.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating? Have a preference for foods high in salt. Eat food on only half of the plate. Be unable to swallow liquids. Forget the names of foods.

Eat food on only half of the plate. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

A client with heart failure has assessment findings of jugular vein distension (JVD) when lying flat in bed. What is the best nursing intervention? Document the finding as the only action. Elevate the head of the bed to 30 to 45 degrees and reassess JVD. Notify the healthcare provider. Obtain orthostatic blood pressure readings.

Elevate the head of the bed to 30 to 45 degrees and reassess JVD. Jugular vein distension should be measured when the head of the client's bed is at 30 to 45 degrees. The healthcare provider may or may not need to be notified, based on the assessment findings with the head of the bed elevated. Further assessment should be performed, but this further assessment does not include obtaining orthostatic blood pressure readings, since these readings do not affect JVD.

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do? Wear support stockings. Rest frequently with the legs elevated. Enroll in a supervised exercise training program. Avoid walking when the pain occurs.

Enroll in a supervised exercise training program. Decreased blood flow is a common characteristic of all PVD. When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. The nurse should suggest that the client enroll in a supervised exercise training program that will assist the client to gradually increase walking distances without pain. Not walking and resting will not increase blood flow to the legs. Support stockings may be prescribed, but the client should improve the capacity to walk and obtain exercise.

A client newly diagnosed with deep vein thrombosis (DVT) of the left lower left extremity is on bed rest. What should the nurse instruct the unlicensed assistive personnel (UAP) providing routine morning care for the client to do? Ensure that the lower extremity is elevated. Place one or two pillows under the client's left knee. Check that the legs are in a low, dependent position. Massage the leg and foot with lotion.

Ensure that the lower extremity is elevated. DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return. Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow under the knee would position the foot in a low position, and pressure behind the knee may obstruct venous flow. Massaging the extremity could dislodge the thrombus.

A nurse is caring for a client with first-degree atrioventricular (AV) block. When instructing the spouse using a diagram, identify the area in the conduction cycle where this block occurs.

First-degree AV block is a conduction disturbance in which electrical impulses flow normally from the sinoatrial node through the atria but are delayed at the AV node, thus prolonging the PR interval on an ECG. Although the conduction is slowed, there are no missed beats.

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? High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). Low density lipoproteins (LDL) increase from 180 mg/dl (4.66 mmol/L to 190 mg/dl (4.92 mmol/L). Triglycerides increase from 225 mg/dl (5.83 mmol/L) to 250 mg/dl (6.47 mmol/L). Total cholesterol level increases from 250 mg/dl to 275 mg/dl (6.48 mmol/L to 7.12 mmol/L).

High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). 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.

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)? Identify the time of onset of the stroke. Ask what medications the client is taking. Determine if the client is scheduled for any surgical procedures. Complete a history and health assessment.

Identify the time of onset of the stroke. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first? Increase the oxygen flow rate from 2 to 4 L/min. Obtain a sample for arterial blood gas analysis. Call the health care provider (HCP) immediately. Provide reassurance to the client.

Increase the oxygen flow rate from 2 to 4 L/min. The first action is to increase the oxygen flow rate from 2 to 4 L/min to help ensure adequate oxygenation for the client. Although it is important to notify the HCP for additional prescriptions and to obtain further assessment data, such as arterial blood gas measurements, it is a priority to support the client's cardiopulmonary system. It would be appropriate to reassure the client while these other interventions are occurring.

Which of the following explains the influence of aging on the development of peripheral vascular disease? Increased viscosity. Decreased resistance. Increased resistance. Decreased viscosity.

Increased resistance. As people age, the accumulation of collagen in the intima of the blood vessels results in the vessels' becoming stiff and less flexible. Consequently, there is an increased resistance within the aging adult's circulatory system.

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

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

Inform the HCP. 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 peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediately after surgery? Relieve pain. Provide education. Prevent infection. Maintain circulation.

Maintain circulation. Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent. Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.

The nurse reviews the morning laboratory results from a client admitted with a deep vein thrombosis. The client is receiving intravenous heparin. Based on the client's current laboratory values, what should the nurse do?

Maintain the current rate of the heparin infusion. An aPTT of 65 seconds is considered therapeutic with a control of 30. Therapeutic levels for heparin are 1.5 to 2.5 times the control, which would make therapeutic level between 45 seconds 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 are within normal limits; the client does not need to increase fluid intake beyond 3,000 mL. The hemoglobin and hematocrit are within normal limits; it is not necessary to obtain frequent oxygen saturation levels.

What is the most important goal of nursing care for a client who is in shock? Manage fluid overload. Manage vasoconstriction of vascular beds. Manage increased cardiac output. Manage inadequate tissue perfusion.

Manage inadequate tissue perfusion. Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. What should the nurse do first? Notify the health care provider (HCP). Increase the IV infusion rate 150 mL per hour. Increase the oxygen concentration to 4 L/min. Administer a prescribed analgesic.

Notify the health care provider (HCP). PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the HCP should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

When a client has a troponin level of 0.9 ng/mL, which nursing intervention should be implemented? Apply oxygen at 2 L/minute per nasal cannula. Document the finding as the only action. Notify the healthcare provider. Encourage the client to ambulate.

Notify the healthcare provider. Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction. The healthcare provider should be immediately notified when the troponin level is > 0.1 ng/mL. The client should not be ambulated at this time. Applying oxygen is appropriate, although the use of a nasal cannula is not recommended.

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? Observe neurologic function every 15 minutes. Monitor skin warmth and turgor. Monitor the laboratory values. Observe the puncture site for swelling and bleeding.

Observe the puncture site for swelling and bleeding. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

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? Arrange for an emergency hemodialysis session. Obtain an order for calcium gluconate 2 g I.V. push over 2-5 minutes. Obtain an order for furosemide 80 mg I.V. push. Increase the rate of the client's I.V. fluid to 150 ml/hour.

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

The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. Obtain intake and outputs on a client experiencing heart failure. Obtain vital signs for a client admitted yesterday. Assess pedal pulses on a client who just returned from a cardiac angiogram. Administer acetaminophen to a client with a pain level of "5" out of "10." Administer oxygen via nasal cannula to a client with a saturation of 89%.

Obtain vital signs for a client admitted yesterday. Obtain intake and outputs on a client experiencing heart failure. Taking vital signs and obtaining intake and output are tasks that can be delegated to UAP. Assessing pedal pulses and administering medications or oxygen are skills that require nursing judgment.

The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? Partial thromboplastin time, 1.5 to 2.5 times the normal control. Thrombin clotting time, 10 to 15 seconds. Prothrombin time, 1.5 to 2.5 times the normal control. International Normalized Ratio, 2 to 3 seconds.

Partial thromboplastin time, 1.5 to 2.5 times the normal control. The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of warfarin, oral anticoagulation therapy. The thrombin clotting time is used to confirm disseminated intravascular coagulation.

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? Platelet count Bleeding time Partial thromboplastin time (PTT) Prothrombin time (PT)

Prothrombin time (PT) PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose approximately 99% of bleeding disorders on the basis of PT and PTT values.

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. Administer morphine. Administer nitroglycerin. Provide oxygen. Administer aspirin. Administer acetaminophen Insert a Foley catheter.

Provide oxygen. Administer nitroglycerin. Administer aspirin. Administer morphine. 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.

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

Renal insufficiency and failure. Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication.

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? Restricting activity of the client's left side. Restricting oral fluid intake. Administering pain medication routinely. Measuring vital signs and urine output hourly.

Restricting activity of the client's left side. 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 client with deep vein thrombosis has been receiving warfarin for 2 months. The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do? Decrease the dose of the warfarin. Notify the health care provider (HCP) about the bleeding. Return to laboratory for analysis of prothrombin times. Decrease the amount of vitamin K in the diet.

Return to laboratory for analysis of prothrombin times. These symptoms suggest that the client is receiving too much warfarin; the client should return to the laboratory and have a blood sample drawn to determine the prothrombin levels and have the dosage of warfarin adjusted. The diet can influence clotting, but the client needs to first have the prothrombin levels checked. It is not necessary to contact the HCP; the client should return to the laboratory first, and the results of the prothrombin time will be reported to the HCP.

A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first? Alert the charge nurse that they made a medication error. Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. Document the medication error and completion of the variance report in the client's chart and notify the physician. Check the second client's identification and administer the remaining medication to him.

Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. The nurse should return to the room to check the client's identification against the medication administration record. If there was an error, the nurse should then complete a variance report in accordance with facility policy and check the remaining medication before administering it to the second client. The client record shouldn't include documentation of a completed variance report. The nurse should inform the charge nurse of the error after confirming that an error has been made.

36. 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? Reduce coronary artery vasospasm. Control the arrhythmias associated with MI. Revascularize the blocked coronary artery. Control chest pain.

Revascularize the blocked coronary artery. 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.

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

Review the blood coagulation laboratory values. Before starting a heparin infusion, it is essential for the nurse to know the client's baseline blood coagulation values (hematocrit, hemoglobin, and red blood cell and platelet counts). 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.

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 gas exchange Risk for infection Chronic pain Impaired memory

Risk for infection 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.

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? Assess leg pulses with a Doppler test. Palpate the abdomen for presence of a mass. Start an IV infusion. Obtain consent for emergency surgery.

Start an IV infusion. 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.

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? Call for help and place the client in a wheelchair. Obtain the client's blood pressure and heart rate. Administer nitroglycerin. Stop and assess the client further.

Stop and assess the client further. 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 are important when 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 (HCP) has prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen balance.

One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. What should the nurse instruct the client to do to achieve this goal? Elevate the legs above the heart. Stop smoking. Avoid eating low-fat foods. Jog daily.

Stop smoking. Nicotine causes vasospasm and impedes blood flow. Stopping smoking is the most significant lifestyle change the client can make. The client should eat low-fat foods as part of a balanced diet. The legs should not be elevated above the heart because this will impede arterial flow. The legs should be in a slightly dependent position. Jogging is not necessary and probably is not possible for many clients with arterial occlusive disease. A rehabilitation program that includes daily walking is suggested.

A client has a throbbing headache when nitroglycerin is taken for angina. What should the nurse instruct the client to do? Limit the frequency of using nitroglycerin. Rest in a supine position to minimize the headache. Take acetaminophen or ibuprofen. Take the nitroglycerin with a few glasses of water.

Take acetaminophen or ibuprofen. Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.

A nurse is caring for a client with advanced heart failure. The client can't care for themself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses their desire for "nature to take its course." The client's family is pleading with the client to have a feeding tube inserted. What is the most appropriate action for the nurse to take? Talk with the client's family about the client's right to decide for themself. Schedule a conference to help the client and the client's family reach a consensus about the feeding tube. Schedule feeding tube placement and hope that the nurse can persuade the client to agree to it. Ask a priest to talk with the client about the importance of preserving life.

Talk with the client's family about the client's right to decide for themself. Advocating for a client's wishes is a key nursing role. It's especially important when a client's family disagrees with the client's wishes. The nurse should be sure that the client has all the information needed to make an informed decision. Then the nurse should support the client's decision. The nurse shouldn't contact a clergyman without the client's consent, call a family conference, or schedule intubation in violation of the client's wishes.

The nurse is evaluating an electrocardiogram (ECG) tracing. Which graphic shows the QT interval?

The QT interval extends from the beginning of the QRS complex to the end of the T wave. It measures the time needed for ventricular depolarization and repolarization. Option B shows the PR interval, which is measured from the beginning of the P wave to the beginning of the QRS complex. It tracks the atrial impulse from the sinus node through the atrioventricular (AV) node. Option C shows the ST segment, which represents the end of ventricular depolarization. Option D shows the QRS duration and represents impulse conduction through the ventricles.

The nurse is administering an IV potassium chloride supplement to a client who has heart failure. What should the nurse consider when developing a plan of care for this client? The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L. Hyperkalemia will intensify the action of the client's digoxin preparation. The client's potassium levels will be unaffected by a potassium-sparing diuretic. Metabolic alkalosis will increase the client's serum potassium levels.

The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L. When administering IV potassium chloride, the administration should not exceed 10 or a concentration of 40 via a peripheral line. These limits are extremely important to prevent the development of hyperkalemia and the possibility of cardiac dysrhythmias. In some situations, with dangerously low serum potassium levels, the client may need cardiac monitoring and more than 10 mEq (mmol/L) of potassium per hour. Potassium-sparing diuretics may lead to hyperkalemia because they affect the kidney's ability to excrete excess potassium. Metabolic alkalosis can cause potassium to shift into the cells, thus decreasing the client's serum potassium levels. Hypokalemia can lead to digoxin toxicity.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? The client exhibits a heart rate within normal limits. The client demonstrates ability to tolerate more activity without chest pain. The client requests information regarding smoking cessation. The client is able to verbalize the action of all prescribed medications.

The client demonstrates ability to tolerate more activity without chest pain. The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. A heart rate within the normal limits of 60-100 per minute does not necessarily indicate a favorable response to treatment. Smoking is a cardiovascular risk factor that the client would be wise to eliminate, but it does not indicate favorable response to treatment. Knowledge of prescribed meds is a good thing, but again does not impact response to treatment.

A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which finding requires immediate nursing action? There is a low, grade 1 intensity mitral regurgitation murmur. Urine output decreased from 60 mL/hour to 40 mL over the last hour. The client has become more somnolent. SpO2 is 94% on 2 liters of oxygen via nasal cannula.

The client has become more somnolent. A complication of balloon valvuloplasty is emboli resulting in a stroke. The client's increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely, but do not warrant concern.

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. 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.

The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. What evidence will indicate to the nurse that the client understands the discharge plan? The client verbalizes safety precautions needed to prevent pacemaker malfunction. The client states a need for bed rest for 1 week after discharge. The client selects a low-cholesterol diet to control coronary artery disease. The client explains signs and symptoms of myocardial infarction (MI).

The client verbalizes safety precautions needed to prevent pacemaker malfunction. Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb (1.35 kg) or stretching and bending. The client should know how to count the pulse and do so daily or as instructed by the health care provider (HCP). The client will not necessarily be placed on a low cholesterol diet. The client should resume activities, and does not need to remain on bed rest. The client should know signs and symptoms of a MI, but is not at risk because of the pacemaker.

A client has peripheral artery disease of both lower extremities. The client tells the nurse, "I've really tried to manage my condition well." Which example indicates the client is using appropriate care management strategies? The client rests with the legs elevated above the level of the heart. The client limits activity to walking around the house. The client wears antiembolism stockings at all times when out of bed. The client walks slowly but steadily for 30 minutes twice a day.

The client walks slowly but steadily for 30 minutes twice a day. Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.

A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? The dobutamine needs to be increased. The dobutamine may need to be decreased. The client is experiencing an exacerbation of the heart failure. The client is experiencing an allergic reaction to the dobutamine.

The dobutamine may need to be decreased. Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client does not show symptoms of allergic reaction or heart failure.

A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? The number of premature ventricular contractions is decreasing. The ventricular rate is increasing. The fine ventricular fibrillation changes to coarse ventricular fibrillation. The absent pulse is now palpable.

The number of premature ventricular contractions is decreasing. Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.

The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?

The presence of a strong dorsalis pedis pulse indicates that there is circulation to the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows the nurse obtaining an apical pulse.

A client returns from left aortofemoral bypass surgery. Identify the area on the illustration where the nurse should place the Doppler ultrasound to assess the left dorsalis pedis pulse.

The pulse is located on the anterior aspect of the left foot.

The nurse is planning care for a client who had an abdominal aortic aneurysm repair 3 days ago. The nurse is reviewing the progress notes shown. Two units of packed red blood cells (PRBCs) have been prescribed for transfusion. What should the nurse do first? Transfuse PRBCs. Administer furosemide. Increase the drip rate of IV fluids. Initiate a dopamine drip.

Transfuse PRBCs. A blood transfusion is required postoperatively with significant blood loss from surgery or bleeding. Data from the progress notes indicate the client is hypovolemic and has a low hemoglobin level, which warrants transfusion at this time rather than IV fluids. The nurse must continue to assess the client for signs of bleeding. Correction of hypovolemia precedes a dopamine infusion. The transfusion should improve the hemodynamics, and the hemoglobin and hematocrit are reassessed after the transfusion. The client has fluid volume deficit, so furosemide is not needed at this time.

A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema the client is on complete bed rest. To maintain skin integrity, what should the nurse do? Administer pain medication. Ensure fluid intake of 3,000 ml per 24 hours. Turn the client every 1 to 2 hours. Maintain hygiene.

Turn the client every 1 to 2 hours. The client is at greater risk for skin breakdown in the lower extremities related to the edema and to remaining in one position, which increases capillary pressure. Turning the client every 1 to 2 hours promotes vasodilation and prevents vascular compression. Administering pain medication will not have an effect on skin integrity. Encouraging fluids is not a direct intervention for maintaining skin integrity, although being well hydrated is a goal for most clients. Maintaining hygiene does influence skin integrity but is secondary in this situation.

What measure should the nurse take that will be most helpful in preventing wound infection when changing a client's dressing after coronary artery bypass surgery? Use prepackaged sterile dressings to cover the incision. Wash hands before changing the dressing. Place soiled dressings a hazardous waste container. Clean the incisional area with an antiseptic.

Wash hands before changing the dressing. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.

A client is receiving digoxin, and the pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should do what first? Administer the digoxin. Notify the charge nurse. Withhold the digoxin. Notify the health care provider (HCP).

Withhold the digoxin. The nurse's initial response should be to withhold the digoxin. The nurse should then notify the HCP if the apical pulse is 60 bpm or lower because of the risk of digoxin toxicity. The charge nurse does not need to be notified, but the nurse needs to document the notification and follow-up in the medical record.

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? Withhold the dose of the medication and contact the HCP. Contact the pharmacist for a lower dose of the medication. Administer the medication as prescribed. Assess the client for signs of bruising on the extremities.

Withhold the dose of the medication and contact the HCP. Based on the laboratory findings, prothrombin time and 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 withhold the enoxaparin and contact the HCP. The HCP, not the pharmacist, will make the decision about the dose of the enoxaparin. The decision about administering the drug will be based on laboratory results, not evidence of bruising or bleeding.

A client is about to undergo cardiac catheterization for which informed consent was obtained. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Withhold the medication and cancel the procedure. Medicate the client and document his comment. Explain that cardiac catheterization does not involve open heart surgery, and then medicate the client. Withhold the medication and notify the physician immediately.

Withhold the medication and notify the physician immediately. The nurse should withhold the medication and notify the physician that the client does not understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client does not understand, there cannot be a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse may not just medicate the client and document the finding; the physician must be notified. The procedure does not need to be cancelled, only postponed until the client receives more education and is able to give informed consent.

An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written which prescription for taking the metformin before the procedure? Increase the amount of protein in the diet the day before. Withhold the metformin. Give the metformin before breakfast. Administer the metformin with only a sip of water.

Withhold the metformin. The nurse should verify that the HCP has requested to withhold the metformin prior to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system. The HCP may prescribe sliding scale insulin during this time if needed. Regardless of how or when the medication is administered, the medication should be withheld. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.

The transducer system of an arterial line was disconnected from the monitoring cable. What is the best action by the nurse after reconnecting the transducer system to the monitoring cable? Perform a dynamic response test. Zero the transducer system. Change the tubing. Perform a square wave test.

Zero the transducer system. The nurse should zero the transducer system to ensure the accuracy of the readings once the transducer system is reconnected to the monitoring cable. Changing the tubing is not needed. If the tubing needed to be changed, it should be changed prior to the transducer system being zeroed. Performing a square wave test can be completed after the transducer system is zeroed. "Dynamic response test" is merely another term for "square wave test."

Which client is at greatest risk for Buerger's disease? a 65-year-old male with atherosclerosis. a 29-year-old male with a 14-year history of cigarette smoking. a 54-year-old female with adult onset diabetes. a 38-year-old female who is taking birth control pills.

a 29-year-old male with a 14-year history of cigarette smoking. Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men less than 40 years of age, and there is a very strong relationship with tobacco use.Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus.

Which client is at greatest risk for coronary artery disease? a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L) a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago a 43-year-old male with a family history of coronary artery disease (CAD) and cholesterol level of 158 (8.8 mmol/L) a 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin

a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L) The woman who is 65 years old, overweight, and has an elevated LDL is at greatest risk. Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.

A nurse is caring for 4 clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? a client 1 day post coronary stent placement a client with hypertrophic cardiomyopathy a client with a history of repaired ventricular septal defect a client 4 days postoperative after mitral valve replacement

a client 4 days postoperative after mitral valve replacement Having prosthetic cardiac valves places the client at high risk for infective endocarditis. Hypertrophic cardiomyopathy and repaired ventricular septal defects are moderate risks for infective endocarditis. Coronary stent placement isn't a risk factor for infective endocarditis.

Which client admitted to the emergency department should the nurse see first? a client with a blood pressure of 170/95 mm Hg a client with a urine output of 240 mL in 12 hours a client experiencing a "ripping" sensation in the chest a client taking anticoagulants with bloody stool

a client experiencing a "ripping" sensation in the chest A client experiencing a "ripping" sensation in the chest is indicative of a ruptured thoracic aneurysm and warrants an immediate intervention. While a blood pressure of 170/95 mm Hg is high, there is not enough information that suggests that this client is a higher priority than the others. A urine output of 240 mL in 12 hours is less than 30 ml/hour; however, this is this client's only problem now, and the nurse can investigate the cause next. A client experiencing bloody stools will need to be seen; however, no other information is present that would warrant this client being seen first.

The nurse is teaching a group of women about risk for varicose veins. Which client is at risk for varicose veins? a client who has had anemia a client who has had a cerebrovascular accident a client who has had transient ischemic attacks a client who has had thrombophlebitis

a client who has had thrombophlebitis Secondary varicosities can result from previous thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebrovascular accident, anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins.

An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician orders a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client's well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine whether the client has other major risk factors for CAD, the nurse should assess for elevated high-density lipoprotein (HDL) levels. a history of diabetes mellitus. alcoholism. a history of ischemic heart disease.

a history of diabetes mellitus. Diabetes mellitus, smoking, and hypertension are other major risk factors for CAD. Elevated HDL levels aren't a risk factor for CAD; in fact, increased HDL levels seem to protect against CAD. Ischemic heart disease is another term for CAD, not a risk factor. Alcoholism hasn't been identified as a major risk factor for CAD.

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 fourth heart sound (S4). a third heart sound (S3). a first heart sound (S1). a murmur.

a third heart sound (S3). 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.

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60 a Sa02 reading of 92% a urinary output of 50 mL in the past 3 hours a white blood cell count of 19,000/mm3

a urinary output of 50 mL in the past 3 hours Sepsis can cause the release of myoglobin from the cells which will directly block the renal tubules, causing decreased urinary output. If it is not treated with hydration and antibiotics, the client could develop renal failure. A high white blood cell count is expected with sepsis. Temperature can be elevated or below normal in clients with sepsis. The elevated pulse and respirations are normal in the presence of infection and should be monitored. The saturated oxygen level is within normal limits as is the blood pressure.

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 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.

The most common site of aneurysm formation is in the aortic arch, around the ascending and descending aorta. ascending aorta, around the aortic arch. descending aorta, beyond the subclavian arteries. abdominal aorta, just below the renal arteries.

abdominal aorta, just below the renal arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.

A sedentary, obese, middle-aged client is recovering from surgery to remove an embolus in the right iliac artery. The nurse should develop a discharge plan with the client that will focus on participating in which activities? Select all that apply. stress management weight control strength training aerobic activity wearing supportive athletic shoes

aerobic activity weight control Discharge teaching begins when the client enters the hospital. One of the risk factors for clot formation is a sedentary lifestyle, and the client should engage in daily aerobic activity, such as biking or swimming (non-weight-bearing). The client is also overweight and should plan to control the weight through dietary counseling or attending weight management programs in the community. Strength training is beneficial by increasing strength and lean body mass, but not helpful in preventing vascular disease. Stress management is not a focus based on the client's needs at this time. It is not necessary to wear special supportive shoes; comfortable shoes for walking are adequate.

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

an arterial blood pressure of 80/50 mm Hg 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 of 26 and a creatinine of 1.2 are normal findings. While +1 pedal pulses may be an abnormal finding, it is not uncommon, and it is important to compare this finding to previous assessments and note if this is a change of the strength of the pedal pulses. Absent bowel sound and mild abdominal distension is expected for a client immediately following surgery. However this finding should be monitored as it could indicate a paralytic ileus.

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 decreased serum digoxin level. a decreased serum CK level. an increased serum creatine kinase (CK) level. an increased serum creatinine level.

an increased serum creatine kinase (CK) level. 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.

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which finding requires further evaluation? heart rate 57 bpm ankle brachial index of 0.65 blood pressure 134/82 mm Hg SpO2 of 94% on room air

ankle brachial index of 0.65 An ankle-brachial index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history.

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an antibiotic. antihypertensive. anticonvulsant. anticoagulant.

anticoagulant. During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses don't routinely give antibiotics during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.

Three days after surgery to insert a mechanical mitral valve, the client asks what can be done to muffle the clicking sound since it is embarrassing and others will know an artificial valve is in the heart. The nurse's response should reflect the understanding that the client may be experiencing which concern? altered tissue perfusion anxiety related to altered health status lack of knowledge regarding the postoperative course anxiety related to altered body image

anxiety related to altered body image Verbalized concerns from this client may stem from anxiety over the insertion of a mechanical heart valve that makes an audible clicking sound and fear that others will become aware of the sound and ask questions. Although the client may experience anxiety related to the altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in body image. The client is not concerned about altered tissue perfusion.

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? arterial blood gas (ABG) findings oxygen saturation level red blood cells (RBCs) and hemoglobin count findings white blood cell differential

arterial blood gas (ABG) findings Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.

A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will require long-term administration of pentoxifylline or acetaminophen. penicillin V or erythromycin. aspirin or acetaminophen. aspirin or clopidogrel.

aspirin or clopidogrel. After PTCA, the client begins long-term aspirin or clopidogrel therapy to prevent thromboembolism. Physicians order heparin for anticoagulation during this procedure; some physicians discharge clients with a prescription for long-term warfarin or low-molecular-weight heparin therapy. Pentoxifylline, a vasodilator used to treat chronic arterial occlusion, isn't required after PTCA because the procedure itself opens the vessel. The physician may order short-term acetaminophen therapy to manage fever or discomfort, but prolonged therapy isn't warranted. The client may need an antibiotic, such as penicillin or erythromycin, for a brief period to prevent infection associated with an invasive procedure; long-term therapy isn't necessary.

A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m. (0700), before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to give the client an I.M. vitamin K injection and notify the physician of the results. assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. call the physician to request an increase in the warfarin dose. notify the next shift to hold the daily 5 p.m. dose of warfarin.

assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the physician of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a physician's order. The nurse should notify the physician before holding a medication scheduled to be administered during another shift.

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? assessing troponin 1 levels monitoring the white blood cell count assessing B-type natriuretic peptide levels monitoring the platelet count

assessing troponin 1 levels Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority.

Which condition most commonly results in coronary artery disease (CAD)? atherosclerosis myocardial infarction renal failure diabetes mellitus

atherosclerosis Atherosclerosis (plaque formation), is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related.

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: drinks fluids through a straw. clenches the teeth while moving in bed. assumes a side-lying position. avoids holding the breath during activity.

avoids holding the breath during activity. 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.

A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? dependent edema bibasilar crackles right upper quadrant pain jugular vein distention

bibasilar crackles Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

The nurse is assessing a client with chronic bronchitis. For which finding should the nurse suspect that the client is developing right-sided heart failure? bilateral edema of the feet and ankles bilateral crackles that clear with coughing clubbing of the fingernails on both hands dyspnea on exertion

bilateral edema of the feet and ankles A client with chronic bronchitis, a form of chronic obstructive pulmonary disease (COPD), may experience symptoms that are similar to those of left-sided heart failure, such as dyspnea on exertion. However, without other risk factors, the client with COPD is at risk for right-sided, not left-sided, heart failure. Bilateral edema of the feet and ankles would not occur with chronic bronchitis but is evidence of right-sided heart failure due to the resistance to venous return to the right side of the heart. Bilateral crackles that clear with coughing would occur with chronic bronchitis. Note that pulmonary edema is not expected with right-sided heart failure. Nail clubbing develops in chronic bronchitis because of chronic oxygen deprivation and is not evidence of heart failure.

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. During admission, what should the nurse assess first? urine output blood pressure skin breakdown serum potassium level

blood pressure It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.

The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? pulse rate blood pressure respiratory rate oxygen saturation

blood pressure Nitroglycerin can cause hypotension. A priority nursing assessment after the administration of nitroglycerin is the client's blood pressure.

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? pulse rate of 84 beats/minute respiration 26 breaths/minute temperature of 100.2° F (37.9° C) blood pressure 84/52 mm Hg

blood pressure 84/52 mm Hg Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute urine output of 15 ml/hour and 2+ hematuria urine output of 150 ml/hour and heart rate of 45 beats/minute

blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should assess the client for which changes? seizure hypertension cardiac arrhythmias hypothermia

cardiac arrhythmias Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA.

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider suspects the client is experiencing a dissecting aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm? stroke pulmonary edema myocardial infarction cardiac tamponade

cardiac tamponade Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm. The sudden, painful "tearing" sensation is typically associated with the sudden release of blood, and the client may experience cardiac arrest. Stroke, pulmonary edema, and myocardial infarction are not common complications of a dissecting aneurysm.

A nurse is preparing a teaching plan for a male client newly prescribed atenolol. Which information is important for the nurse to teach this client? prevention of constipation control of excessive flatus causes and treatments for erectile dysfunction management of incontinence

causes and treatments for erectile dysfunction Erectile dysfunction is a potential adverse effect of beta blockers.

The nurse is assessing a client with an atrial septal defect (ASD). Which finding requires immediate nursing intervention? client having tachycardia at a rate of 100 beats/min client not taking angiotensin-converting enzyme inhibitor this morning fixed split S2, which does not vary with respiration client having an uneven smile and facial droop

client having an uneven smile and facial droop A fixed S2 split is the hallmark of ASD. The neurologic finding of a facial droop could indicate embolization and stroke; the nurse should notify the healthcare provider immediately. If the client has missed a medication, the nurse should measure the vital signs and administer the medication as soon as possible; however, symptoms of stroke are the priority. The nurse should further assess tachycardia to determine the underlying cause, such as pain or fever, before intervening.

Which clinical manifestation would be most indicative of complete arterial obstruction in the lower extremities? coldness numbness and tingling aching pain burning sensations

coldness Coldness is the assessment finding most consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor.Aching pain, burning sensations, numbness, and tingling are all earlier signs of tissue hypoxia and ischemia and are associated with incomplete obstruction.

The nurse is caring for a client following a myocardial infarction and is aware that complications can occur due to damage to the myocardium. Which interventions would be appropriate for this client? Select all that apply. continuous cardiac monitoring via telemetry maintaining bed rest for 72 hours auscultating apical pulse every 2 hours electrocardiogram with any chest pain ambulating length of hall in first 24 hours

continuous cardiac monitoring via telemetry auscultating apical pulse every 2 hours electrocardiogram with any chest pain After a myocardial infarction, it is important to monitor the client carefully for complications. An EKG should be done with any chest pain to assess for any changes that would indicate additional damage to the heart muscle. Auscultating the apical pulse and continuous cardiac monitoring would identify a change in status. Bed rest would be maintained for 24 hours, and ambulation would be added gradually, not in the first 24 hours.

The nurse is assessing a client with a known history of chronic heart failure. Which finding indicates poor perfusion to the tissues? shortness of breath when supine cool, pale extremities heart rate 104 bpm blood pressure 102/64 mm Hg

cool, pale extremities In heart failure, the heart is unable to adequately meet the body's metabolic demands; in an attempt to supply major organs, less blood is circulated to extremities, leaving them cool, pale and potentially cyanotic. A blood pressure of 102/64 mm Hg is lower than average, but it may be normal for this client and would not indicate poor perfusion to tissues. It is not unusual for the client with heart failure to have a slightly elevated heart rate (unless taking medications to lower the heart rate) because the increased rate may help compensate for reduced stroke volume (and therefore, decreased cardiac output). Shortness of breath may occur with heart failure as a result of poor pumping action of the heart that allows fluid to accumulate in the lungs, however, it is not an indicator of peripheral perfusion.

A client is admitted for treatment of Prinzmetal's angina. When developing this client's care plan, the nurse should keep in mind that this type of angina can result from: the same type of activity that caused previous angina episodes. an unpredictable amount of activity. coronary artery spasm. activities that increase myocardial oxygen demand.

coronary artery spasm. Prinzmetal's angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; anginal pain becomes increasingly severe.

A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply. serum glucose creatine kinase (CK) blood urea nitrogen (BUN) myoglobin troponin T and troponin I hemoglobin and hematocrit (HCT)

creatine kinase (CK) troponin T and troponin I myoglobin With myocardial ischemia or infarction, levels of CK, troponin T, and troponin I typically rise because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage.

A client presents to the ED in shock. During what phase of shock does the nurse know that metabolic acidosis is going to most likely occur? compensation irreversible decompensation early

decompensation The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.

Metoprolol is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension who has been initially treated with furosemide and ramipril. The nurse should evaluate the client for which expected therapeutic effect? lessening of fatigue. increase in urine output. decrease in heart rate. improvement in blood sugar levels.

decrease in heart rate. The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output.

A client with hypertrophic cardiomyopathy (HCM) is experiencing dyspnea, chest pain, syncope, fatigue, and palpitations and has an apical systolic thrill and heave, fourth heart sound (S4), and systolic murmur. Which nursing diagnosis should the nurse use to guide this client's care? risk for activity intolerance ineffective peripheral tissue perfusion risk for deficient fluid volume decreased cardiac output

decreased cardiac output Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of risk for deficient fluid volume is not applicable. Ineffective peripheral tissue perfusion would be applicable if the client is experiencing an alteration in peripheral pulses, capillary refill time greater than 3 seconds, or a change in skin characteristics. Although it might seem that the diagnosis of risk for activity intolerance would be applicable because of dyspnea and fatigue, addressing cardiac output will help reduce these symptoms.

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

The nurse is caring for a client with cardiomyopathy. Which diagnosis should the nurse make a priority to guide this client's care? decreased cardiac output related to reduced myocardial contractility excess fluid volume related to fluid retention and altered compensatory mechanisms ineffective coping related to fear of debilitating illness anxiety related to actual threat to health status

decreased cardiac output related to reduced myocardial contractility Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although excess fluid volume, ineffective coping, and anxiety are important nursing diagnoses, the nurse can address them when the client has improved cardiac output and myocardial contractility.

The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an aortic aneurysm. What is a priority assessment for this client? decreased urinary output wound infection anxiety electrolyte imbalance

decreased urinary output Following surgical repair of an aortic aneurysm, there is a potential for an alteration in renal perfusion, manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during surgery. Electrolyte imbalance and anxiety do not present imminent risk for this client; signs of wound infection are generally not evident immediately following surgery, but the nurse should monitor the incision on an ongoing basis.

The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which condition? development of congestive heart failure acute renal failure a hypoglycemic reaction cardiogenic shock associated with heart block

development of congestive heart failure Crackles probably signify pulmonary edema, which occurs when there is left-sided congestive heart failure. The client is very dyspneic, and the heart appears to be compensating (increased rate because of respiratory congestion). Initiation of measures to help strengthen the heartbeat is a very important priority. Signs and symptoms do not indicate hypoglycemic reaction or renal failure. Heart block would be indicated by bradycardia.

Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The client is exercising using a stationary bicycle. The nurse should evaluate the client's response to exercise by assessing the presence of which condition? muscle atrophy diabetic neuropathy transient ischemic attacks Raynaud's disease

diabetic neuropathy A common complication of diabetes is diabetic neuropathy. Diabetic neuropathy results from the metabolic and vascular factors related to hyperglycemia. Damage leads to sensory deficits and peripheral pain. Muscle atrophy can result from disuse, but it is not a direct consequence of diabetes. Raynaud's disease is associated with vasospasms in the hands and feet. Transient ischemic attacks involve the cerebrum.

An older adult is admitted to the hospital with nausea and vomiting. The client has a history of heart failure and is being treated with digoxin. The client has been nauseated for a week and began vomiting 2 days ago. Laboratory values indicate hypokalemia. Because of these clinical findings, the nurse should assess the client carefully for: exacerbation of heart failure. chronic renal failure. metabolic acidosis. digoxin toxicity.

digoxin toxicity. Nausea and vomiting, along with hypokalemia, are likely indicators of digoxin toxicity. Hypokalemia is a common cause of digoxin toxicity; therefore, serum potassium levels should be carefully monitored if the client is taking digoxin. The earliest clinical signs of digoxin toxicity are anorexia, nausea, and vomiting. Bradycardia, other dysrhythmias, and visual disturbances are also common signs. Chronic renal failure usually causes hyperkalemia. With persistent vomiting, the client is more likely to develop metabolic alkalosis than metabolic acidosis.

What is the expected outcome of thrombolytic drug therapy for stroke? increased vascular permeability vasoconstriction prevention of hemorrhage dissolved emboli

dissolved emboli Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

A client returns from a left heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client? posterior to the right knee anterior to the right tibia dorsal surface of the right foot right mid-inguinal area

dorsal surface of the right foot To best monitor that the client's circulation remains intact, the dorsal surface of the right foot should be palpated. When the left-side of the heart is catheterized, the cannula enters via an artery. In this instance, the right femoral artery was accessed. While all options assess arterial points of the right leg, the dorsal surface of the right foot (the pedal pulse) is the most distal. If this pulse point is present and unchanged from before the procedure, the other pulse points should also be intact.

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. stress e-cigarette use hypertension genetics gender

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

The nurse is preparing to teach a client with iron deficiency anemia about the diet to follow after discharge. Which food should be included in the diet? citrus fruits cheese eggs lettuce

eggs For the client with iron deficiency anemia, a rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green, leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium

The rapid response team arrives in the room of a client who has had a cardiac arrest. The nurse should first apply which piece of monitoring equipment? electrocardiogram (ECG) electrodes Doppler pulse detection unit pulse oximeter blood pressure cuff

electrocardiogram (ECG) electrodes The nurse should first apply the ECG electrodes to the client's chest. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate the client. Pulse oximetry is not an immediate priority. The client's oxygenation is evaluated in a code situation using arterial blood gas analysis. The client's blood pressure is evaluated after the ECG rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of a pulse or to check the blood pressure in a code situation.

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: lidocaine level. electrocardiogram (ECG). troponin level. blood pressure.

electrocardiogram (ECG). 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 fourth heart sound (S4) indicates a dilated aorta. normally functioning heart. decreased myocardial contractility. failure of the ventricle to eject all blood during systole.

failure of the ventricle to eject all blood during systole. An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. A nurse doesn't hear an S4 in a normally functioning heart.

A young adult has been diagnosed with hypertrophic cardiomyopathy. The nurse should further assess the client for which complication? fatigue and shortness of breath angina abdominal pain hypertension

fatigue and shortness of breath Cardiomyopathy is a broad term that includes three major forms: dilated, hypertrophic, and restrictive cardiomyopathies. The underlying etiology of hypertrophic cardiomyopathy is unknown; it is typically observed in young men but is not limited to them. Common symptoms are fatigue, low tolerance to activity related to the low ejection fraction, and shortness of breath. Angina may be observed if coronary artery disease is present. Abdominal pain and hypertension are not common.

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

fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) 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.

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

fewer episodes of numbness in the fingers 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.

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. How should the nurse document these findings? heart rate irregular with S4 heart rate irregular with mitral stenosis heart rate irregular with S3 heart rate irregular with aortic regurgitation

heart rate irregular with S3 An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex, and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.

A client has risk factors for coronary artery disease, including smoking cigarettes, eating a diet high in saturated fat, and leading a sedentary lifestyle. Which coaching strategies from the nurse will be most effective in assisting the client improve his or her health? helping the client establish a wellness vision to reduce the health risks withholding praise until the client changes the risky behavior explaining how the risk factors lead to poor health instilling mild fear into the client about the potential outcomes of the risky health behaviors

helping the client establish a wellness vision to reduce the health risks In health coaching, unlike traditional client education techniques in which the nurse provides information, the goal of coaching is to encourage the client to explore the reasons for the behavior and establish a vision for health behavior and the way he or she can make changes to improve their health behavior and reduce or eliminate health risks. When coaching a client, the nurse does not provide information, withhold praise, or instill fear.

Which finding is a risk factor for hypovolemic shock? antigen-antibody reaction gram-negative bacteria vasodilation hemorrhage

hemorrhage Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.

A nurse is counseling a client about risk factors for hypertension. While reviewing the client's history, which information is consistent with the diagnosis of primary hypertension? Select all that apply. hormonal contraceptives diabetes mellitus head injury high intake of sodium or saturated fat obesity stress

high intake of sodium or saturated fat obesity stress Primary or essential hypertension has no identifiable cause, although it is thought to be linked to genetics, and tends to develop gradually over years. Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes mellitus, head injury, and hormonal contraceptive use are risk factors for secondary hypertension.

The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance? hypocalcemia hyperkalemia hypermagnesemia hyponatremia

hyperkalemia Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.

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? immediate defibrillation synchronized cardioversion an I.V. push of digoxin an I.V. line for emergency medications

immediate defibrillation 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 caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse? insertion of an I.V. line scheduling a pacemaker insertion immediate defibrillation administration of digoxin

immediate defibrillation When ventricular fibrillation is verified, the first intervention is defibrillation. It is the only intervention that will terminate this lethal dysrhythmia. Digoxin will not help in this situation. An I.V. line will need to be established, but it is not the priority. A pacemaker may be needed, but not until the client is stabilized.

The client with peripheral artery disease has been prescribed diltiazem. To determine the effectiveness of this medication, the nurse should assess the client for which intended outcome? improved blood flow cooler extremities prolonged sleep decreased anxiety

improved blood flow Diltiazem is a calcium channel blocker that blocks the influx of calcium into the cell. The primary use of diltiazem for this client is to promote vasodilation and prevent spasms of the arteries so blood, oxygen, and nutrients can reach the muscle and tissues. Diltiazem is not an antianxiety agent and does not promote sleep. It also does not cause vasoconstriction, which would cause coolness in the extremities and is contraindicated for the client with peripheral vascular disease.

The client returns to the hospital 3 days after diagnosis of deep vein thrombosis, with reports of cough, hemoptysis, shortness of breath, and sharp pain under the right scapula. The client is subsequently is diagnosed with a pulmonary embolus (PE). The client asks the nurse, "How did I even get a pulmonary embolus?" What is the best response by the nurse? Select all that apply. having any condition that produces venous stasis increased blood coagulability taking medications such as warfarin sodium frequent falls venous endothelial changes

increased blood coagulability venous endothelial changes having any condition that produces venous stasis The nurse should relay to the client that a pulmonary embolism is caused by blood clots that travel to the lungs from the legs or, rarely, other parts of the body. Because the clots block blood flow to the lungs, a pulmonary embolism can be life-threatening. Major risk factors for the development of PE include any condition that produces venous stasis, increased blood coagulability, or venous endothelial changes. Major risk factors do not include frequent falls or taking medications such as warfarin sodium and should not be communicated to the client.

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? decreased mean pulmonary artery pressure increased pulmonary artery diastolic pressure increase in the cardiac index decreased central venous pressure

increased pulmonary artery diastolic pressure Increased pulmonary artery diastolic pressure suggests left-sided heart failure. Central venous pressure increases in heart failure rather than decreases. The cardiac index decreases in heart failure. The mean pulmonary artery pressure increases in heart failure.

The plan of care for a client with hypertension taking propranolol hydrochloride should include: instructing the client to notify the health care provider of irregular or slowed pulse rate. instructing the client to discontinue the drug if nausea occurs. monitoring blood pressure every week and adjusting the medication dose accordingly. measuring partial thromboplastin time weekly to evaluate blood clotting status.

instructing the client to notify the health care provider of irregular or slowed pulse rate. 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 client needs to be instructed not to discontinue medication because sudden withdrawal of propranolol hydrochloride may cause rebound hypertension.

During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the nurse palpates the radial pulse and notices which signs? a weak, thready pulse pulse rate below 60 bpm irregular rhythm with pulse rate greater than 100 bpm two regular beats followed by one irregular beat

irregular rhythm with pulse rate greater than 100 bpm Characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the health care provider (HCP) . A weak, thready pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction.

A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume? supine prone semi-Fowler's leaning forward while sitting

leaning forward while sitting The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis.

Before surgery to repair an aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for: disorientation. anxiety. headache. loss of consciousness.

loss of consciousness. If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain.

When listening to a client's heart, the nurse hears a rumbling, low-pitched diastolic murmur with the bell. This sound is consistent with which condition? mitral stenosis aortic stenosis an S3 gallop pericardial friction rub

mitral stenosis Mitral stenosis causes a diastolic, rumbling, low-pitched murmur.

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 medical record, as shown. What is most likely contributing to the client's abdominal distention? IV fluid intake ice chips nasogastric (NG) tube morphine

morphine The client is experiencing paralytic ileus. One of the adverse effects of morphine used to manage pain is decreased GI 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 client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem? liver failure renal failure myocardial infarction myocarditis

myocarditis Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection. The T lymphocytes respond to the viral infection by secreting cytokines to kill the virus, but they also kill the virus-infected myocardium. Myocardial infarction, renal failure, and liver failure are not direct consequences of a viral or parasitic infection.

A nurse reviews a client's medication history before administering a cholinergic blocking agent. Adverse effects of a cholinergic blocking agent may delay absorption of diphenhydramine. nitroglycerin. digoxin. amantadine.

nitroglycerin. A cholinergic blocking agent may cause dry mouth and delay the sublingual absorption of nitroglycerin. The nurse should offer the client sips of water before administering nitroglycerin. Amantadine, digoxin, and diphenhydramine can interact with a cholinergic blocking agent but not through delayed absorption. Amantadine and diphenhydramine enhance the effects of anticholinergic agents.

When performing cardiopulmonary resuscitation (CPR), which finding indicates that external chest compressions are effective? pupillary dilation cool, dry skin mottling of the skin palpable pulse

palpable pulse With CPR, effectiveness of external chest compressions is indicated by palpable peripheral pulses, the disappearance of mottling and cyanosis, the return of pupils to normal size, and warm, dry skin. To determine whether the victim of cardiopulmonary arrest has resumed spontaneous breathing and circulation, chest compressions must be stopped for 5 seconds at the end of the first minute and every few minutes thereafter.

A client has been diagnosed with peripheral arterial occlusive disease. In order to promote circulation to the extremities, the nurse should instruct the client to: use a heating pad to promote warmth. participate in a regular walking program. massage calf muscles if pain occurs. keep the extremities elevated slightly.

participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and resume activity when pain subsides.With arterial disease, extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation.To avoid burns, heating pads should not be used by anyone with impaired circulation.Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? nasal cannula flow rate capillary refill IV fluid infusion rate pedal pulses

pedal pulses With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply. apple juice pepperoni pizza cheese soft drinks bacon oatmeal

pepperoni pizza cheese soft drinks bacon Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content.

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? complete heart block pericardial tamponade left-sided heart failure aortic regurgitation

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

place the client in high Fowler's position. 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 in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? potassium platelet count calcium white blood cell (WBC) count

potassium Diuretics, such as furosemide, are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin, and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.

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? phytonadione (vitamin K) thrombin plasma protein fraction protamine sulfate

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

pulmonary hypertension 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.

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 pulse rate body temperature blood pressure

pulse rate 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.

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

reducing cholesterol levels, increasing activity levels progressively, and coping strategies 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 whose condition remains stable after a myocardial infarction is to gradually increase activity. Which sign best indicates that the activity is appropriate for the client? edema skin color weight respiratory rate

respiratory rate Physical activity is gradually increased after a myocardial infarction while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When any of these symptoms appears, the client should reduce activity and progress more slowly. Edema suggests a circulatory problem that must be addressed but does not necessarily indicate overexertion. Cyanosis indicates reduced oxygen-carrying capacity of red blood cells and indicates a severe pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss indicates several factors but not overexertion.

A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline, metoprolol, and furosemide. On postoperative day 1, the 1200 vital signs are: temperature 98.9° F (37.2° C); heart rate 132 bpm; respiratory rate 20 breaths/min; blood pressure 126/78 mm hg. Urine output is 50 to 70 mL/h. The hemoglobin and the hematocrit are stable. The medications have not been prescribed for administration after surgery. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse contacts the health care provider (HCP) and recommends to: restart the metoprolol. increase the IV fluids. resume the furosemide. continue the pentoxifylline.

restart the metoprolol. The client is experiencing a rebound tachycardia from abrupt withdrawal of the beta blocker. The beta blocker should be restarted due to the tachycardia, history of hypertension, and the desire to reduce the risk of postoperative myocardial morbidity. The bypass surgery should correct the claudication and need for pentoxifylline. The furosemide and increase in fluids are not indicated since the client's urine output and blood pressure are satisfactory and there is no indication of bleeding. The nurse should also determine the potassium level before starting the furosemide.

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: determining how long the client can walk. using ultrasound to estimate the velocity changes in the blood vessels. showing the location of the obstruction and the collateral circulation. scanning the affected extremity and identifying the areas of volume changes.

showing the location of the obstruction and the collateral circulation. 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.

Which position is best for a client with heart failure who has orthopnea? semi-sitting (low Fowler's position) with legs elevated on pillows sitting upright (high Fowler's position) with legs resting on the mattress lying on the back with the head lowered (Trendelenburg position) and legs elevated lying on the right side (Sims' position) with a pillow between the legs

sitting upright (high Fowler's position) with legs resting on the mattress Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg position.

A physician admits a client to the healthcare facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind when formulating interventions? stabilizing heart rate and blood pressure and easing anxiety decreasing blood pressure and increasing mobility increasing blood pressure and reducing mobility increasing blood pressure and monitoring fluid intake and output

stabilizing heart rate and blood pressure and easing anxiety For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.

Considering a client's atrial fibrillation, a nurse must administer digoxin with caution because it affects the sympathetic division of the autonomic nervous system, decreasing vagal tone. can trigger proarrhythmia by increasing stroke volume. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. can induce a hypertensive crisis by constricting arteries.

stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. A nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, increasing the potential for new arrhythmias to develop. Digoxin doesn't constrict arteries. Although digoxin can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).

A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client? avoid trauma to extremities begin a walking exercise program report wounds promptly to healthcare provider stop smoking

stop smoking Buerger's disease is a nonatherosclerotic, recurrent inflammatory disorder of the small- and medium-sized arteries and veins of the upper and lower extremities. The disease occurs mostly in young men with a long history of tobacco use and chronic periodontal infection, but without other CVD risk factors such as hypertension, hyperlipidemia, and diabetes. Absolute cessation of nicotine is required to reduce the risk for amputation. Conservative management includes avoiding limb exposure to cold temperatures, a supervised walking program, antibiotics to treat any infected ulcers, and analgesics to manage the ischemic pain. Teach clients to avoid trauma to the extremities.

Which set of postural vital signs in a client with hypertension should the nurse report to the health care provider (HCP)? supine 100/70 mm Hg, 72 bpmsitting 100/68 mm Hg, 74 bpmstanding 98/68 mm Hg, 80 bpm supine 120/70 mm Hg, 70 bpmsitting 102/64 mm Hg, 86 bpmstanding 100/60 mm Hg, 92 bpm supine 124/76 mm Hg, 88 bpmsitting 124/74 mm Hg, 92 bpmstanding 122/74 mm Hg, 92 bpm supine 138/86 mm Hg, 74 bpmsitting 136/84 mm Hg, 80 bpmstanding 134/82 mm Hg, 82 bpm

supine 120/70 mm Hg, 70 bpmsitting 102/64 mm Hg, 86 bpm standing 100/60 mm Hg, 92 bpm There was a significant change in both blood pressure and heart rate with position change, indicating inadequate blood volume to sustain normal values. The nurse should report this change to the HCP. Normal postural changes allow for an increase in heart rate of 5 to 20 bpm, a possible slight decrease of <5 mm Hg in the systolic blood pressure, and a possible slight increase of <5 mm Hg in the diastolic blood pressure.

A client who had an exploratory laparotomy 3 days ago now has a white blood cell (WBC) count of 15,000 µL (15x109/L). For which clinical findings of this laboratory report should the nurse assess the client? Select all that apply. weak pedal pulses nonproductive cough redness around the incision elevated temperature swelling around the incision

swelling around the incision redness around the incision elevated temperature The client has an elevated white count. Normal white count is 4,300 to 10,800 µL (4.3 to 10.8 x 109/L). The client is at risk for infection, and the nurse should assess the client for inflammation around the incision site, redness at the incision site, and elevated temperature. The client should be encouraged to cough and deep breathe, and it is unlikely that a cough is related to an incisional infection. Weak pedal pulses are not indications of an infection, but the nurse should report this finding if it persists.

Which indicates hypovolemic shock in a client who has had a 15% blood loss? pulse rate less than 60 bpm pupils unequally dilated respiratory rate of 4 breaths/minute systolic blood pressure less than 90 mm Hg

systolic blood pressure less than 90 mm Hg Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.

On a routine visit to the health care provider, a client with chronic arterial occlusive disease reports quitting smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend? taking daily walks abstaining from foods that increase levels of high-density lipoproteins (HDLs) reducing daily fat intake to less than 45% of total calories engaging in anaerobic exercise

taking daily walks Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.

When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should: encourage the client to wear clothing designed especially for people who have had a CVA. teach the client to put on clothing on the affected side first. advise the client to ask for help when dressing. dress the client, explaining each step of the process as it is completed.

teach the client to put on clothing on the affected side first. When dressing, the client will find it easier to dress if clothing is put on the affected side first.Clients who have had cerebrovascular accidents should wear normal clothing, if possible.Dressing the client does not promote self-care skills.Other people may help the client dress, but the emphasis should be on self-care.

The client asks the nurse, "Why won't the health care provider tell me exactly how much of my leg he is going to take off? Don't you think I should know that?" On which information should the nurse base the response? the ease with which a prosthesis can be fitted the need to remove as much of the leg as possible the client's ability to walk with a prosthesis the adequacy of the blood supply to the tissues

the adequacy of the blood supply to the tissues The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply, the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.

A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? the client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday the client with a history of cardioversion for sustained ventricular tachycardia 2 days ago the client with a history of heart failure who has bibasilar crackles and pitting edema in both feet the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block

the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client who underwent cardioversion 2 days ago has likely had the underlying reason for the sustained ventricular tachycardia corrected. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first is not necessary. The client who underwent PCI with stenting was at risk for reperfusion arrhythmias and/or bleeding from the arterial puncture site but could be considered to be stable 24 hours post-procedure.

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

the client is going into cardiogenic shock. 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.

The nurse's unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught? the amount of education the acute MI clients received on the telemetry unit the quality of teaching by the nurses who educate the acute MI clients on the telemetry unit the clients' perception of the quality of the discharge instructions the percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity

the percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity The unit council needs to assess the number of clients diagnosed with an acute MI on the telemetry unit who were actually taught about resuming sexual activity. The unit council needs to identify the number of clients who were taught, not the quality of the teaching. Only education about resuming sexual activity is pertinent to this performance improvement study. The nurses' assessment of the quality of client education isn't pertinent to this study either.

The primary goal for the client with Buerger's disease is to prevent: thrombus formation. thrombophlebitis. fat embolus formation. embolus formation.

thrombus formation. Because of the inflammation, a common complication of Buerger's disease is thrombus formation and potential occlusion of the vessel. Inflammation of the immediate and small arteries and veins is involved in the disease process.Embolus is a potential risk if a thrombus has developed.Fat embolus is associated with fractures of the bones.Thrombophlebitis occurs after thrombus formation.

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 improve the gastric acidity of the stomach to address the fluctuation in blood sugar to reduce the amount of fecal elimination to reduce the metabolic workload of digestion

to reduce the metabolic workload of digestion 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 discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having which procedure? tooth extraction an IV line inserted blood drawn an X-ray examination

tooth extraction The client with a synthetic graft may need to be treated with prophylactic antibiotics before undergoing major dental work and should notify the HCP before any such procedure. Prophylactic antibiotic treatment reduces the danger of systemic infection caused by bacteria from the oral cavity. Venous access for drawing blood, IV line insertion, and X-rays do not contribute to the risk of infection.

A client is scheduled for 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) prior to the stress test? prothrombin time troponin level cholesterol level erythrocyte sedimentation rate

troponin level The elevated troponin level should be reported to the HCP prior to the stress test as 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 has an International normalized ratio (INR) of 1.6, creatine kinase-MB (CK-MB) of 90 μ/L, troponin 2.1 ng/L, and myoglobin 90 μg/L. Which result requires the nurse to take action? myoglobin 90 μg/L CK-MB of 90 μ/L troponin of 2.1 ng/L INR of 1.6

troponin of 2.1 ng/L Troponins I and T are cardiac enzymes that are only released when the cardiac muscle is damaged. Elevation of these values above the respective reference ranges of 0-0.1 ng/L or 0-0.2 ng/L indicates a myocardial infarction. Myoglobin is released when muscle cells are damaged. Myoglobin may rise above the normal level of 0-90 μg/L with a myocardial infarction (MI) but is not a clear indicator of MI because it can also rise during strenuous exercise, traumatic injury, and intramuscular injections. CK-MB will rise following MI, but may be elevated by events that also raise myoglobin. A normal range for CK-MB is between 30 and 170 μ/L. The INR test is a measure of blood clotting. An INR value of 1.6 is within the normal range.

A client with refractory angina pectoris is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab. Before beginning the infusion, the nurse should ensure the client has up-to-date partial thromboplastin time (PTT) result in his record. ampule of naloxone at the bedside. continuous electrocardiogram (ECG) monitoring. negative history of tonic-clonic seizures.

up-to-date partial thromboplastin time (PTT) result in his record. Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation and, thereby, reduces cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date PTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid; therefore, an opioid antagonist doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab.

As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: causing an increased myocardial oxygen demand. antispasmodic effects on the pericardium. improved conductivity in the myocardium. vasodilation of peripheral vasculature.

vasodilation of peripheral vasculature. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents ventricular repolarization. ventricular depolarization. atrial repolarization. atrial depolarization.

ventricular depolarization. The QRS complex on the ECG strip represents ventricular depolarization. Atrial repolarization usually occurs at the same time as ventricular depolarization and is impossible to distinguish on the ECG. The T wave represents ventricular repolarization. The P wave represents atrial depolarization.

The nurse interprets the rhythm strip (see figure) from a client's bedside monitor as which rhythm? ventricular fibrillation sinus tachycardia ventricular tachycardia normal sinus rhythm

ventricular tachycardia This rhythm is ventricular tachycardia, which is characterized by an absent P wave and a heart rate of 140 to 220 bpm. Ventricular tachycardia requires immediate intervention, usually with lidocaine.

The nurse is counseling a client about the prevention of coronary heart disease. Which vitamins should the nurse recommend the client include in the diet to reduce homocysteine levels? Select all that apply. vitamin B6 vitamin K vitamin D folate vitamin B12

vitamin B6 folate vitamin B12 Vitamin B6, folate, and vitamin B12 have been shown to reduce homocysteine levels.

A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to: weigh daily. have a serum potassium level drawn weekly. take blood pressure daily. keep a daily record of urine output.

weigh daily. Monitoring daily weight will help determine the effectiveness of diuretic therapy. A client who gains weight without diet changes most probably is retaining fluids, so the diuretic therapy should be adjusted. Blood pressure monitoring is useful when diuretics are prescribed to control blood pressure. However, in clients with heart failure, the primary indication is to promote sodium and water excretion by the kidneys. While it may be useful to monitor intake and urinary output in the hospital, daily weights are a sensitive indicator of fluid status and more practical for home management. The client may be told to eat a potassium-rich diet; however, serum potassium levels are not used to determine the effectiveness of diuretic therapy.