Cardiovascular NCLEX

Which condition most commonly results in coronary artery disease (CAD)?

atherosclerosis

A client receiving a loop diuretic should be encouraged to eat which foods to prevent potassium loss? Select all that apply.

banana dried fruit orange juice

The correct landmark for obtaining an apical pulse is the

left fifth intercostal space, midclavicular line.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?

Lie down or sit in a chair for 5 to 10 minutes after taking the drug.

When a client has a troponin level of 0.9 ng/mL, which nursing intervention should be implemented?

Notify the healthcare provider.

The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin?

blood pressure

A client has been diagnosed with atrial fibrillation. The health care provider prescribed warfarin to be taken on a daily basis. The nurse instructs the client to avoid using which over-the-counter medication while taking warfarin?

aspirin Aspirin is an antiplatelet medication. The use of aspirin is contraindicated while taking warfarin because it will potentiate the drug's effects.

Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?

canned tomato juice

When the nurse is assessing an individual with peripheral artery disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?

coldness of the left foot and ankle

A nurse is awaiting the arrival of a client from the emergency department with a diagnosis of anterior wall myocardial infarction. In caring for this client, the nurse would be alert for which signs and symptoms of left-sided heart failure? Select all that apply.

dyspnea crackles tachycardia

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?

rheumatic fever Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections.

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?

"I already have my airline ticket, so I won't miss my meeting tomorrow."

During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use?

1 mg I.V.

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?

"We will try to assign you the same nurse as often as possible."

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.

-"Gradually increasing my exercise levels will help enhance circulation through 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." -"Walking is excellent exercise to strengthen my heart."

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

Assess respiratory status.

A client who has a history of bacterial endocarditis is scheduled to have oral surgery to remove a tooth. What should the nurse instruct the client to do?

Be sure the dentist prescribes a prophylactic antibiotic prior to the oral surgery.

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 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.

A client is recovering from coronary artery bypass graft (CABG) surgery and begins to experience chest pain, shortness of breath, and tachycardia. Further assessment reveals a widened QRS complex and an elevated ST segment. Which nursing diagnosis takes highest priority at this time?

Decreased cardiac output related to depressed myocardial function. For a client recovering from CABG surgery and experiencing these symptoms, decreased cardiac output is the most important nursing diagnosis. Complications of CABG include hemorrhage, dysrhythmias, and myocardial infarction (MI) leading to decreased cardiac output

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. What should the nurse instruct the client to do?

Take a nitroglycerin tablet before climbing the stairs.

Which client is at greatest risk for Buerger's disease?

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

The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hours ago. Which finding warrants further evaluation?

an arterial blood pressure of 80/50 mm Hg

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?

anxiety related to altered body image

The nurse is assigned to a client in the ICU. During the initial assessment, the nurse notes jugular vein distention and recognizes that the plan of care will follow which disorder?

heart failure Elevated venous pressure, exhibited as jugular vein distention, indicates the heart's failure to pump.

A client is admitted to the emergency department with a history of abdominal aortic aneurysm. The nurse assesses the client for which sign or symptom that suggests the client's abdominal aortic aneurysm is extending?

increased abdominal and back pain

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 depolarization.

The nurse is teaching a client how to apply nitroglycerin topical ointment. Which statement indicates that the client needs additional clarification of the instructions?

"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 newly admitted client reports taking digoxin and warfarin. Which statement would the nurse include in the discharge instructions?

"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 client with heart failure asks the nurse about the reason for taking enalapril maleate. The nurse should tell the client:

"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.

The client has had hypertension for 20 years. The nurse should assess the client for?

Renal insufficiency and failure.

The nurse is observing the electrocardiogram (EKG) rhythm of a client with a permanent pacemaker and determines there is not a QRS complex that follows the pacemaker spike. Which follow-up action is most appropriate?

Report to the health care provider that the pacemaker is failing to capture. Failure to capture is observed when the pacemaker fails to generate a complex; in this case, the pacemaker fails to generate a ventricular complex with the QRS. This needs to be reported to the health care provider and the client should be assessed to determine any clinical manifestations of low blood flow due to this.

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?

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 the onset of MI.

A visiting nurse is teaching a client with heart failure about taking their medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene?

Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications.

The nurse is administering *adenosine* to a client with supraventricular tachycardia. What is the expected therapeutic response?

a short period of asystole The expected response to this medication is a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain followed by a return to normal sinus rhythm. It is used to convert dysrhythmias to normal sinus rhythm and should not cause ventricular tachycardia

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?

ankle brachial index of 0.65 >0.9 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication

The nurse is preparing the client newly diagnosed with peripheral arterial disease for discharge with the medication atorvastatin. What laboratory work should the nurse obtain to establish a baseline before starting the medication?

creatinine level and liver function tests Atorvastatin has serious adverse reactions of hepatotoxicity and acute renal failure, so it is recommended that creatinine level and liver function tests be performed at baseline as a monitoring parameter.

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 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.

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. --Propranolol hydrochloride is a ?-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.

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

26

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first?

Assess the client's orientation and vital signs.

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.

pepperoni pizza bacon cheese soft drinks

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?

Wash hands before changing the dressing.

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).

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 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.

A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem?

myocarditis

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:

digoxin toxicity.

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort?

red, warm, palpable linear cord along the vein that is painful on palpation -Superficial thrombophlebitis is associated with pain, warmth, and erythema. The nurse can request a prescription for warm packs to relieve the pain. -Venous insufficiency causes edema and a brown discoloration of the lower leg. -Varicose veins are dark, protruding veins, and symptoms of discomfort increase with standing. -Pain on dorsiflexion of the foot indicates deep vein thrombosis (DVT); the client does not indicate having this pain.

A client had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client about residual limb care. Which statement by the client indicates that the client understands how to implement the plan of care?

"I should rewrap the stump as often as needed." The purpose of wrapping the residual limb is to shape the residual limb to accept a prosthesis and bear weight. The compression bandaging should be worn at all times for many weeks after surgery and should be reapplied as needed to keep it free of wrinkles and snug. The dressing should be changed daily to allow for inspection of the stump incision. No lotions should be applied to the stump unless specifically prescribed by the health care provider (HCP) . The stump should not be elevated on pillows because this will contribute to the formation of flexion contractures.

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 clergy member who is assigned to the transplant team.

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 beta-active agent

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?

aorta

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?

confusion, urine output 15 mL over the last 2 hours, orthopnea A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure.

A client is taking spironolactone to control hypertension. The client's serum potassium level is [6 mEq/L (56mmol/L)]. For this client, the nurse's priority should be to assess their

electrocardiogram (ECG) results. Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation.

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:

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.

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?

Pulse

A client is taking spironolactone. Which change in the diet should the nurse teach the client to make when taking this drug?

Avoid eating foods high in potassium. =Spironolactone is a potassium-sparing diuretic that causes excretion of sodium. When taking this drug, it is important that the client not eat foods high in potassium to avoid elevating serum potassium levels. =The client does not need to restrict sodium intake as the drug promotes sodium excretion.

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?

Pedal Pulse, dorsal foot

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?

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 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?

Risk for infection. 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.

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.

In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open-heart surgery, what should the nurse tell the family?

The client will receive medication to relieve pain. Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed.

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 notify the physician immediately.

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

history of aortic valve replacement. A heart valve prosthesis such as an aortic valve replacement is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression.

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?

irregular rhythm with pulse rate greater than 100 bpm

Which action is most important for the nurse to perform post procedure in a client with impaired renal function who is scheduled for a multidetector-computed tomography (MDCT) to evaluate peripheral circulation?

monitoring strict intake and output. Clients with impaired renal function scheduled for MDCT should be monitored closely after the procedure for urine output of at least 0.5 mmL/kg/hr because they are at risk for contrast-induced nephropathy. Before the procedure, there may be an indication for IV fluids and sodium bicarbonate to alkalinize urine and protect against free radical damage. Allergies should also be assessed prior to the procedure and treated with steroids and/or histamine blockers if necessary.

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 adequacy of the blood supply to the tissues

Which client has a need for prophylactic antibiotic therapy prior to dental manipulations?

the client who had an aortic valve replacement 5 years ago. Other implanted devices (hip, knee, ICD-implant cardio defib) can increase the risk of infection, but the client with the greatest risk is the one with the valve replacement.

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first?

the client with heart failure who is having some difficulty breathing

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603 mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how to lower their cholesterol. The nurse should tell the client that

the nurse will ask the dietitian to talk with the client about modifying their diet.

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:

vasodilation of peripheral vasculature. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand.

A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?

"I'll keep a log of each time my ICD discharges." 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.

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?

"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.

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.

-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.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should

place the client in high Fowler's position.

A client with severe angina pectoris and ST-segment elevation on an electrocardiogram is being seen in the emergency department. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a:

troponin level. Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction (MI). It's the best serum indicator of MI and is more indicative of cardiac damage than creatine kinase.

A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action?

weight gain of 2.5 kg (5.5 lb) in 24 hours

A client with chest pain doesn't respond to nitroglycerin. When the client is admitted to the emergency department, the healthcare team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

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?

diabetic neuropathy

The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:

encourage the client to avoid standing in one position for long periods of time. The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time.

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

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.

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?

pericardial tamponade A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery.

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 percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity

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.

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 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.

A client with neutropenia has an absolute neutrophil count (ANC) of 900 (0.9 × 109/L). The nurse teaches the client to prevent which risk of neutropenia?

infection. A client is at moderate risk for infection when the ANC is <1,000 (1 × 109/L).

A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about:

left end-diastolic pressure. When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon.

A nurse is caring for 4 clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?

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.

The nurse is developing a discharge plan for a client who has had a myocardial infarction and been in the cardiac care unit for 2 days. The client will be transferred to a telemetry unit tomorrow. When can the client begin cardiac rehabilitation?

Today, with a gradual increase of daily activities A basic principle of rehabilitation, including cardiac rehabilitation, is that rehabilitation begins on hospital admission and the client should increase activities as tolerated each day. It is not necessary to wait until the client is moved to a telemetry unit as the client will have EKG monitoring in both units. It is not necessary for the client to have normal sinus rhythm to increase activity; monitoring will detect potentially dangerous dysrhythmias. Delaying rehabilitation activities is associated with poorer client outcomes.

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

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.

A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client makes which statement?

"I'll try to lose weight by following a reduced-calorie, balanced diet."