Cardiovascular: NCLEX

A nurse has given instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse would need to reinforce the teaching if a family member made which of the following statements?

"A daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control." (Clients generally increase activity by beginning a simple walking program, starting with distances of 400 feet twice daily and gradually increasing the distance until able to walk ¼ mile (usually at the end of the second week). Exercise has physiological and psychological benefits.)

A nurse has completed counseling about smoking cessation with a client with coronary artery disease. The nurse determines that the client has understood the material best if the client states that:

"A smoker has twice the risk of having a heart attack than a nonsmoker." (Cigarette smokers have twice the risk of having a myocardial infarction than a nonsmoker and have two to four times the risk of having sudden cardiac death. Smoking cessation will reduce its damaging effects on the cardiovascular system; however, its cessation will not cut the risk to zero in 1 year.)

A nurse is providing discharge teaching for a post myocardial infarction (MI) client who will be taking one baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement?

"I will take this medication every day."

A nurse determines that a client with coronary artery disease (CAD) has the necessary understanding of disease management if the client makes which statement?

"I will walk for one-half hour daily." (Lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue.)

A nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement would the nurse make to the client to try to motivate the client to quit smoking?

"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in three to four years." (The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is comparable to that of a person who never smoked.)

While a nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only a nurse. I want my doctor." Which response by the nurse would be therapeutic?

"So you're saying that you want to talk to your health care provider?" (In option 3, the nurse uses the therapeutic communication technique of reflection to redirect the client's feelings back for validation.)

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates the best understanding of this stress reduction measure?

"The best thing about this is that I can use it anywhere, anytime." (Guided imagery involves the client's creation of an image in the mind, concentrating on the image, and gradually become less aware of the offending stimulus. It does not require any adjuncts and does not need to be done in a quiet area only, although some clients may use other relaxation techniques or play music with it.)

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." The appropriate nursing response is which of the following?

"You are concerned about losing your leg?" (The appropriate response is the one that uses the therapeutic technique of restatement. Option 2 restates the client's concern and provides an opportunity for the client to further discuss the concern.)

A client had an aortic valve replacement 2 days ago. This morning, the client says to the nurse, "I don't feel any better than I did before surgery." The appropriate response by the nurse is:

"You are concerned that you don't feel any better after surgery?" (Paraphrasing is restating the client's message in the nurse's own words. Paraphrasing may be in the form of a question. Option 4 uses the therapeutic communication technique of paraphrasing. The client is frustrated and is searching for understanding.)

A nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac arrest victim. What is the proper compression-to-ventilation ratio for one-person CPR?

30:2 (Current CPR guidelines based on evidence-based practice for one-person CPR recommend a 30 compression: 2 respiration ratio. )

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which of the following fibrinogen levels?

90 mg/dL (The normal fibrinogen level is 180 to 340 mg/dL for men and 190 to 420 mg/dL for women. A critical value is less than 100 mg/dL. With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. For these reasons, the nurse should become most concerned with the level of 90 mg/dL.)

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin grains 1/150 sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next?

Administer another nitroglycerin tablet. (In the hospitalized client, nitroglycerin tablets usually are prescribed one every 5 minutes as needed (PRN) for chest pain up to a total dose of three tablets. The nurse in this question should administer the second tablet. The client with known angina pectoris should have low-flow oxygen at a rate of 1 to 3 L/minute via nasal cannula. A 12-lead ECG would be done if prescribed by standing protocol or by individual health care provider prescription.)

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The nurse is told that the client's prothrombin time is 18 seconds with a control of 11 seconds. The nurse plans to:

Administer the next dose of warfarin sodium. (The therapeutic range for prothrombin time (PT) is one and one half to two times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual is 16.5 to 22 seconds. The nurse should administer the next dose as usual.)

A nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130. The nurse notifies the registered nurse immediately and prepares the client for which initial intervention?

Administration of a calcium channel blocker (The initial treatment goal when atrial fibrillation suddenly occurs is to control the rate of impulses with the administration of a calcium-channel blocker or a β-blocker. Defibrillation is indicated when a client is in pulseless ventricular tachycardia or ventricular fibrillation. Electrical cardioversion is an option for atrial fibrillation if the client is clinically unstable or if the client has not responded to chemical cardioversion after a 6-week period of anticoagulant therapy. Anticoagulant therapy, for example, with a continuous heparin infusion, is indicated to prevent development of thrombus formation in the atria but is not the priority over rate control.)

A client undergoing computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting?

Anaphylactic (Injection of contrast media may result in anaphylaxis and most likely occurs as a result of mast cell degranulation. If not recognized and treated immediately, the client will progress to anaphylactic shock. Septic shock is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock occurs when there is loss of sympathetic tone. Cardiogenic shock occurs when the heart fails as a pump.)

A client has an inoperable abdominal aortic aneurysm (AAA). The nurse teaches the client about the need for:

Antihypertensives (The medical treatment for AAA is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bedrest. A low-fiber diet is not helpful and will cause constipation.)

The nurse notes this dysrhythmia on the client's cardiac monitor (refer to figure).

Atrial fibrillation (Atrial fibrillation is characterized by no distinct P waves and an irregular ventricular response. In sinus bradycardia and normal sinus rhythm there will be clear distinct P waves and a regular ventricular rhythm. In ventricular fibrillation there are no clear P waves or QRS complexes.)

A nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which of the following food items from the dietary menu?

Baked haddock, steamed broccoli, herbed rice, sliced strawberries (A client trying to lower fat and cholesterol in the diet should decrease the use of fatty cuts of meats such as beef, lamb or pork, organ meats, sausage, hot dogs, bacon, and sardines; avoid vegetables prepared in butter, cream, or other sauces; use low-fat milk products instead of whole milk products and cream; and decrease the amount of commercially prepared baked goods. Option 2 is the only option that identifies low-fat and low-cholesterol foods.)

A nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which of the following would be the best dinner choice from the daily menu?

Baked pollack, mashed potatoes, and carrot-raisin salad (Furosemide depletes potassium, and a client on digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. Hypokalemia may make the client more susceptible to digoxin toxicity. The recommended daily intake for potassium is 2000 mg. Option 1 is not the best choice because beef vegetable soup contains a high amount of sodium and a minimal amount of potassium. Macaroni and cheese is also high in sodium and contains no potassium. Option 2 is not the best choice because beef ravioli is high in sodium and contains no potassium. Spinach soufflé is a good source of potassium but also contains sodium. Option 4 is not the best choice because roasted chicken breast, brown rice, and stewed tomatoes contain a minimal amount of potassium. Option 3 is the best choice because all three foods are high in potassium and low in sodium.)

A client has a history of left-sided heart failure. The nurse would look for the presence of which of the following to determine whether the problem is currently active?

Bilateral lung crackles (The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Breath sounds are an accurate indicator of left-sided heart function. Peripheral edema, jugular vein distention, and ascites can be present as a result of insufficiency of the pumping action of the right side of the heart.)

A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check the client's:

Blood pressure (Assessing the blood pressure is a priority before administering nitroglycerin to determine the vasodilating effect of the medication and to monitor for a drop in blood pressure. Cardiac rhythm and respiratory rate are also important to assess after checking the blood pressure. Peripheral pulses do not need to be checked before administering this medication.)

A client is scheduled for a dipyridamole (Persantine) thallium scan. The nurse would check to make sure that the client has not had which of the following before the procedure?

Caffeine (This test is an alternative to the exercise stress test. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as well as aminophylline or theophylline forms of medication. Aminophylline is the antagonist to dipyridamole.)

A sublingual nitroglycerin (Nitrostat) tablet administered to a client for chest pain has relieved the pain. The nurse ensures that the client has which important item within easy reach before leaving the room?

Call bell (The highest priority is to ensure that the client has the call bell so the client can call for help if the pain returns.)

A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to:

Cardiac arrest (The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization, and move back during repolarization. Depolarization is responsible for cardiac contraction)

A nurse enters a client's room and finds the client slumped down in the chair. Breathing is shallow and a pulse is present. Based on these data, the nurse determines that the priority would be to:

Check the vital signs and level of consciousness. (The client is breathing and has a pulse; therefore further data are needed before any other action. The vital signs and level of consciousness should be checked. Once that assessment is made, the health care provider is notified, who will then contact the family. Activating the emergency response system is not indicated at present)

A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which of the following items?

Chest pain (The client is taught before cardiac catheterization to immediately report chest pain or any unusual sensations. The client is taught that a warm, flushed feeling may accompany dye injection, occasional palpitations may occur, and the urge to cough may occur as the catheter tip touches the cardiac muscle. The client may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site.)

A nurse determines that which of the following clients is most likely to be a candidate for cardioversion?

Client with unstable rapid atrial fibrillation (Cardioversion is a synchronized shock, delivered during ventricular depolarization. The machine must be able to seek out R waves and mark them so that the device delivers the shock at the appropriate time. Clients in atrial fibrillation are candidates for this treatment, and the goal is to try to restore normal sinus rhythm through cardioversion. Although the client with ventricular tachycardia can be cardioverted because of the presence of QRS complexes, this is done only when the client has a pulse. Pulseless ventricular tachycardia and ventricular fibrillation clients always are defibrillated. Junctional rhythm is neither cardioverted nor defibrillated.)

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. A nurse listens to breath sounds, expecting to hear bilateral:

Crackles (Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.)

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which of the following typical characteristics?

Deep and painful (Arterial leg ulcers tend to be deep and painful. The client usually has rest pain, and the ulcer site is painful. Surrounding skin has coloration consistent with peripheral arterial disease. )

An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which of the following best describes the client's response?

Denial (Denial is the most common reaction when a client has a myocardial infarction or anginal pain. No angry behavior was identified in the question. Phobias and obsessive-compulsive disorders are mental health diagnoses.)

A nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as:

Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease (A fasting blood glucose of 200 mg/dL signals the presence of diabetes mellitus. Diabetes mellitus predisposes a client to coronary artery disease. )

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse determines that which of the following items would be of most help to the client?

Elevating the head of the bed to at least 45 degrees (The management of dyspnea generally is directed toward alleviation of the cause. Symptom relief may be achieved or at least aided by placing the client at rest with the head of the bed elevated. In severe cases, supplemental oxygen is used. )

The nurse observes the following rhythm on the cardiac monitor. (Refer to the figure.)

Evaluate the client for hypotension and assess mental status. (After determining that the client is in sinus bradycardia with a heart rate of 40 beats per minute, the nurse should evaluate the client first for signs and symptoms of decreased cardiac output. Signs and symptoms of decreased cardiac output include hypotension, altered mental status, weak peripheral pulses, and decreased urinary output. If the bradycardia is new or the client has evidence of decreased cardiac output, the health care provider would then be notified. Transcutaneous pacing or atropine administration may be instituted if evidence of decreased cardiac output is present.)

A client is at risk for complications of heart failure. What is the nurse's priority for early detection of the most likely cause of complications with this client?

Evaluating total body fluid (Fluid overload can cause complications for the client with heart failure. Therefore the nurse evaluates the client's fluid balance to forestall activation of harmful compensatory mechanisms and deterioration of other organ systems that increasing total body fluid can cause. This is the nurse's priority because balancing the client's fluid status has the broadest range of potential benefits for the client, including improving oxygenation. The vital signs, serum electrolytes, and electrocardiogram are important assessments, yet remain secondary in importance to fluid status because they are items that are affected by fluid balance.)

A male client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time?

Explore the specific concerns with the client. (The therapeutic action by the nurse is one that gathers more data. This then allows the nurse to formulate the appropriate response.)

A nurse working the 3:00 to 11:00 PM shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?

Fasting for 12 hours (To obtain an accurate cholesterol level, a client must fast 12 hours before the tests)

A client who has undergone a left heart catheterization using the right femoral approach is returned to the nursing unit. Thirty minutes later the client complains of numbness and tingling of the right foot. The pedal pulse is weak, and the foot is pale. The nurse notifies the registered nurse immediately because these symptoms are consistent with:

Femoral artery thrombus or hematoma (Adverse changes such as numbness and tingling, coolness, pallor, cyanosis, or sudden loss of peripheral pulses indicate serious circulatory impairment and are reported to the registered nurse immediately, who then contacts the health care provider.)

A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs or symptoms?

Fever and sore throat (Rheumatic heart disease can occur as a result of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting for the presence of sore throat and fever. )

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN would assist the RN by placing the bed in which of the following positions for the reading?

Flat (To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. )

A nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which of the following meals?

Fresh strawberries, steamed vegetables, and baked fish (Diets high in saturated fats raise the serum lipid level, which, in turn, raises the blood cholesterol. Over time, high blood cholesterol levels lead to the development of atherosclerosis and diseases such as CAD. A diet that is low in saturated fats is helpful in reducing the progression of atherosclerosis. Meats and dairy products tend to be higher in fat than other food groups.)

A nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next?

Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions. (After completing the stat ECG, the nurse should administer a nitroglycerin tablet to dilate the coronary arteries and relieve ischemic pain. The nurse should not wait to see whether pain resolves on its own but should determine whether the pain is relieved with nitroglycerin. The nurse should do a repeat ECG if it is prescribed. The nurse would report the episode of pain to the health care provider but would administer the nitroglycerin before doing so.)

A nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which of the following actions to assist this client?

Gives the client a device holder to wear around the waist (The nurse applies electrocardiographic (ECG) monitoring leads to the chest in the usual fashion and gives the client a sling or holder to carry the transistor-sized monitor, which is worn around the chest or waist. The nurse would remind the client to maintain a normal schedule and to keep a diary of all activity and symptoms. The client should avoid activities that could interfere with the ECG recorder, such as using heavy machinery, electric shavers, hair dryers, or bathing or showering. )

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer, expecting to note that the ulcer:

Has a brownish or "brawny" appearance (Venous leg ulcers, also called stasis ulcers, are typically partial-thick wounds that extend through the epidermis and portions of the dermis. The skin of the lower leg is leathery, with a characteristic brownish or "brawny" appearance from the hemosiderin deposition. The edges of the ulcer are irregular and the tissue is a ruddy color. The client also may exhibit peripheral edema.)

A nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?

Hypokalemia (The nurse assesses the client's serum laboratory results for hypokalemia. The client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect.)

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which of the following areas?

In the groove behind the medial malleolus and the Achilles tendon (The posterior tibialis pulse can be located in the groove behind the medial malleolus or the inside of the ankle behind the bone. The femoral pulse is palpated just below the inguinal ligament halfway between the pubis and anterior superior iliac spine. Popliteal pulses, although difficult to palpate, may be felt behind the knee in the popliteal fossa. The dorsalis pedis pulse is located on the top of the foot.)

A nurse has given simple instructions on preventing some of the complications of bedrest to a client who experienced a myocardial infarction. The nurse would intervene if the client were performing which of these activities, which would be contraindicated?

Isometric exercises of the arms and legs (The client with myocardial infarction should avoid activities that tense the muscles, such as isometric exercises. These increase intra-abdominal and intrathoracic pressures and can decrease the cardiac output. They also can trigger vagal stimulation, causing bradycardia.)

A nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse tells the client to do which of the following?

Keep the ankles uncrossed. (A graft can become clotted from any form of pressure, which results in impaired blood flow through the graft. Positions and movements to be avoided include bending at the hip or knee, crossing the knees or ankles, or the use of a knee gatch or pillows under the knees.)

A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which of the following?

Lung crackles, peripheral edema, and weight gain (The client with infective endocarditis may experience both left- and right-sided heart failure, and thus the nurse monitors the client for both pulmonary and peripheral symptoms, such as lung crackles, peripheral edema, and weight gain. )

A nurse is caring for a client with Buerger's disease. Which finding would the nurse determine is a potential complication associated with this disease?

Numbness and tingling in the legs (Buerger's disease (thromboangiitis obliterans), which affects men between 20 and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small and medium-sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. Options 1, 2, and 3 are not complications of this disorder. The finding that can be interpreted as a complication of the disorder is numbness and tingling in the legs.)

A nurse is using a stethoscope to listen to the client's heart and hears this sound. (Click on the sound button.)

Palpate the carotid pulse for a pulsation. (The sound that the nurse hears is the first heart sound, S1. The first heart sound (S1) is created by the closure of the mitral and tricuspid valve (atrioventricular [A-V] valves). It marks the onset of systole (ventricular contraction). When auscultated, the first heart sound (S1) is softer and longer than the second heart sound (S2). S1 is of a low pitch and is best heard at the left lower sternal border or the apex of the heart. It may be identified by palpating the carotid pulse while listening. S1 marks the beginning of ventricular systole and occurs right after the QRS complex on the electrocardiogram (ECG). Disease and stiffened A-V valves (as seen in rheumatic heart disease) may augment S1. Phonetically, if both heart sounds (S1 and S2) are auscultated as "lub-dup," S1 is the "lub." To assess S1 the nurse should assist the client to a supine position (head of the bed may be elevated slightly if necessary). Although the nurse may need to ask another nurse to verify the heart sound, this is not the initial best action and may cause anxiety in the client.)

A nurse is auscultating a client's heart sounds and hears these sounds. (Click on the sound button.) The nurse identifies these as being produced during which phase of the cardiac cycle?

Passive filling phase of ventricles (The sound that the nurse hears is the third heart sound (S3). Diastolic filling sounds or gallops (S3, the third heart sound, and S4, the fourth heart sound) are produced when there is decreased compliance of either or both ventricles. S3 is termed ventricular gallop and S4 is referred to as atrial gallop. The S3 heart sound (a gallop sound) occurs in early diastole, during passive, rapid filling of the ventricles. The bell of the stethoscope is placed at the apex and at the left lower sternal border, and the sound is heard during expiration. Therefore options 1, 3, and 4 are incorrect. An S3 heart sound is most likely to be a normal finding in children or young adults up to 30 years of age. An S3 gallop in clients older than 35 years of age is considered abnormal and represents a decrease in left ventricular compliance. S3 also can be detected as an early sign of heart failure or as ventricular septal defect.)

A nurse is evaluating the effects of care for the client with deep vein thrombosis. Which of the following limb observations would the nurse note as indicating the least success in meeting the outcome criteria for this problem?

Pedal edema that is 3+ (Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain. Option 3 indicates full resolution of the problem, whereas options 2 and 4 indicate partial resolution. Option 1 is the correct option because it indicates the least degree of symptom reversal.)

A nurse is caring for a client who has a malignant lung neoplasm and has developed cardiopulmonary complications. On auscultation, the nurse hears these breath sounds over the left lower sternal border (over the apical area) and interprets the sounds as which of the following? (Click on the sound button.)

Pericardial friction rub (The sound that the nurse hears is a pericardial friction rub. Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac. (Acute pericarditis is associated with malignant neoplasms.) It may be heard with the diaphragm of the stethoscope positioned at the left lower sternal border (over the apical area). It is a scratchy, high-pitched rubbing sound produced when the inflamed, roughened pericardial layers create friction as their surfaces rub together. Stridor is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. Passage of air through a narrowed airway is associated with wheezes (a high-pitched, musical sound similar to a squeak).)

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notes documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action in the care of the client?

Place the client on a cardiac monitor. (The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.)

A client who is 36 hours post myocardial infarction has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation was made?

Preactivity pulse rate 86 beats per minute, postactivity pulse rate 94 beats per minute (The nurse checks vital signs and the level of fatigue with each activity. The client is not tolerating the activity if systolic BP drops more than 20 mm Hg, pulse rate increases more than 20 beats per minute, or if the client experiences dyspnea or chest pain. In addition, a significant drop in BP can indicate orthostatic hypotension, which is an abnormal condition. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise)

A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could:

Precipitate rebound hypertension (β-adrenergic blocking agents should be tapered slowly. This will avoid abrupt withdrawal syndrome, characterized by headache, malaise, palpitations, tremors, sweating, rebound hypertension, dysrhythmias, and possibly myocardial infarction (in clients with cardiac disorders, including angina pectoris).

A nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which of the following to effectively accomplish this goal?

Provide a quiet and low-stimulus environment. (Chest pain can be minimized by a quiet, low-stimulus environment, which reduces factors that trigger chest pain, such as emotional excitement. )

A nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade?

Pulse rate of 58 beats per minute (Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure, accompanied by pulsus paradoxus (a drop in inspiratory blood pressure by greater than 10 mm Hg). Bradycardia is the symptom that is unrelated.)

A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe?

Restricting the client's potassium intake (Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. Restricting potassium makes the client more prone to digoxin toxicity. Digoxin should be held and the health care provider notified when the client's heart rate is less than 60 beats per minute, unless otherwise prescribed. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged.)

A nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse implements which action?

Reviews the intake and output records for the last 2 days (Edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg). To determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days.)

A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation?

Semi-Fowler's (Coolness, pallor, and tachycardia are consistent with clinical indicators of hypoxia related to inadequate cardiac output. To reduce the myocardial workload, improve cardiac output, and promote tissue oxygenation, the nurse positions the client in the semi-Fowler's position to maintain perfusion to vital organs and promote chest expansion (option 3), as long as the client's neurological status is stable.)

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next check the client for:

Smoking history (The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component)

A nurse is monitoring a client following cardioversion. Which of the following observations would be of highest priority to the nurse?

Status of airway (Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.)

The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which of the following should the nurse institute when providing care for the client?

Take daily weights and monitor trends. (BNP levels greater than 500 pg/mL indicate that heart failure is probable. Nursing measures are geared toward decreasing intravascular volume, decreasing preload, and decreasing afterload.)

A client with angina pectoris who was given a first dose of newly prescribed nitroglycerin (Nitrostat) sublingual tablet complains of slight dizziness and headache. The nurse takes which action first?

Takes the client's blood pressure (Clients receiving nitroglycerin for the first time are more likely to experience side effects of this coronary vasodilator, which includes a drop in blood pressure and headache. The nurse should take the blood pressure first. The nurse can then give acetaminophen for headache, and document or report the side effects)

A nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?

The client complains of leg edema, and skin breakdown has started. (Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common)

A nurse is assisting in the care of a client diagnosed with rheumatic heart disease. When teaching the client about self-management of this health problem, the nurse reminds the client to alert his dentist about the condition because:

The client requires prophylactic antibiotics before treatment. (The client with a history of rheumatic fever is at risk for developing infective endocarditis. The client should tell all health care providers and dentists about this problem so that prophylactic antibiotic therapy can be given before any procedure that is invasive or carries a risk of bleeding.)

In order to assess the dorsalis pedis pulse of a client diagnosed with arterial vascular disease, the nurse palpates which anatomical location? Refer to figure.

Top of the foot (The dorsalis pedis pulse is located on the dorsum (top) of the foot. The carotid artery is located in the neck region. The radial artery is located in the wrist. The posterior tibial artery is located at the medial aspect of the ankle.)

A nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease. The nurse would determine the teaching as successful if the client stated that a safe weight loss goal is:

Two pounds per week (Most people, including the mildly and moderately obese, can lose only about 2 pounds per week of weight from fat loss. Weight loss beyond that level is probably due to protein and water loss alone.)

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate the:

Vagus nerve to slow the heart rate (Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.)

A client with a diagnosis of congestive heart failure is preparing for discharge to home from the hospital. The nurse determines that the client is ready for discharge to home if the client can:

Verbally describe the daily medications, doses, and times to be administered. (Medication therapy is an essential part of the therapeutic regimen for treating heart failure. The client must have a clear understanding of which medications to take and when.)

A nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse would reinforce with the client the importance of complying with which of the following measures to prevent a recurrence?

Weigh self every morning before breakfast. (A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. The client should weigh himself or herself daily as a means of determining fluid balance and possible overload. The client should sleep with the head elevated as high as needed to prevent pulmonary congestion during sleep. The client should not self-adjust any medication dosages.)

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects that the health care provider wrote a prescription for the client to remain on bedrest:

With the head of bed elevated no more than 30 degrees (Following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bedrest is enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The affected leg is kept straight and the head is elevated no more than 30 degrees until hemostasis is adequately achieved.)

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and collecting initial data, the nurse places a sign above the bed stating that the client should remain on bedrest:

With the head of the bed elevated no more than 15 degrees (Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bedrest is necessary for 4 to 6 hours. The client may turn from side to side. The head of the bed is not elevated more than 30 degrees to prevent kinking of the blood vessel at the groin and possible arterial occlusion.)

A nurse is providing dietary instructions to a client with congestive heart failure (CHF). The nurse determines that the client understands the instructions if the client states that which of the following food items will be avoided?

Catsup (Catsup is high in sodium. Leafy green vegetables, cooked cereal, and sherbet all are low in sodium. Clients with CHF should monitor sodium intake.)

A nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which of the following questions?

"Where is the pain located?" (If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, precipitating factors, location, radiation, and quality. )

An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question would best help the nurse to discriminate pain caused by a noncardiac problem?

"Does the pain get worse when you breathe in?" (Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms)

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?

"I need to adhere to my dietary restrictions." (Following the angioplasty, the client needs to be instructed about specific dietary restrictions that must be followed. Following the recommended dietary and lifestyle changes assists to prevent further atherosclerosis. Abrupt closure of the artery can occur if the recommended dietary and lifestyle changes are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.)

A nurse provides instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?

"I should avoid sitting in one position for long periods of time." (Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, to maintain normal coagulability, and to prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily are an inadequate amount of fluid.)

A nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?

"I should routinely use polyunsaturated oils in my diet." (The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hyperlipidemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.)

A client with chronic atrial fibrillation is being started on amiodarone (Cordarone) as maintenance therapy for dysrhythmia suppression. A nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction?

"I will stop taking the prescribed anticoagulant after starting this new medication." (Amiodarone is used for the dysrhythmia atrial fibrillation. The medication will have no effect in preventing thrombus formation within the atria so anticoagulants need to be continued. The medication increases sun sensitivity so protective measures are essential. Thyroid function studies should be monitored as the medication can affect thyroid function. Because the medication can cause corneal microdeposits, follow-up with the ophthalmologist is important.)

A nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which of the following statements?

"I will walk for one-half hour daily." (Lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. )

A nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching?

"It is best to exercise once a week for an hour." (Exercise is most effective when done at least three times a week for 20 to 30 minutes to reach a target heart rate. Other healthy habits include limiting salt and fat in the diet and using stress management techniques. The client should also be taught to take nitroglycerin before any activity that causes pain, and to take the medication at the first sign of chest discomfort.)

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first?

"When was the last time you had your blood pressure checked?" (The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's non-modifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.)

A nurse finds a client tensing while lying in bed staring at the cardiac monitor. What is the nurse's best response when the client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!"?

"Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" (The nurse should initially respond to validate the client's concern and then should determine the client's knowledge level of the cardiac monitor. This gives the nurse an opportunity to do client education if necessary. Bringing in the family, friends, or chaplain as an alternate resource may provide the client with additional psychological support. Pharmacological interventions should be considered only if necessary. Minimizing the client's concern is a communication block)

A nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply.

1. Cut down on the amount of fats consumed in the diet. 3. Walk each day to increase circulation to the legs. 4. Be careful not to injure the legs or feet. 5. Eat a well-balanced diet every day. (Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.)

A nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health?

Ability to take an accurate pulse in either the wrist or neck (Clients with permanent pacemakers must be able to accurately take their pulse in the wrist and/or neck. The client needs to identify any variation in the pulse rate or rhythm and immediately report the variation to the health care provider. Clients can safely operate microwave ovens, radios, electric blankets, lawn mowers, leaf blowers, and cars (proper grounding must be ensured if the client is to operate electrical items). Sexual activity is not resumed until 6 weeks after surgery. The arms and shoulders should not be moved vigorously for 6 weeks after insertion. The remaining options do not have the same impact on long-term cardiac health as does the correct option.)

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for:

Acute renal failure (The client who undergoes cardiac surgery is at risk for acute renal failure from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal failure is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis._

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure?

Allergy to iodine or shellfish (This procedure requires a signed informed consent, because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure.)

A nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client for a history of:

Allergy to shellfish (Allergy to seafood, iodine, or iodine contrast media in the pre-procedure period may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium. The other options are important parts of the client's history but are not specific to a cardiac catheterization procedure.)

A nurse is planning to use an external cardiac defibrillator on a client. Which one of the following actions should the nurse perform to check the cardiac rhythm?

Applying the adhesive patch electrodes to the skin and moving away from the client (The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.)

A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the nurse stands and begins to walk, the client begins to complain of chest pain. The nurse should initially take which action?

Assist the client to get back into bed. (The client is assisted back to bed to put the client at rest. The nurse can then measure vital signs and administer nitroglycerin that is prescribed for as-needed (PRN) use. The nurse should then report the chest pain episode to the health care provider. The nurse would not continue to assist the client into the bathroom because it places the client in danger because of continued myocardial oxygen demands.)

A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first?

Assist the client to sit or lie down. (Chest pain is caused by an imbalance between myocardial oxygen supply and demand. During episodes of pain, the nurse first limits the client's activity and assists the client to a position of comfort, checks the vital signs, administers oxygen and medication according to protocol, and obtains a 12-lead electrocardiogram.)

A clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which of the following positions?

At the midclavicular line at the fifth left intercostal space (The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex.)

A nurse is providing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of doing which of the following?

Avoiding exposure to either very hot or very cold weather (The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output.)

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed?

Bathroom privileges and self-care activities (Upon transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).)

A client is diagnosed with thrombophlebitis. The nurse tells the client that which of the following will likely be prescribed?

Bedrest, with elevation of the affected extremity (Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated and bedrest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. )

A nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted?

Blood pressure that increases from 114/82 to 118/86 mm Hg (General indicators that a client is tolerating exercise include an absence of chest pain or dyspnea, a pulse rate increase of less than 20 beats per minute, and a blood pressure change of less than 10 mm Hg.)

A nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT) followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first?

Call for help and initiate cardiopulmonary resuscitation (CPR). (When VF occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client)

A nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client reports chest pain. When the administration of a sublingual nitroglycerin tablet as prescribed does not relieve the chest pain, the next nursing action is to:`

Check the blood pressure and administer another nitroglycerin tablet. (Nitroglycerin tablets are administered once every 5 minutes three times for chest pain as long as the client maintains a systolic blood pressure of 100 or more. Increasing the flow rate of the oxygen may be prescribed by the health care provider, but it is not the next nursing action. If three nitroglycerin tablets do not relieve the client's chest pain, the health care provider should be notified.)

A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse would first:

Check the client status and lead placement. (Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.)

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which of the following breath sounds are noted?

Crackles in the lung bases (Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy pink-tinged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the client's condition improves, the amount of fluid in the alveoli decreases and may be detected by crackles in the bases. (Clear lung sounds would indicate full resolution of the episode). Wheezes and rhonchi are not associated with pulmonary edema)

A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse responds to the client, using the knowledge that:

Denial is a common occurrence early after MI. (An early initial coping response following MI is denial. The nurse uses this knowledge of this common response in planning care for the client.)

A nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition?

Dependent edema (Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.)

A client brings the following medications to the clinic for her yearly physical. The nurse realizes which medication has been prescribed to treat heart failure?

Digoxin (Lanoxin) (Digoxin strengthens the heart beat, as well as decreases the heart rate. It is used in the treatment of congestive heart failure. Potassium chloride increases the potassium level. Although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. Warfarin and amiodarone do not treat congestive heart failure.)

A nurse understands that which of the following is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider?

Each rescue breath should be given over 1 second and should produce a visible chest rise. (During adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. Health care providers should employ a 30-compression-to-2-ventilation ratio for the adult victim.)

A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). The nurse determines that the client indicates an initial understanding of lifestyle alterations if the client states an intention to:

Eat a diet that is low in fat and cholesterol. (A diet that is low in fat and cholesterol helps slow the progression of CAD. This must be accompanied by regular exercise and cessation of smoking. If these measures are effective, the client may not need daily medication.)

A nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention will be included in the post-procedure plan of care?

Encourage the client to increase fluid intake. (Immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. Placing the client in the Fowler's position increases the risk of hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. Flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. The regularly scheduled medications are needed to treat acute and chronic conditions.)

A nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Based on this finding, the nurse should:

Explore with the client the sources of stress in life. (The nurse should encourage the client to explore and verbalize stressors. Later, the nurse can teach the client strategies for coping with stress, such as the basic relaxation techniques of deep breathing, progressive muscle relaxation, and visualization. )

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. The nurse interprets that the boot:

Has been applied too tightly (An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. )

A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action first?

Have the client stop and lie back down in bed. (The pain associated with coronary artery disease is called angina pectoris, and it occurs because of myocardial tissue ischemia from insufficient blood flow to the heart. The nurse should first have the client stop the activity and lie back down to decrease the workload and oxygen demand on the heart. )

A nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse plans to maintain bedrest with:

Head elevation of no more than 30 degrees (After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period. The client may turn from side to side. The head of the bed is not elevated to more than 30 degrees to keep the affected leg straight at the groin and prevent arterial occlusion. Bathroom privileges are not allowed during the immediate postcatheterization period. For the high Fowler's position, the head of the bed is elevated 90 degrees.)

A nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. The nurse provides medication instructions and tells the client that acetaminophen (Tylenol) is usually prescribed to be taken before the administration of the topical nitrate because:

Headache is a common side effect of nitrates. (Headache occurs as a side effect of nitrates. Acetaminophen may be given before nitrates to prevent headaches or to minimize the discomfort from the headaches.)

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain. The nurse further collects data on the client to see whether these episodes occur with:

Ingestion of coffee or chocolate (Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.)

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should do which of the following to care for this client in a holistic manner?

Instruct the family member to dress the client warmly before going outside. (The nurse should meet both the physiological and psychosocial needs of the client in a holistic manner by asking the family member to be sure that the client is dressed warmly before going outside. Option 4 is correct because dressing the client warmly will decrease the chance of vasoconstriction, which may lead to an angina attack.)

A nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to teach the client that this type of angina:

Is generally treated with calcium-channel blocking agents (Prinzmetal's angina results from spasm of the coronary arteries. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not indicated.)

A nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which of the following beverages does the nurse instruct the client to select from the menu?

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

The nurse is caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgment of the pacing catheter by implementing which intervention?

Limiting movement and abduction of the right arm (In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.)

A nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). The nurse should alter the environment to ensure that it is:

Low stimulus, low stress (An environment that is low stimulus and low stress is needed to decrease anxiety and metabolic demands for the client after MI. Nursing care is directed at promoting rest and assisting with activities of daily living.)

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk?

Marking the location of the pedal pulses on the right leg (A problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.)

A nurse has given instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further instructions if the client states that:

Moving to a warmer climate should help. (Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial, because the symptoms could still occur with the use of air conditioning and during periods of cooler weather)

A nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:

Normal, caused by increased blood flow through the leg (An expected outcome of surgery is warmth, redness, and edema in the surgical extremity cause by increased blood flow.)

A nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which of the following?

Oxygen supply to the heart cells that is deficient results in angina pectoris pain. (The pain associated with angina is derived from ischemic myocardial cells. The pain is often associated with activity that places more oxygen demand on heart muscle. Supplemental oxygen helps meet the added demands on the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus formation, or directly calm the client.)

A nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which of the following is available at the bedside?

Oxygen tubing and flowmeter (CAD causes obstruction to blood flow through one or more major coronary arteries, cutting off oxygen and nutrients to the cardiac cells, and resulting in chest pain. Providing oxygen to the client is important to help decrease pain and prevent its recurrence. A bedside commode and ECG machine may be helpful but are not the priority. A rolling shower chair has no value for this client because the client would be able to walk and shower if pain-free and an activity prescription allows it.)

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which manifestation that differentiates pericarditis from other cardiopulmonary problems?

Pericardial friction rub (A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders.)

A nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse would:

Place the client in high-Fowler's position. (The client in pulmonary edema is placed in high-Fowler's position if the blood pressure is adequate. Vigorous suctioning may deplete the client of vital oxygen at a time when the respiratory system is compromised. Assembling medications is useful but not critical to the immediate well-being of the client. The client may or may not need mechanical ventilation.)

A client receiving parenteral nutrition (PN) has a history of congestive heart failure. The health care provider has prescribed furosemide (Lasix) 40 mg orally daily to prevent fluid overload. The nurse monitors which laboratory value to identify an adverse effect from this medication?

Potassium (Furosemide is a non-potassium-sparing diuretic, and insufficient replacement of potassium may lead to hypokalemia. Although the glucose, sodium, and magnesium levels may be monitored, these laboratory values are not specific to administering furosemide.)

A nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which of the following to enable the client to best tolerate the ambulation?

Premedicate the client with an analgesic before ambulating. (The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.)

Acetylsalicylic acid (Aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. The nurse informs the client that the aspirin will:

Prevent the formation of clots. (Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure.)

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is:

Pulmonary embolism (Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension)

A licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor:

Respirations and blood pressure (Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client who experienced an MI. Although monitoring mental status is a component of the nurse's assessment, it is not the priority following administration of morphine sulfate. The nurse should monitor the client's respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature is also not associated with the use of this medication.)

A nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia?

ST-segment depression (In the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. The client may also exhibit a flat T wave.)

A nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition?

Shock (A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and slightly elevating the head and shoulders. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, vital to the treatment of shock. The remaining conditions would not benefit from and, in some cases, would worsen because of this position.)

A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The nurse interprets that the client is experiencing which of the following types of angina?

Stable (Stable angina, also known as exertional angina, is triggered by a predictable amount of effort or emotion. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than classic angina and tend to occur early in the day and at rest. Intractable angina is chronic and incapacitating, and is refractory to medical therapy.)

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse would check the client for signs and symptoms of concurrent:

Streptococcal infection (Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A β-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis)

When preparing a client for a pericardiocentesis, how does the nurse position the client?

Supine with the head of bed elevated at a 45- to 60-degree angle (The client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60-degree angle. This places the heart in proximity to the chest wall for easier insertion of the needle into the pericardial sac. The remaining options are incorrect positions for this procedure.)

A nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is in the client's hospital room?

Surgical tourniquet (Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.)

A nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse would incorporate which of the following in discussions with the client?

Take in adequate daily fiber to prevent straining during a bowel movement. (Standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen program to prevent straining and constipation, and maintaining fluid and electrolyte balance. Increasing fluids to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease.)

A nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?

Tall, peaked T waves (The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the ECG, such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia.)

A client with no history of heart disease has experienced an acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator (t-PA). The nurse interprets that the client is likely experiencing a complication of this therapy if which of the following occurs?

Tarry stools (Thrombolytic agents are used to dissolve existing thrombi, and the nurse must monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes testing secretions for occult blood. Option 1 is the only option that indicates the presence of blood.)

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

Teaches about the effects of cocaine on the heart and offers referral for further help (To provide the most holistic care, the nurse should meet the information needs of the client about the effects of cocaine on the heart and offer referral for further help with this possible addiction.)

A nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). The nurse identifies that the priority problem during the acute phase would be:

The client's pain (Pain is the prevailing symptom of acute MI. Relief of pain is a priority. Pain stimulates the autonomic nervous system, increasing myocardial oxygen demand)

A nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse would interpret that the pain is likely a result of myocardial infarction (MI) if which of the following observations is made by the nurse?

The pain has not been unrelieved by rest and nitroglycerin tablets. (The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may also radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief.)

For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which of the following client activities will contribute to achieving this goal?

Using a bedside commode for stools (Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client's legs increases venous return to the heart, resulting in an increase in cardiac workload. The supine position can increase respiratory effort and decrease oxygenation. This increases cardiac workload. Meat tenderizers are high in sodium. Sodium contributes to hypertension which increases cardiac workload)

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as:

Variant angina (Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. The data in the question is characteristic of a type of angina pain and therefore option 4 is incorrect. )

A client with angina pectoris has just been started on medication therapy with nitroglycerin (Nitrostat). In planning care for this client, the nurse would place priority on measuring:

Vital signs (The nurse would place priority on measuring vital signs, especially the blood pressure, because of the vasodilator action of the medication. Drug levels are not measured for nitroglycerin, and the medication does not affect serum glucose level. Intake and output may be measured as part of the general plan of care for the client with heart disease, but it is not directly related to administration of this medication.)

A client has experienced several episodes of sickle cell crisis. Which instruction should be included in the client's teaching plan to prevent recurrence?

Wear shoes and socks when walking outside to prevent damage to the feet. (Wearing socks and shoes will prevent wounds to the legs and feet, which heal slowly and frequently become infected in clients with sickle cell disease. Vigorous exercise and iced liquids can precipitate a crisis and should be avoided. Opioid tolerance is not a priority or immediate concern for clients experiencing a sickle cell crisis. These clients experience a great deal of pain and require opioids for pain relief.)

A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign that indicates that the medications are not having the intended effect?

Weight gain of 2 to 3 pounds in a few days (Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in daytime voiding is expected while on diuretic therapy (Lasix). A cough as a result of respiratory infection does not necessarily indicate that heart failure is exacerbating.)

A client returns to the nursing unit after an above-the-knee amputation of the right leg. The nurse positions the client:

With the foot of the bed elevated (During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.)

A client is receiving a continuous intravenous (IV) infusion of heparin in the treatment of deep vein thrombosis. The nurse is told that the client's activated partial thromboplastin time (aPTT) level is 65 seconds and that the client's baseline before the initiation of therapy was 30 seconds. The nurse identifies these results as:

Within the therapeutic range (The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus the client's aPTT is within the therapeutic range, and the dose should remain unchanged.)