Chapter 25

The nurse admits an adult female client with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. What response by the nurse will be most appropriate?

"A woman's heart is smaller and has smaller arteries that become occluded more easily."

A 52-year-old female patient is going through menopause and asks the nurse about estrogen replacement for its cardioprotective benefits. What is the best response by the nurse?

"Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks."

The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?

"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."

You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment?

"Have you had any episodes of dizziness or fainting?"

The nurse is administering a stool softener to a client who experienced a myocardial infarction. The client says, "I had a heart attack; I don't have a problem with constipation." What explanation will the nurse use to answer the client's question?

"If you strain to have a bowel movement, you can cause a drop in your heart rate that can be dangerous."

A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education?

"My family is bringing me a cup of coffee to drink before the test."

The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response?

"The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill."

The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?

Assess the client.

The nurse observes that a patient has 2+ pitting edema in the lower extremities. What does the nurse know that the presence of pitting edema indicates regarding fluid retention?

A weight gain of 10 lbs

The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" What is the appropriate response by the nurse?

Apricots, dried peas and beans, dates

A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply.)

Assessing the peripheral pulses in the affected extremity Checking the insertion site for hematoma formation Evaluating temperature and color in the affected extremity

A client has undergone cardiac catheterization and will be discharged today. What information should the nurse emphasize during discharge teaching?

Avoid heavy lifting for the next 24 hours.

The nurse is providing discharge education for a client going home after cardiac catheterization. What information is a priority to include when providing discharge education?

Avoid tub baths, but shower as desired.

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal?

B-type natriuretic peptide (BNP)

The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure?

Baroreceptors

The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease (CVD). Which symptoms correlate with the client's diagnosis?

Chest pain, weight gain, fatigue

The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?

Chordae tendineae

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the health care provider and report the findings.

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate?

Continue to monitor the client as ordered.

The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider?

K+ 3.1 mEq/L

The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit?

Count the heart rate at the apex.

A patient has been diagnosed with congestive heart failure (CHF). The health care provider has ordered a medication to enhance contractility. The nurse would expect which medication to be prescribed for the patient?

Digoxin

The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmia. Which of the following assessment considerations is essential when caring for this client?

Digoxin level

The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a co-morbidity of multiple sclerosis, so the nurse knows the stress test will be drug-induced. What drug will be used to dilate the coronary arteries?

Dobutamine

The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. What explanation will the nurse offer to explain the urination?

Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidneys.

You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels?

Enzymes

The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure?

Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard.

The nurse is completing a cardiac assessment. Upon auscultation, the nurse hears a grating sound using the diaphragm of the stethoscope. How will the nurse best document this finding?

Friction rub

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition?

Heart failure

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following a therapeutic regimen?

High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl.

The nurse reviews a client's lab results and notes a serum calcium level of 7.9 mg/dL. It is most appropriate for the nurse to monitor the client for what condition?

Impaired myocardial contractility

The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. What nursing intervention is a priority after the procedure?

Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex.

The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position?

Left 5th intercostal space at the midclavicular line

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is:

Loud and may be associated with a thrill sound similar to (a purring cat).

While the nurse is preparing a client for a cardiac catheterization, the client states that they have allergies to seafood. Which of the following medications may the nurse give prior to the procedure?

Methylprednisolone

The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer?

Metoprolol

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?

Obtain an oxygen saturation level.

The nurse screens a client prior to a magnetic resonance angiogram (MRA) of the heart. Which action should the nurse complete prior to the client undergoing the procedure? Select all that apply.

Offer the client a headset to listen to music during the procedure. Remove the client's jewelry. Remove the client's Transderm Nitro patch.

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure?

Pulse pressure

The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse?

Rate, quality, and rhythm

The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin?

Report any incident of bloody urine, stools, or both.

It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur:

Right ventricular pressure must be higher than pulmonary arterial pressure.

The nurse is assessing heart sounds in a patient with heart failure. An abnormal heart sound is detected early in diastole. How would the nurse document this?

S3

The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing?

ST-segment changes on the ECG

A nurse is aware that the patient's heart rate is influenced by many factors. The nurse understands that the heart rate can be decreased by:

Stimulation of the vagus nerve.

The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response?

The autonomic nervous system controls the heart rate.

A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient?

The patient had a vagal response.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?

The sinoatrial node

The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?

The thin fibrous sac encasing the heart

The nurse is admitting an older adult client with heart failure. Which education will the nurse prepare for this client prior to discharge?"

Try to avoid emotional stress and take part in mild physical stress only.

The cardiologist has scheduled a client for drug-induced stress testing. What instructions should the nurse provide to prepare the client for this test?

You will receive medication via IV administration.

A client is seen in the emergency department and reports left arm pain, fatigue, palpitations, and shortness of breath. Which condition would the nurse suspect?

acute coronary syndrome

The nurse accompanies a client to an exercise stress test. The client can achieve the target heart rate, but the electrocardiogram indicates ST-segment elevation. Which procedure will the nurse prepare the client for next?

cardiac catheterization

The nurse cares for a client with an intra-arterial blood pressure monitoring device. The nurse recognizes the most preventable complication associated with hemodynamic monitoring includes which condition?

catheter-related bloodstream infections

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

contractility

During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse:

deficit.

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which data is necessary to collect if the client is experiencing chest pain?

description of the pain

The nurse cares for a client in the ICU diagnosed with coronary artery disease (CAD). Which assessment data indicates the client is experiencing a decrease in cardiac output?

disorientation, 20 mL of urine over the last 2 hours

Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue?

endocardium

Which area of the heart is located at the third intercostal (IC) space to the left of the sternum?

erb point

The nurse auscultates the apex beat at which anatomical location?

fifth intercostal space, midclavicular line

The nurse cares for a client in the emergency department who has a B-type natriuretic peptide (BNP) level of 115 pg/mL. The nurse recognizes that this finding is most indicative of which condition?

heart failure

The nurse is explaining vasovagal syncope to a client. What does the nurse associate the temporary loss of consciousness with for the client?

heart rate 48

The nurse cares for a client in the ICU who is being monitored with a central venous pressure (CVP) catheter. The nurse records the client's CVP as 8 mm Hg and recognizes that this finding indicates the client is experiencing which condition?

hypervolemia

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate?

international normalized ratio (INR)

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving oxygenated blood from the lungs?

left atrium

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?

left ventricle

A student nurse prepares to assess a client for postural blood pressure changes. Which action indicates the student nurse needs further education?

letting 30 seconds elapse after each position change before measuring BP and HR

What does decreased pulse pressure reflect?

reduced stroke volume

Central venous pressure is measured in which heart chamber?

right atrium

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to the lungs to be oxygenated?

right ventricle

The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension?

supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure?

wheezes with wet lung sounds