Chapter 25 PrepU
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? "You can take a tub bath or a shower when you get home." "Contact your primary care provider if you develop a temperature above 102°F." "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." "If any discharge occurs at the puncture site, call 911 immediately."
Correct response: "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." Explanation: The nurse should instruct the client to follow these guidelines: For the next 24 hours, do not bend at the waist, strain, or lift heavy objects if the artery of the groin was used; contact the primary provider if swelling, new bruising or pain from the procedure puncture site, or a temperature of 101°F or more occur. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The client should not drive to the hospital.
Your client is being prepared for echocardiography when they ask you why they need to have this test. What would be your best response? "This test will find any congenital heart defects." "This test can tell us a lot about your heart." "Echocardiography is a way of determining the functioning of the left ventricle of your heart." "Echocardiography will tell your doctor if you have cancer of the heart."
Correct response: "Echocardiography is a way of determining the functioning of the left ventricle of your heart." Explanation: Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. All answers are correct. C is the best answer as it addresses the client's question without making them anxious or minimizing their question.
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? Potassium B-type natriuretic peptide (BNP) C-reactive protein (CRP) Platelet count
Correct response: B-type natriuretic peptide (BNP) Explanation: The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.
The nurse prepares to apply ECG electrodes to a male client who requires continuous cardiac monitoring. Which action should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? Clip the client's chest hair prior to applying the electrodes. Apply baby powder to the client's chest prior to placing the electrodes. Clean the client's chest with alcohol prior to application of the electrodes. Once the electrodes are applied, change them every 72 hours.
Correct response: Clip the client's chest hair prior to applying the electrodes. Explanation: The nurse should complete the following actions when applying cardiac electrodes: (1) Clip (do not shave) hair from around the electrode site, if needed; (2) if the client is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; (3) debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer); (4) change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); (5) examine the skin for irritation and apply the electrodes to different locations.
A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? Call the health care provider and obtain an order for a fluid bolus. Re-zero the equipment and take another reading. Call the physician and obtain an order for a diuretic. Continue to monitor the client as ordered.
Correct response: Continue to monitor the client as ordered. Explanation: Normal CVP ranges from 2 to 6 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to re-zero the equipment. Calling a health care provider and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 2 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 6 mm Hg. (Note: normal values can vary by reference source.)
A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing? Dipyridamole Lanoxin Thallium 201 Cardiolite
Correct response: Dipyridamole Explanation: If the patient is unable to exercise, a pharmacologic stress test is performed by injecting a vasodilating agent, dipyridamole or adenosine, to mimic the physiologic effects of exercise. The stress test may be combined with an echocardiogram or radionuclide imaging techniques to examine myocardial function during exercise and rest. Digoxin would not be used for stress testing. Thallium 201 and Cardiolite are radioisotopes used in myocardial perfusion scanning.
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? Thallium Ativan Diazepam Dobutamine
Correct response: Dobutamine Explanation: Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. The other options would not dilate the coronary arteries.
When caring for a client with dysfunction in the conduction system, at which period would the nurse note that cells are resistant to stimulation? During polarization During depolarization During repolarization During the refractory period
Correct response: During the refractory period Explanation: The refractory period is the time when cells are resistant to electrical stimulation. Repolarization is when the ions realign themselves to wait for an electrical signal. Depolarization occurs during muscle contraction when positive ions move inside the myocardial cell membrane and negative ions move outside. Before an impulse is generated, the cells are in a polarized state.
A patient's gradual decline in activity tolerance and increased shortness of breath have prompted her health care provider to assess the structure and size of her heart. Which of the following diagnostic tests is most likely to yield these assessment data? Echocardiography Electrocardiography (ECG) Cardiac catheterization Angiography
Correct response: Echocardiography Explanation: An echocardiogram yields a two-dimensional rendering of the heart's structure and mechanical function. An ECG indicates the heart's electrical activity, and angiography and cardiac catheterization are used to assess the patency of the coronary arteries.
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? RBC Platelets Enzymes WBC
Correct response: Enzymes Explanation: When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage. After an MI, RBCs and platelets should not be elevated. WBCs would only be elevated if there was a bacterial infection present.
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? Pulmonary embolism Myocardial infarction Pericarditis Heart failure
Correct response: Heart failure Explanation: An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.
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 Enhanced sensitivity to digitalis Increased risk of heart block Inclination to ventricular fibrillation
Correct response: Impaired myocardial contractility Explanation: Normal serum calcium is 8.9 to 10.3 mg/dL. A reading of 7.9 is below normal. Hypocalcemia is associated with slow nodal functioning and impaired myocardial contractility, which can increase the risk of heart failure.
The nurse is caring for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which assessment finding would the nurse anticipate relating to the infarction location? Respiratory compromise Chronic chest pain Irregular heart rate Cyanosis
Correct response: Irregular heart rate Explanation: The posterior wall of the right atrium is the location of the sinoatrial node (SA node), which is the pacemaker of the heart. Damage to this location may result in an irregular heart rate due to a disturbance of electrical pulse initiation. Depending on muscle damage, the client may have respiratory compromise, chest pain, and/or cyanosis.
A nurse is performing a cardiac assessment on an elderly client. Which finding warrants further investigation? Fourth heart sound (S4) Increased PR interval Orthostatic hypotension Irregularly irregular heart rate
Correct response: Irregularly irregular heart rate Explanation: An irregularly irregular heart rate indicates atrial fibrillation and should be investigated further. It's normal for an elderly client to have a prolonged systole, which causes an S4 heart sound. It's also normal for an elderly client to have slowed conduction, causing an increased PR interval. As a person ages, it's normal for baroreceptors in the body to decrease their response to changes in body position, which can cause orthostatic hypotension.
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? Na+ 140 mEq/L Ca++ 9 mg/dL K+ 3.1 mEq/L Mg++ 2 mEq/L
Correct response: K+ 3.1 mEq/L Explanation: All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation.
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. Monitor the puncture site and assess the affected extremity. Keep the client turned to the right side and watch for bleeding from the site. Observe for bloody urine and stools.
Correct response: Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. Explanation: During the recovery period, the client must have the head of the bed elevated 45 degrees to avoid aspiration. The nurse should restrict food and fluids until the return of the gag reflex and the client is fully awake and alert. There will be no puncture site after an transesophageal echocardiogram. There is no need to turn the client on the right side or watching for bleeding from the esophagus. There are no anticoagulants given during this procedure, so bloody stools or urine should not occur.
The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer? Diltiazem Metoprolol Amiodarone Propafenone
Correct response: Metoprolol Explanation: Patients may receive beta-blockers prior to the scan to control heart rate and rhythm.
A nurse is caring for a client taking diltiazem for arrhythmias. The nurse knows that diltiazem helps decrease arrhythmias by working during which phase of the cardiac action potential? Phase 0 Phase 1 Phase 2 Phase 3
Correct response: Phase 0 Explanation: Diltiazem, a calcium channel blocker, blocks the influx of calcium into the cells during phase 0 of the cardiac action potential. This action causes the sinoatrial node and atrioventricular (AV) node to slow their response times, which results in slowed AV conduction, decreased ventricular depolarization, and arrhythmias. Diltiazem doesn't work during phase 1, 2, or 3 of the cardiac action potential.
The nurse observes a client during an exercise stress test (bicycle). Which finding indicates a positive test and the need for further diagnostic testing? Dizziness and leg cramping BP changes; 148/80 mm Hg to 166/90 mm Hg ST-segment changes on the ECG Heart rate changes; 78 bpm to 112 bpm
Correct response: ST-segment changes on the ECG Explanation: During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; blood pressure; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated when the target heart rate is achieved or if the client experiences signs of myocardial ischemia. Further diagnostic testing, such as a cardiac catheterization, may be warranted if the client develops chest pain, extreme fatigue, a decrease in blood pressure or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. The other findings would not warrant stopping the test.
The nurse uses which term for the normal pacemaker of the heart? Sinoatrial (SA) node Atrioventricular (AV) node Purkinje fibers Bundle of His
Correct response: Sinoatrial (SA) node Explanation: The sinoatrial node is the primary pacemaker of the heart. The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.
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: An excess level of thyroid hormone. Stimulation of the vagus nerve. An increased level of catecholamines. Sympathetic nervous system stimulation.
Correct response: Stimulation of the vagus nerve. Explanation: Parasympathetic impulses, which travel to the heart through the vagus nerve, can slow the cardiac rate. The other choices cause an increase in heart rate.
The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider? The client is at risk for renal failure due to the contrast agent that will be given during the procedure. These values show a risk for dysrhythmias. The client is overhydrated, which puts him at risk for heart failure during the procedure. The client is at risk for bleeding.
Correct response: The client is at risk for renal failure due to the contrast agent that will be given during the procedure. Explanation: The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment, indicated by the increased BUN and creatinine, the risk for contrast agent-induced nephropathy and renal failure is high. Renal impairment is not usually associated with dysrhythmias. The increased BUN and creatinine do not indicate overhydration, but decreased kidney function. The BUN and creatinine levels do not interfere with coagulability or bleeding.
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 may have had a myocardial infarction. The patient had a vagal response. The patient was anxious about being constipated. The patient may have an abdominal aortic aneurysm.
Correct response: The patient had a vagal response. Explanation: When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response. Myocardial infarction is damage to the heart and clients will experience pain or shortness of breath. Anxiety causes the heart rate to increase. The client with an abdominal aortic aneurysm will experience back or abdominal pain, not a decrease in heart rate.
The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? The AV node The Purkinje fibers The sinoatrial node The ventricles
Correct response: The sinoatrial node Explanation: The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body (Weber & Kelley, 2010).
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. You will need to wear comfortable shoes to the test. You will begin exercising at a slow speed. You may experience an onset of dizziness during the test.
Correct response: You will receive medication via IV administration. Explanation: Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. Drugs may be used to stress the heart for clients with sedentary lifestyles or those with a physical disability, such as severe arthritis, that interferes with exercise testing. Drug-induced stress testing does not require the client to exercise. Instead, drugs are used to stress the heart. Clients performing exercise electrocardiography should report chest pain, dizziness, leg cramps, or weakness if they experience them during the test.
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 telemetry monitoring transesophageal echocardiogram pharmacologic stress test
Correct response: cardiac catheterization Explanation: An elevated ST-segment means an evolving myocardial infarction. A cardiac catheterization would be the logical next step. Telemetry monitoring will only provide dysrhythmia detection. A transesophageal echocardiogram is a diagnostic test to assess cardiac function. The pharmacologic stress test is diagnostic and will determine heart function.
What does decreased pulse pressure reflect? tachycardia reduced distensibility of the arteries reduced stroke volume elevated stroke volume
Correct response: reduced stroke volume Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.
Central venous pressure is measured in which heart chamber? right atrium left atrium left ventricle right ventricle
Correct response: right atrium Explanation: The pressure in the right atrium is used to assess right ventricular function and venous blood return to the heart. The left atrium receives oxygenated blood from the pulmonary circulation. The left ventricle receives oxygenated blood from the left atrium. The right ventricle is not the central collecting chamber of venous circulation.
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 left ventricle right atrium left atrium
Correct response: right ventricle Explanation: The right ventricle pumps blood to the lungs to be oxygenated. The left ventricle pumps that blood to all the cells and tissues of the body. The right atrium receives deoxygenated blood from the venous system. The left atrium receives oxygenated blood from the lungs.
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority? insert an oral airway. withhold food and fluids. position the client on his side. introduce a nasogastric (NG) tube.
Correct response: withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.
Catecholamines
hormones secreted by the adrenal medulla that affect the sympathetic nervous system in stress response epi norepi dopamine etc
Normal Creatinine
0.6-1.2
Magnesium levels
1.5-2.5 mEq/L
Normal BUN levels
10-20 mg/dL
