Exam 2 - Practice Questions
Chapter 30: Assessment of the Cardiovascular System
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Chapter 31: Concepts of Care for Patients With Dysrhythmias
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A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? a. Potassium 2.8 mEq/L b. Digoxin level 0.7 ng/mL c. Hemoglobin 9.8 g/dL d. Calcium 8.0 mg
Answer: Potassium 2.8 mEq/L A flattened T wave or the development of U waves is indicative of a low potassium level.
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? a. An elevated B-type natriuretic peptide (BNP). b. An elevated creatine kinase (CK-MB). c. A positive D-dimer. d. A positive ventilation/perfusion (V/Q) scan.
Answer: a. An elevated B-type natriuretic peptide (BNP). BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF. An elevated CK-MB would indicate a myocardial infarction, not severe CHF. CK-MB is an isoenzyme. A positive D-dimer would indicate a pulmonary embolus. A positive ventilation/perfusion (V/Q) scan (ratio) would indicate a pulmonary embolus. TEST-TAKING HINT: This question requires the test taker to discriminate between CHF, MI, and PE.
The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept? a. The client has a large abdomen and a positive tympanic wave. b. The client has paroxysmal nocturnal dyspnea. c. The client has 2+ glucose in the urine. d. The client has a comorbid condition of myocardial infarction.
Answer: b. The client has paroxysmal nocturnal dyspnea. Dyspnea occurring at night when the client is in a recumbent position indicates that the cardiac muscle is not able to compensate for extra fluid returning to the heart during sleep.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.
Answer: a, b, c. a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. If the client has kidney disease, fluids may be given 12 to 24 hours before the procedure for renal protection. Hydration would continue after the procedure. The client would be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. Baseline renal labs would be assessed. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade f. Dysrhythmias
Answer: a, c, e. a. Thrombophlebitis c. Pulmonary embolism e. Cardiac tamponade Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of left-sided heart catheterizations.
A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 mcmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)
Answer: a, c, e. a. Total cholesterol: 280 mg/dL (7.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.
The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? a. "Chest pain is caused by decreased oxygen to the heart muscle." b. "There is ischemia to the myocardium as a result of hypoxemia." c. "The heart muscle is unable to pump effectively to perfuse the body." d. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."
Answer: a. "Chest pain is caused by decreased oxygen to the heart muscle." This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement would the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."
Answer: a. "Clean the skin and clip hairs if needed." To ensure the best signal transmission, the skin would be clean and hairs clipped. Electrodes would be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.
An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."
Answer: a. "I get short of breath when I climb stairs." Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone daily to prevent PACs."
Answer: a. "Minimize or abstain from caffeine." PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse would explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first would try lifestyle changes to control them.
The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? a. "Your heart is damaged and needs about four(4) to six (6) weeks to heal." b. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." c. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." d. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."
Answer: a. "Your heart is damaged and needs about four(4) to six (6) weeks to heal." The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement? a. Administer the medication as ordered. b. Prepare to administer vitamin K (Aqua-Mephyton). c. Hold the medication and notify the HCP. d. Assess the client for abnormal bleeding.
Answer: a. Administer the medication as ordered. The therapeutic range for most clients' INR is 2 to 3, but for a client with a mechanical valve replacement it is 2 to 3.5. The medication should be given as ordered and not withheld.
The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the healthcare provider to order for this client? a. Amiodarone. b. Atropine. c. Digoxin. d. Adenosine.
Answer: a. Amiodarone. Amiodarone suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? a. Apical pulse rate of 110 and 4+ pitting edema of feet. b. Thick white sputum and crackles that clear with cough. c. The client sleeping with no pillow and eupnea. d. Radial pulse rate of 90 and capillary refill time <3 seconds.
Answer: a. Apical pulse rate of 110 and 4+ pitting edema of feet. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status. TEST-TAKING HINT: In option "3," the word "no" is an absolute term, and usually absolutes, such as "no," "never," "always," and "only," are incorrect because there is no room for any other possible answer. If the test taker is looking for abnormal data, then the test taker should exclude the options that have normal values in them, such as eupnea, pulse rate of 90, and capillary refill time (CRT) <3 seconds.
A nurse cares for a client who is on a cardiac monitor. The EKG reading presents ventricular tachycardia. What action would the nurse take first? a. Assess airway, breathing, and circulation. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator.
Answer: a. Assess airway, breathing, and circulation. Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a potentially lethal dysrhythmia. The nurse would first assess if the client is alert, breathing, and has a pulse. If this client is pulseless, then the nurse would call a Code Blue and begin CPR. The treatment of choice for pulseless ventricular tachycardia is defibrillation. If the client has a pulse, then cardioversion would be indicated. Amiodarone is an appropriate antidysrhythmic, but it is not the first action.
The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge? a. Carry your nitroglycerin tablets in a brown bottle. b. Swallow a nitroglycerin tablet at the first sign of angina. c. If one nitroglycerin tablet does not work in 10 minutes, take another. d. Nitroglycerin tablets have a fruity odor if they are potent.
Answer: a. Carry your nitroglycerin tablets in a brown bottle. Nitroglycerin tablets are dispensed in small brown bottles to preserve the potency. The client should not change the tablets to another container.
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? a. Coarse crackles b. Wheezes c. Rhonchi d. Friction rub
Answer: a. Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.
A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client's chart as the only action.
Answer: a. Compare the results with previous blood pressure readings. The most recent range for normal blood pressure is less than 140 mm Hg systolic and less than 90mm Hg diastolic. This client's blood pressure is at the upper range of acceptable, so the nurse would compare the client's current reading with those previously recorded before doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor would the nurse necessarily notify the primary health care provider. Documentation is important, but the nurse first checks previous readings.
A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min
Answer: a. Heart rate of 120 beats/min When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.
The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? a. Instruct the client to use a soft-bristle toothbrush. b. Discuss the importance of getting a monthly-partial thromboplastin time (PTT). c. Teach the client about signs of pacemakermalfunction. d. Explain to the client the procedure for synchronized cardioversion.
Answer: a. Instruct the client to use a soft-bristle toothbrush. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.
A nurse prepares to discharge a client with a cardiac dysrhythmia who is prescribed home health care services. Which priority information would be communicated to the home health nurse upon discharge? a. Medication orders for home b. Immunization history c. Religious beliefs d. Nutrition preferences
Answer: a. Medication orders for home The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information might be used to plan care, but not as the priority.
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Midsternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
Answer: a. Midsternal chest pain Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and would be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.
The nurse is functioning in the role of medication nurse during a code. Which should the nurse implement when administering amiodarone for ventricular tachycardia? a. Mix the medication in 100 mL of fluid and administer rapidly. b. Push the amiodarone directly into the nearest IV port and raise the arm. c. Question the physician's order because it is not ACLS recommended. d. Administer via an IV pump based on mg/kg/min.
Answer: a. Mix the medication in 100 mL of fluid and administer rapidly Amiodarone is administered during a code rapidly after being mixed in 100 mL of fluid.
The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first? a. Notify the health care provider (HCP). b. Assess what the client ate at the last meal. c. Request a STAT 12 lead electrocardiogram. d. Administer furosemide IVP.
Answer: a. Notify the health care provider (HCP). "Has developed" indicates a new issue; the nurse should notify the HCP of the assessment findings, which indicate that the client has developed heart failure.
The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? a. Notify the health-care provider immediately. b. Elevate the head of the client's bed. c. Document this as a normal and expected finding. d. Administer morphine intravenously.
Answer: a. Notify the health-care provider immediately. An S3 indicates left ventricular failure and should be reported to the health-care provider. It is a potential life-threatening complication of a myocardial infarction.
A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? a. Prothrombin time b. WBC count c. Platelet count d. Hematocrit
Answer: a. Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.
A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect? a. Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. b. The client is experiencing premature ventricular complexes at 12/min. c. Telemetry monitoring shows pacing spikes with no QRS complexes. d. The client is experiencing hiccups.
Answer: a. Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min, because the client's intrinsic rate overrides the set rate of the pacemaker.
The nurse has received shift report. Which client should the nurse assess first? a. The client diagnosed with coronary artery disease complaining of severe indigestion. b. The client diagnosed with congestive heart failure who has 3+ pitting edema. c. The client diagnosed with atrial fibrillation whose apical rate is 110 and irregular. d. The client diagnosed with sinus bradycardia who is complaining of being constipated.
Answer: a. The client diagnosed with coronary artery disease complaining of severe indigestion. A complaint of indigestion could be cardiac chest pain. The nurse should assess this client because of the diagnosis of CAD and the word "severe" in the option.
The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? a. The client diagnosed with myocardial infarction who has an audible S3 heart sound. b. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. c. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. d. The client with chronic renal failure who has an elevated creatinine level.
Answer: a. The client diagnosed with myocardial infarction who has an audible S3 heart sound. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure. TEST-TAKING HINT: Because the nurse will be assessing each client, the test taker must determine which client is a priority.
The nurse identifies the concept of tissue perfusion as a client problem. Which is an antecedent of tissue perfusion? a. The client has a history of coronary artery disease (CAD). b. The client has a history of diabetes insipidus (DI). c. The client has a history of chronic obstructive pulmonary disease (COPD). d. The client has a history of multiple fractures from a motor-vehicle accident.
Answer: a. The client has a history of coronary artery disease (CAD). CAD narrows the arteries of the heart, causing the tissues not to be perfused, especially when an embolus or a thrombus occurs.
A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? a. Weight gain 1 kg (2.2 lb) in 1 day b. Pitting edema +1 c. Client report of nocturnal cough d. B-Type Natriuretic Peptide (BNP) level of 100 pg/mL
Answer: a. Weight gain 1 kg (2.2 lb) in 1 day. A weight gain of 1 kg (2.2 lb) in 1 day alerts the nurse that the client is retaining fluid and is at risk of fluid volume overload. This is an indication that the client's heart failure is worsening.
An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath
Answer: b, c, e. b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.
A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the primary health care provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.
Answer: b, d, e. b. Prepare for continuous blood pressure and pulse monitoring. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination. Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3-to-6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, would be performed. Beta blockers are often held prior to the procedure as they lower the heart rate and may result in inaccurate results.
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor f. Oxygen saturation 93% on room air
Answer: b, d, e. b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding hematoma signifies bleeding. Rhythm changes on the monitor are a known complication. These findings would require prompt action. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours. The oxygen saturation is slightly low but not critical and there is no baseline to compare it to.
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."
Answer: b. "Avoid straining while having a bowel movement." Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.
A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching? a. "I should eat foods high in saturated fat." b. "Before taking my medication, I will count my radial pulse rate." c. "I will exercise once per week for an hour at the health club." d. "I will stop taking my medication when my blood pressure is within a normal range."
Answer: b. "Before taking my medication, I will count my radial pulse rate." A beta blocker will induce bradycardia. The client should take her pulse rate for 1 min before self-administration.
Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? a. "I will not eat more than six (6) eggs a week." b. "I should bake or grill any meats I eat." c. "I will drink eight (8) ounces of whole milk a day." d. "I should not eat any type of pork products."
Answer: b. "I should bake or grill any meats I eat." The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "I would wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I would participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."
Answer: b. "I will avoid sources of strong electromagnetic fields." The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields, such as devices emitting microwaves (not microwave ovens); transformers; radio, television, and radar transmitters; large electrical generators; metal detectors, including handheld security devices at airports; antitheft devices; arc welding equipment; and sources of 60-cycle (Hz) interference. Also avoid leaning directly over the alternator of a running motor of a car or boat. Clients would avoid tight clothing, which could cause irritation over the ICD generator. The client would be encouraged to exercise but would not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client would continue all prescribed medications.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day.". c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."
Answer: b. "My shoes fit tighter by the end of the day.". Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "You should balance weight loss with consuming necessary nutrients." c. "A nutritionist will provide you with information about your new diet." d. "If you exercise more frequently, you won't need to change your diet."
Answer: b. "You should balance weight loss with consuming necessary nutrients." Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse would encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse would include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.
A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily. b. A 50-year-old who is post coronary artery bypass graft surgery. c. A 78-year-old who had a carotid endarterectomy. d. An 80-year-old with chronic obstructive pulmonary disease.
Answer: b. A 50-year-old who is post coronary artery bypass graft surgery. Atrial fibrillation occurs commonly in clients with cardiac disease. Other risk factors include hypertension (HTN), previous ischemic stroke, transient ischemic attack (TIA) or other thromboembolic event, diabetes mellitus, heart failure, obesity, hyperthyroidism, chronic kidney disease, excessive alcohol use, and mitral valve disease. The other conditions do not place these clients at higher risk for atrial fibrillation.
The client is in complete heart block. Which intervention should the nurse implement first? a. Prepare to insert a pacemaker. b. Administer atropine, an antidysrhythmic. c. Obtain a STAT electrocardiogram (ECG). d. Notify the health-care provider.
Answer: b. Administer atropine, an antidysrhythmic. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention.
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? a. Medicate the client with intravenous morphine. b. Assess the client's chest dressing and vital signs. c. Encourage the client to turn from side to side. d. Check the client's telemetry monitor.
Answer: b. Assess the client's chest dressing and vital signs. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? a. Perform passive range-of-motion exercises. b. Assess the client's neurovascular status. c. Keep the client in high Fowler's position. d. Assess the gag reflex prior to feeding the client.
Answer: b. Assess the client's neurovascular status. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor.
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. What action would the nurse take next? a. Administer intravenous diltiazem. b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.
Answer: b. Assess vital signs and level of consciousness. In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike would be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse would assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? a. P waves occurring at 0.16 seconds before each QRS complex b. Atrial rate of 300/min with QRS complex of 80/min c. Ventricular rate of 82/min with an atrial rate of 80/min d. An irregular ventricular rate of 125/min with a wide QRS pattern
Answer: b. Atrial rate of 300/min with QRS complex of 80/min The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? a. Midepigastric pain and pyrosis. b. Diaphoresis and cool, clammy skin. c. Intermittent claudication and pallor. d. Jugular vein distention and dependent edema.
Answer: b. Diaphoresis and cool, clammy skin. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? a. Be able to ambulate in the hall by date of discharge. b. Have an audible S1 and S2 with no S3 heard by end of shift. c. Turn, cough, and deep breathe every two (2) hours. d. Have a pulse oximeter reading of 98% by day two (2) of care.
Answer: b. Have an audible S1 and S2 with no S3 heard by end of shift. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. Turning the patient is a nursing intervention, not a short-term goal for the patient. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output. TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test taker must be sure that the answer selected addresses the problem. An answer option may be appropriate care for the disease process but may not fit with the problem or etiology. Remember, when given an etiology in a nursing diagnosis, the answer will be doing something about the problem (etiology).
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access
Answer: b. Initiation of an external pacemaker The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.
The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? a. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. b. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. c. Determine if the client has gained weight and instruct the client to keep the legs elevated. d. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
Answer: b. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels. Weight gain is monitored in clients with CHF, and elevating the legs would decrease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps. Ambulating frequently and performing leg-stretching exercises will not be effective in alleviating the leg cramps.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the primary health care provider before scheduling the MRI. c. Request lab for cardiac enzymes from the primary health care provider. d. Instruct the client to increase fluid intake the day before the MRI.
Answer: b. Notify the primary health care provider before scheduling the MRI. The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but the nurse needs to notify the primary health care provider.
A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take? a. Obtain blood samples to test platelet function. b. Prepare for replacement of the missing clotting factor. c. Administer aspirin for the client's pain. d. Place the bleeding joint in the dependent position.
Answer: b. Prepare for replacement of the missing clotting factor. Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range of motion in repeatedly affected joints.
A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity
Answer: b. Speech alterations Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? a. Put a nitroglycerin tablet under the tongue. b. Stop the activity immediately and rest. c. Document when and what activity caused angina. d. Notify the health-care provider immediately.
Answer: b. Stop the activity immediately and rest. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain).
The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? a. Instruct the client to take a cough suppressant if a cough develops. b. Teach the client how to prevent orthostatic hypotension. c. Encourage the client to eat bananas to increase potassium level. d. Explain the importance of taking the medication with food.
Answer: b. Teach the client how to prevent orthostatic hypotension. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored. If a cough develops, the client should notify the health-care provider because this is an adverse reaction and the HCP will discontinue the medication. ACE inhibitors may cause the client to retain potassium; therefore, the client should not increase potassium intake. An ACE inhibitor should be taken one (1) hour before meals or two (2) hours after a meal to increase absorption of the medication.
The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? a. The client has a BP of 110/70. b. The client has an apical pulse of 56. c. The client is complaining of a headache. d. The client's potassium level is 4.5 mEq/L.
Answer: b. The client has an apical pulse of 56. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.
The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor? a. The client admitted for diagnostic tests to rule out valvular heart disease.2 b. The client three (3) days post-myocardial infarction being discharged tomorrow. c. The client exhibiting supraventricular tachycardia (SVT) on telemetry. d. The client diagnosed with atrial fibrillation who has an INR of five (5).
Answer: b. The client three (3) days post-myocardial infarction being discharged tomorrow. Because this client is being discharged, it would be an appropriate assignment for the new graduate.
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What action would the nurse take prior to the cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure that a tongue blade is available. d. Position the client on the left side.
Answer: b. Turn off oxygen therapy. For safety during cardioversion, the nurse would turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client would be placed in a supine position.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication would the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol b. Warfarin c. Atropine d. Lidocaine
Answer: b. Warfarin Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for preventing this complication.
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" What is the nurse's best response? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."
Answer: c. "Clients who use cocaine are at risk for fatal dysrhythmias." Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.
A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response? a. "This is a routine test and the risk of death is very low." b. "Would you like to speak with a chaplain prior to test?" c. "Tell me more about your concerns about the test." d. "What support systems do you have to assist you?"
Answer: c. "Tell me more about your concerns about the test." The nurse would discuss the client's feelings and concerns related to the cardiac catheterization. The nurse would not provide false hope or push the client's concerns off on the chaplain. The nurse would address support systems after addressing the client's current issue.
A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "The primary health care provider has prescribed an antacid every morning." c. "What do you understand about what happened to you?" d. "When did you start experiencing this indigestion?"
Answer: c. "What do you understand about what happened to you?" Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain.
A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates.
Answer: c. A 65-year-old woman with diabetes mellitus. Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular disease.
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.
Answer: c. Assess the client's medications. Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However, the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."
Answer: c. Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem.
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? a. Social worker. b. Physical therapy. c. Cardiac rehabilitation. d. Occupational therapy.
Answer: c. Cardiac rehabilitation. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors.
The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? a. Perform isometric exercises daily. b. Walk for 15 minutes three (3) times a week. c. Do not walk outside if it is less than 40 ̊F. d. Wear open-toed shoes when ambulating.
Answer: c. Do not walk outside if it is less than 40 ̊F. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside.
A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm
Answer: c. Fatigue and shortness of breath In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not known to be specific symptoms for women having and MI.
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? a. Administer sublingual nitroglycerin. b. Obtain a STAT electrocardiogram (ECG). c. Have the client sit down immediately. d. Assess the client's vital signs.
Answer: c. Have the client sit down immediately. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.
A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability
Answer: c. Level of consciousness A heart rate of 40 beats/min or less could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse would assess for level of consciousness, dizziness, confusion, syncope, chest pain, shortness of breath. Although the other assessments would be completed, the nurse would assess the client's neurologic status next.
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? a. Instruct the UAP to stop encouraging the leg movements. b. Report this behavior to the charge nurse as soon as possible. c. Praise the UAP for encouraging the client to move the legs. d. Take no action concerning the UAP's behavior.
Answer: c. Praise the UAP for encouraging the client to move the legs. The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring.
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What intervention would the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 L per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask assistive personnel (AP) to help bathe the client.
Answer: c. Schedule periods of exercise and rest during the day. Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse would schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with performing self-care activities and there is no indication for oxygen.
A nurse administers prescribed adenosine to a client. Which response would the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis
Answer: c. Short period of asystole Clients usually respond to adenosine with a short period of asystole, bradycardia with long pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor does it cause increased heart rate or hypertensive crisis.
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg
Answer: c. Slurred speech and confusion A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may not be significant.
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? a. The 44-year-old client diagnosed with a myocardial infarction. b. The 65-year-old client admitted with unstable angina. c. The 75-year-old client scheduled for a cardiac catheterization. d. The 50-year-old client complaining of chest pain.
Answer: c. The 75-year-old client scheduled for a cardiac catheterization. A new graduate should be able to complete a pre-procedure checklist and get this client to the catheterization laboratory.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? a. The client's peripheral pitting edema has gone from 3+ to 4+. b. The client is able to take the radial pulse accurately. c. The client is able to perform ADLs without dyspnea. d. The client has minimal jugular vein distention.
Answer: c. The client is able to perform ADLs without dyspnea. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs. Pitting edema changing from 3+ to 4+ indicates a worsening of the CHF. The client's ability to take the radial pulse would evaluate teaching, not medical treatment. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment. TEST-TAKING HINT: When asked to determine whether treatment is effective, the test taker must know the signs and symptoms of the disease being treated. An improvement in the signs and symptoms indicates effective treatment.
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? a. The client's BP is 110/70 and pulse is 90. b. The client's groin dressing is dry and intact. c. The client refuses to keep the leg straight. d. The client denies any numbness and tingling.
Answer: c. The client refuses to keep the leg straight. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.
The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? a. The client diagnosed with congestive heart failure who is being discharged in the morning. b. The client who is having frequent incontinent liquid bowel movements and vomiting. c. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. d. The client who is complaining of chest pain with inspiration and a nonproductive cough.
Answer: c. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client. This client is stable because discharge is scheduled for the following day. Therefore, this client does not need to be assigned to the most experienced registered nurse. This client is more in need of custodial nursing care than care from the most experienced registered nurse. Therefore, the charge nurse could assign a less experienced nurse to this client. These complaints usually indicate muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration.
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)? a. Creatine kinase (CK-MB). b. Lactate dehydrogenase (LDH). c. Troponin. d. White blood cells (WBCs).
Answer: c. Troponin. Troponin is the enzyme that elevates within 1 to 2 hours.
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? a. Infective endocarditis b. Pericarditis c. Ventricular dysrhythmias d. Pulmonary emboli
Answer: c. Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.
The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? a. "I should keep the tablets in the dark-colored bottle they came in." b. "If the tablets do not burn under my tongue, they are not effective." c. "I should keep the bottle with me in my pocket at all times." d. "If my chest pain is not gone with one tablet, I will go to the ER."
Answer: d. "If my chest pain is not gone with one tablet, I will go to the ER." The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.
A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best "response? a. "I will consult your primary health care provider to prescribe a sleep study." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."
Answer: d. "Use pillows to elevate your head and chest while you are sleeping." The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents
Answer: d. Allergies to iodine-based agents Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take priority for client safety.
The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? a. Sponge the client's forehead. b. Obtain a pulse oximetry reading. c. Take the client's vital signs. d. Assist the client to a sitting position.
Answer: d. Assist the client to a sitting position. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead. Sponging the client's forehead would be appropriate, but it is not the first intervention. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention. Taking the vital signs would be appropriate, but it is not the first intervention.
A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? a. Chest pain is relieved soon after resting. b. Nitroglycerin relieves chest pain. c. Physical exertion does not precipitate chest pain. d. Chest pain lasts longer than 15 min.
Answer: d. Chest pain lasts longer than 15 min. The client who has unstable angina will have chest pain lasting longer than 15 min. This is due to the reduced blood flow in a coronary artery due to atherosclerotic plaque and thrombus formation causing partial arterial obstruction, or from an artery spasm.
An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest.
Answer: d. Client who describes intense squeezing pressure across the chest. All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client 's chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction.
The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? a. Assess the apical heart rate for one (1) full minute. b. Notify the client's cardiac surgeon. c. Prepare the client for synchronized cardioversion. d. Determine if the client is having pain.
Answer: d. Determine if the client is having pain. Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client? a. Make sure that the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 J. d. Ensure that everyone is clear of contact with the client and the bed.
Answer: d. Ensure that everyone is clear of contact with the client and the bed. To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. Defibrillation is done in asynchronous mode. Equipment would not be tested before a client is defibrillated because this is an emergency procedure; equipment would be checked on a routine basis. Defibrillation takes priority over any medications.
The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first? a. Call a Code Blue. b. Assess the telemetry reading. c. Take the client's apical pulse. d. Have the client sit down.
Answer: d. Have the client sit down. The client began to have a problem during physical exertion. Stopping the exertion should be the first action taken by the nurse.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? a. Assist the client to go down to the smoking area for a cigarette. b. Transport the client to the intensive care unit via a stretcher. c. Provide the client going home discharge-teaching instructions. d. Help position the client who is having a portable x-ray done.
Answer: d. Help position the client who is having a portable x-ray done. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment. Allowing the UAP to take a client down to smoke is not cost effective and is not supportive of the medical treatment regimen that discourages smoking. The client going to the ICU would be unstable, and the nurse should not delegate to a UAP any nursing task that involves an unstable client. The nurse cannot delegate teaching.
The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is priority? a. Sleep, rest, activity. b. Comfort. c. Oxygenation. d. Perfusion.
Answer: d. Perfusion The cardiac muscle is not perfused when there is a narrowing of the arteries caused by CAD or when an embolus or a thrombus occludes the artery. Adequate perfusion will supply oxygen to the cardiac muscle, allow for increased activity, and decrease pain.
The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.
Answer: d. Plan for frequent rest periods. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome. Daily weighing monitors fluid volume status, not activity tolerance. Measuring the intake and output is an appropriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find? a. Blood pressure increased from 98/42 to 132/60 mm Hg. b. Respiratory rate decreased from 25 to 14 breaths/min. c. Oxygen saturation increased from 88% to 96%. d. Pulse decreased from 100 to 80 beats/min.
Answer: d. Pulse decreased from 100 to 80 beats/min. Beta blockers block the stimulation of beta1 -adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow for better filling and better cardiac output.
The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? a. The client's apical pulse is 64. b. The client's calcium level is elevated. c. The client's telemetry shows occasional PVCs. d. The client's blood pressure is 90/58.
Answer: d. The client's blood pressure is 90/58. The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How would the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
Answer: d. Ventricular and atrial depolarizations are initiated from different sites. Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.
A nurse assesses a client who has aortic regurgitation. In which location would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
Second intercostal space just to the right of the sternum. The aortic valve is auscultated in the second intercostal space just to the right of the sternum. The pulmonic valve would be heard in location B located in the second intercostal space just left of the sternum. The mitral valve would be heard in location D located in the fifth intercostal space at the apex of the heart. The tricuspid valve would be heard in location C located in the fifth intercostal space at the lower left of the sternal border.
Sinus rythym with PVC
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Ventricular Tachycardia
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