Lippincott Cardiac Health Problems Practice Questions
The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply. 1. Reorient frequently to time, place, and situation. 2. Put the client in a quiet room furthest from the nursing station. 3. Perform necessary procedures quickly. 4. Arrange for familiar pictures or special items at bedside. 5. Limit the client's visitors. 6. Spend time with the client, establishing a trusting relationship.
1,4,6. It is not unusual for the elderly client to become somewhat confused when "relocated" to the hospital, and this may be more difficult for those with known dementia. Frequent reorientation delivered patiently and calmly along with placing familiar items nearby so the client can see them may help decrease confusion related to hospitalization. Establishing a trusting relationship is important with every client but may be more so with this client. Putting the client in a room further from the nursing station may decrease extra noise for the client but will also make it more difficult to observe the client and maintain a safe environment. Procedures should be explained to the client prior to proceeding and should not be rushed. Visits by family and friends may help to keep the client oriented.
When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to: 1. promote hydration. 2. dissolve clots. 3. prevent kidney failure. 4. treat dysrhythmias.
2. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.
A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? Round your answer to a whole number. ____________________ mL/h.
24 mL/h
Which activity would be appropriate to delegate to unlicensed assistive personnel (UAP) for a client diagnosed with a myocardial infarction who is stable? 1. Evaluate the lung sounds. 2. Help the client identify risk factors for CAD. 3. Provide teaching on a 2-g sodium diet. 4. Record the intake and output.
4. UAP are able to measure and record intake and output. The nurse is responsible for client teaching, physical assessments, and evaluating the information collected on the client.
The nurse should assess the client with left-sided heart failure for which findings? Select all that apply. 1. dyspnea 2. jugular vein distention (JVD) 3. crackles 4. right upper quadrant pain 5. oliguria 6. decreased oxygen saturation levels
1,3,5,6. Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure.
Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? 1. 5 to 10 minutes 2. 30 to 60 minutes 3. 2 to 4 hours 4. 6 to 8 hours
1. After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.
What is the major goal of nursing care for a client with heart failure and pulmonary edema? 1. Increase cardiac output. 2. Improve respiratory status. 3. Decrease peripheral edema. 4. Enhance comfort.
1. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.
The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which changes noted from the client's chart to the healthcare provider (HCP)? Nurses Progress Notes BP: 110/70 100/65 T: 98.7 (37.1) 99 (37.2) HR: 70 75 R: 20 26 Urine output: 90 mL/h 20 mL/h 1. urine output 2. heart rate 3. blood pressure 4. respiratory rate
1. Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client's chart are not as significant as the decreased urinary output.
When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol: 1. blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. 2. increases norepinephrine secretion and thus decreases blood pressure and heart rate. 3. is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.
1. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to angiotensin II.
A client is scheduled for a cardiac catheterization. The nurse should do which preprocedure tasks? Select all that apply. 1. Administer all prescribed oral medications. 2. Check for iodine sensitivity. 3. Verify that written consent has been obtained. 4. Withhold food and oral fluids before the procedure. 5. Insert a urinary drainage catheter.
2,3,4. For clients scheduled for a cardiac catheterization, it is important to assess for iodine sensitivity, verify written consent , and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which finding requires immediate nursing action? 1. There is a low, grade 1 intensity mitral regurgitation murmur. 2. SpO2 is 94% on 2 L of oxygen via nasal cannula. 3. Client has become more somnolent. 4. Urine output decreased from 60 mL/h to 40 mL over the last hour.
3. A complication of balloon valvuloplasty is emboli resulting in a stroke. The client's increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely but do not warrant concern.
Which would be most helpful when coaching a client to stop smoking? 1. Review the negative effects of smoking on the body. 2. Discuss the effects of passive smoking on environmental pollution. 3. Establish the client's daily smoking pattern. 4. Explain how smoking worsens high blood pressure.
3. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.
A client with angina is taking nifedipine. What instruction should the nurse give the client? 1. Monitor blood pressure monthly. 2. Perform daily weights. 3. Inspect gums daily. 4. Limit intake of green leafy vegetables.
3. The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables.
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: 1. control chest pain. 2. reduce coronary artery vasospasm. 3. control the arrhythmias associated with MI. 4. revascularize the blocked coronary artery.
4. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.
A client diagnosed with primary (essential) hypertension is taking chlorothiazide. The nurse determines teaching about this medication is effective when the client makes which statement? "I will: (Select all that apply.) 1. take my weight daily at the same time each day." 2. not drink alcoholic beverages while on this medication." 3. reduce salt intake in my diet." 4. reduce my dosage if I have severe dizziness." 5. use sunscreen if I have prolonged exposure to sunlight." 6. take the drug late in the evening."
1,2,3,5. Chlorothiazide causes increased urination and decreased swelling (if there is edema) and weight loss. It is important to check and record weight two to three times per week at same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or take other medications without the approval of the healthcare provider (HCP) . Reducing sodium intake in the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses are less likely to cause adverse effects, and therefore, excessive table salt as well as salty foods should be avoided. Chlorothiazide is a diuretic that is prescribed for lower blood pressure and may cause dizziness and faintness when the client stands up suddenly. This can be prevented or decreased by changing positions slowly. If dizziness is severe, the HCP must be notified. Diuretics may cause sensitivity to sunlight; hence the need to avoid prolonged exposure to sunlight, use sunscreens, and wear protective clothing. Chlorothiazide causes increased urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer bathroom trips mean less interference with sleep and less risk of falls. The client should not change the dosage without consulting the HCP.
A client who has diabetes is taking metoprolol for hypertension. What should the nurse instruct the client to do? Select all that apply. 1. Take the tablets with food at same time each day. 2. Do not crush or chew the tablets. 3. Notify the healthcare provider (HCP) if pulse is 82 beats/min. 4. Have a blood glucose level drawn every 6 to 12 months during therapy. 5. Use an appropriate decongestant if needed. 6. Report any fainting spells to the HCP.
1,2,4,6. Metoprolol is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The HCP should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, and tremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need to be reduced or discontinued.
A client with acute chest pain is receiving IV morphine sulfate. Which is an expected effect of morphine? Select all that apply. 1. reduces myocardial oxygen consumption 2. promotes reduction in respiratory rate 3. prevents ventricular remodeling 4. reduces blood pressure and heart rate 5. reduces anxiety and fear
1,4,5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme inhibitor drugs, not morphine, may help to prevent ventricular remodeling.
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. The client should avoid which activity until after the 1-month postdischarge appointment with the surgeon? 1. showering 2. lifting anything heavier than 10 lb (4.5 kg) 3. a program of gradually progressive walking 4. light housework
2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.
A client is admitted with chest pain and kept overnight for stress testing the next morning. Prior to sending the client to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory value to the healthcare provider (HCP) prior to the stress test? 1. cholesterol level 2. erythrocyte sedimentation rate 3. prothrombin time 4. troponin
4. The elevated troponin level should be reported to the HCP prior to the stress test as this change indicates myocardial damage. Sending the client to walk on a treadmill for stress testing would be contraindicated with evidence of recent myocardial injury and could further extend the damage. The other blood levels are helpful but not critical to this client's welfare at this point in time.
When teaching a client about self-care following placement of a new permanent pacemaker to the left upper chest, the nurse should include which information? Select all that apply. 1. Take and record daily pulse rate. 2. Avoid air travel because of airport security alarms. 3. Immobilize the affected arm for 4 to 6 weeks. 4. Avoid using a microwave oven. 5. Avoid lifting anything heavier than 3 lb (1.36 kg).
1, 5. The nurse must teach the client how to take and record the pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to heal and full range of motion to return. The client should avoid heavy lifting until approved by the healthcare provider (HCP) . The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function.
The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just do not feel good." What actions should the nurse take? Select all that apply. 1. Confirm the client's vital signs, and complete a quick assessment. 2. Inform the charge nurse of the change in condition, and initiate the hospital's rapid/emergency response team. 3. Make a quick check on other assigned clients before spending the amount of time required to take care of this client. 4. Position the client in semi-Fowler's position. 5. Stay with the client, and reassure the client. 6. Call the healthcare provider (HCP), and report the situation using SBAR format.
1,2,4,5,6. The nurse must have assessment data and verify vital signs if necessary in order to determine the action that is required. If there is a significant change in the client's condition, the charge nurse should be notified in order to help the nurse with both this client and the nurse's other assigned clients if necessary; most acute care facilities have a rapid response team that can also help assess and intervene with basic standing orders if necessary. Positioning the client in semi-Fowler's is a nursing action that may assist in breathing and relieve shortness of breath. It is important for the nurse to reassure the client by staying calm and remaining with the client. The nurse must notify the HCP about the change in client's condition; the nurse must have all information available and present it in a concise and accurate manner using SBAR format including a recommendation for treatment if indicated. The nurse should stay with this client and delegate checking on other assigned clients to the charge nurse or UAP .
The nurse is planning care for a group of elderly clients who are affected by orthostatic hypotension. What should the nurse do? Select all that apply. 1. Assist the clients to stand to help prevent falls. 2. Teach clients how to gradually change their position. 3. Request a prescription for antihypertensive medications for clients at high risk. 4. Conduct "fall risk" assessments. 5. Consider the use of sequential compression devices (SCDs) for high-risk clients. 6. Place clients on bed rest.
1,2,4,5. Orthostatic hypotension is a drop in blood pressure that occurs when changing position, usually to a more upright position. Orthostatic hypotension often occurs in elderly clients, and it is a common cause of falls. Nurses must assess clients for orthostatic hypotension and assist all clients with orthostatic hypotension in standing to help prevent falls. Lower limb compression devices aid in prevention of decreased orthostatic systolic blood pressure and reduce symptoms in elderly clients with progressive orthostatic hypotension. Nurses must teach clients how to gradually change their position, and they must conduct "fall risk" assessments. Sequential compression devices may be helpful to high-risk clients and should be considered when developing the care plan. Antihypertensive medications are not necessary for clients with orthostatic hypertension and may precipitate dangerous drops in blood pressure. The clients should be encouraged to be ambulatory.
A client has atrial fibrillation and a heart rate of 165 bpm. In which order from first to last should the nurse implement these prescriptions? All options must be used. 1. Administer oxygen via nasal cannula. 2. Gather supplies for an IV insertion. 3. Place client on a cardiac monitor (ECG). 4. Obtain vital signs including BP, P, R, T, and O2 saturation.
1,3,4,2. Because atrial fibrillation causes a decrease in cardiac output, the heart rate increases in response to this drop. As a result of an increased heart rate, the oxygen demands of the heart increase. It is important for oxygen to be administered first to help compensate for the increased oxygen demand and cardiac workload. Placing the client on a cardiac monitor will help confirm a diagnosis of atrial fibrillation. Performing vital signs will determine the client's response to the abnormal rhythm and responses to treatment. If the rhythm is determined to be atrial fibrillation, it will be necessary for an IV to be inserted so medication can be administered.
An 85-year-old client is admitted to the emergency department (ED) at 2000 hours with syncope, shortness of breath, and reported palpitations (see nurse's notes below). At 2015, the nurse places the client on the ECG monitor and identifies the following rhythm (see below). What should the nurse do? Select all that apply. Nurse's Progress Notes Pulse: 150 BP: 90/62 Oxygen saturation: 92% on room air RR: 22 Progress notes: Client has shortness of breath and states, "My heart is jumping out of my chest and hurts some. I am having trouble catching my breath. I don't want to faint again." 1. Apply oxygen. 2. Prepare to defibrillate the client. 3. Monitor vital signs. 4. Have the client sign consent for cardioversion as prescribed. 5. Teach the client about warfarin treatment and the need for frequent blood testing. 6. Draw blood for a CBC count and thyroid function study.
1,3,4. The client has atrial fibrillation and will have an irregularly irregular pulse and will commonly be tachycardic, with rapid ventricular responses (heart rates) typically in the 110 to 140 range, but rarely over 150 to 170. The goal of treatment is the restoration of sinus rhythm. With a heart rate >150 and symptoms such as shortness of breath, dizziness and syncope, and chest pain, synchronized cardioversion will most likely be the treatment of choice. With more controlled heart rates and more minor signs and symptoms, chemical conversion with drugs such as diltiazem and digoxin prior to other interventions such as synchronized cardioversion with appropriate anticoagulation may be attempted. Because of the decreased cardiac output, monitoring is essential. Obtaining consent for cardioversion requires a prescription from a healthcare provider (HCP) , but with the current heart rate, having cardioversion is a very strong possibility for this client. Defibrillation is used for ventricular fibrillation, not atrial fibrillation. Teaching the client about warfarin will be a possibility, but not an immediate intervention. Clients in continued atrial fibrillation usually require some form of anticoagulation. Drawing labs for CBCs to detect anemia or infection, and thyroid function studies (to determine thyrotoxicosis, a rare, but not-to-be-missed cause, especially in older adults), serum electrolytes, and BUN/creatinine (looking for electrolyte disturbances or renal failure) are commonly drawn for determining the cause of the atrial fibrillation; they are not an immediate action.
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60 mm Hg. The nurse should first: 1. prepare for transcutaneous pacing. 2. prepare to defibrillate the client at 200 J. 3. administer an IV lidocaine infusion. 4. schedule the operating room for insertion of a permanent pacemaker.
1. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker can be inserted.
A nurse working the day shift on a cardiac unit receives the following shift report: At the conclusion of shift report, it is 0730. Put the clients in the order from first to last in which the nurse should plan to assess them. All options must be used. 1. Client 1: Admitted yesterday morning with hypokalemia. Awaiting repeat electrolyte lab results drawn at 06:00. 2. Client 2: Experienced chest pain at 06:30. Pain resolved after 2 sublingual nitroglycerin tablets. 3. Client 3: Scheduled for oral antihypertensive medications at 0900. Incontinent of urine during the night. 4. Client 4: Scheduled for coronary artery bypass surgery at 0800. The client's family is in the client's room.
2,4,3,1. Even though the chest pain experienced by Client 2 is resolved, it was recent and requires reassessment. Client 4 is scheduled to leave for major surgery very soon. The nurse should check this client and the client's chart and make certain that everything is ready so as to not delay the surgery. Client 3 has scheduled medications for blood pressure control. While not experiencing any acute problems, this medication should be administered as scheduled. Client 1 is stable at this time and can be seen last.
A client admitted with normal sinus rhythm converts to the following rhythm on the cardiac monitor. For which symptoms should the nurse assess the client? Select all that apply. 1. carotid bruit 2. light-headedness 3. nausea 4. palpitations 5. shortness of breath 6. systolic murmur
2,4,5. This ECG strip indicates the client has atrial fibrillation. There is no P wave and PR interval; these are replaced with a fine wavy lines. In atrial fibrillation, the ventricular rate may be normal, slow, or fast. Clients with atrial fibrillation may have palpitations secondary to a fast and irregular atrial rhythm. Because atrial fibrillation also may result in a sudden decrease in cardiac output, the client may also experience light-headedness and shortness of breath. A carotid bruit, nausea, and a systolic murmur are not manifestations of new-onset atrial fibrillation.
During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when palpation of the radial pulse reveals: 1. two regular beats followed by one irregular beat. 2. an irregular rhythm with pulse rate > 100. 3. pulse rate below 60 bpm. 4. a weak, thready pulse.
2. Characteristics of atrial fibrillation include pulse rate >100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the healthcare provider (HCP) . A weak, thready pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction.
An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after insertion of a permanent pacemaker? 1. Maintain skin integrity. 2. Maintain cardiac conduction stability. 3. Decrease cardiac output. 4. Increase activity level.
2. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours.
The nurse is assessing a client with heart failure whose blood pressure and weight are being monitored remotely. The nurse reviews data obtained within the last 3 days. Weight 160 (72 kg) 162 (73 kg) 165 (74 kg) Blood Pressure 120/80 130/88 140/90 The nurse calls the client to follow up. The nurse should first ask the client: 1. "How are you feeling today?" 2. "Are you having shortness of breath?" 3. "Did you calibrate the scales before using them?" 4. "How much fluid did you drink during the last 24 hours?"
2. The client has gained 5 lb (2.3 kg) in 3 days with a steady increase in blood pressure. The client is exhibiting signs of heart failure, and if the client is short of breath, this will be another sign. Asking how the client is feeling is too general, and a more focused question will quickly determine the client's current health status. The scales should be calibrated periodically, but a 5-lb (2.3-kg) weight gain, along with increased blood pressure, is not likely due to problems with the scale. The weight gain is likely due to fluid retention, not drinking too much fluid.
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The nurse knows that the client understands the discharge plan when the client: 1. selects a low-cholesterol diet to control coronary artery disease. 2. states a need for bed rest for 1 week after discharge. 3. verbalizes safety precautions needed to prevent pacemaker malfunction. 4. explains signs and symptoms of myocardial infarction (MI).
3. Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb (1.35 kg) or stretching and bending. The client should know how to count the pulse and do so daily or as instructed by the healthcare provider (HCP) . The client will not necessarily be placed on a low-cholesterol diet. The client should resume activities and does not need to remain on bed rest. The client should know signs and symptoms of an MI but is not at risk because of the pacemaker.
What is the most important long-term goal for an obese client with hypertension who smokes? 1. Take medications as prescribed. 2. Stop smoking. 3. Make a commitment to long-term lifestyle changes. 4. Lose weight.
3. In most instances, clients with hypertension require lifelong treatment and their hypertension cannot be managed successfully without changes in health behavior. The client must first commit to making these long-term changes. The changes will involve taking medications, stopping smoking, and losing weight, but the client must first accept the need for a lifelong management and establish a vision and plan to control the hypertension.
A client is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD). The spouse expresses anxiety about what would happen if the device discharges during physical contact. What should the nurse tell the spouse? 1. Physical contact should be avoided whenever possible. 2. They will not feel the countershock. 3. The shock would feel like a "tingle," but it would not cause any harm. 4. A warning device sounds before countershock, so there is time to move away.
3. The spouse can have physical contact with the client, but if the ICD were to discharge while the spouse had contact with the client, the spouse would feel a "tingle" but would not be harmed. There is not a warning device on the ICD.
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which is the most effective way to assure essential information about the client is reported? 1. Give the report face-to-face with both nurses in a quiet room. 2. Audiotape the report for future reference and documentation. 3. Use a printed checklist with information individualized for the client. 4. Document essential transfer information in the client's medical record.
3. Using an individualized, printed checklist ensures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves room for error in memory; using an audiotape or a medical record requires nurses to spend unnecessary time retrieving information.
The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess pedal pulses on a client who just returned from a cardiac angiogram. 2. Administer oxygen via nasal cannula to a client with a saturation of 89%. 3. Administer acetaminophen to a client with a pain level of "5" out of "10." 4. Perform vital signs and oxygen saturation on a client returning from the catheterization lab. 5. Obtain intake and outputs on a client experiencing heart failure.
4,5. Performing vital signs and obtaining intake and outputs are tasks that can be delegated to UAP . Assessing pedal pulses and administering medications and oxygen are skills that require nursing judgments.
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which data are the best indicators that nursing interventions of monitoring and teaching have been effective? 1. Ninety percent of clients have not gained weight. 2. Seventy-five percent of the clients viewed the educational DVD. 3. Eighty percent of the clients reported that they are taking their medications. 4. Five percent of the clients required hospitalization in the last 90 days.
4. The goals of managing clients outside of the hospital are for the clients to maintain health and prevent readmission; thus, interventions, such as monitoring and teaching, appear to have contributed to the low readmission rate in this group of clients. Although it is important that clients do not gain weight, view educational material, and continue to take their medication, the primary indicator of effectiveness of the program is the lack of rehospitalization.
A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client? 1. "You will continue to take your medications until the morning of the test." 2. "You might be sedated during the procedure and will not remember what has happened." 3. "This test is a noninvasive method of determining the effectiveness of your medication regimen." 4. "During the procedure, the healthcare provider will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms."
4. The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmia. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmia without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.
Which food should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? 1. apples 2. canned tomato juice 3. whole wheat bread 4. beef tenderloin
2. Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.
Which set of postural vital signs (BP in mm Hg and heart rate in beats per minute) indicate inadequate blood volume? 1. Supine 124/76, 88 Sitting 124/74, 92 Standing 122/74, 92 2. Supine 120/70, 70 Sitting 102/64, 86 Standing 100/60, 92 3. Supine 138/86, 74 Sitting 136/84, 80 Standing 134/82, 82 4. Supine 100/70, 72 Sitting 100/68, 74 Standing 98/68, 80
2. There was a significant change in both blood pressure and heart rate with position change. This indicates inadequate blood volume to sustain normal values. Normal postural changes allow for an increase in heart rate of 5 to 20 bpm, a possible slight decrease of <5 mm Hg in the systolic blood pressure, and a possible slight increase of <5 mm Hg in the diastolic blood pressure.
A client returns from a left heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client? 1. anterior to the right tibia 2. dorsal surface of the right foot 3. posterior to the right knee 4. right midinguinal area
2. To best monitor that the client's circulation remains intact, the dorsal surface of the right foot should be palpated. When the left side of the heart is catheterized, the cannula enters via an artery. In this instance, the right femoral artery was accessed. While all options assess arterial points of the right leg, the dorsal surface of the right foot (the pedal pulse) is the most distal. If this pulse point is present and unchanged from before the procedure, the other pulse points should also be intact.
The client who experiences angina has been told to follow a low-cholesterol diet. Which meal would be best? 1. hamburger, salad, and milk shake 2. baked liver, green beans, and coffee 3. spaghetti with tomato sauce, salad, and coffee 4. fried chicken, green beans, and skim milk
3. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milk shakes, liver, and fried foods tend to be high in cholesterol.
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram strip). The nurse should: 1. notify the healthcare provider (HCP). 2. call the rapid response team. 3. assess the client for changes in the rhythm. 4. administer lidocaine as prescribed.
3. The client is experiencing a single PVC. PVCs are characterized by a QRS of longer than 0.12 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted. PVCs are potentially serious and can lead to ventricular fibrillation or cardiac arrest when they occur more than 6 to 10 in an hour in clients with myocardial infarction. The nurse should continue to monitor the client and note if the PVCs are increasing. It is not necessary to notify the HCP or call the rapid response team at this point. Lidocaine is not indicated from the data on this ECG.
Furosemide 40 mg intravenous push (IVP) is prescribed. Furosemide 10 mg/mL is available. How much should the nurse administer? Round your answer to a whole number. ____________________ mL.
4 mL. Desired amount (D) divided by what is available (H) times quantity (Q) = amount to administer. D = 40 mg divided by H = 10 mg/mL equals 40 divided by 10 = 4 mL.
Which would most likely assist the client with hypertension in maintaining an exercise program? 1. Give the client a written exercise program. 2. Explain the exercise program to the client's spouse. 3. Reassure the client that he or she can do the exercise program. 4. Tailor a program to the client's needs and abilities.
4. Tailoring or individualizing a program to the client's lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client's spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.
A client with aortic stenosis has increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
To assess a murmur from aortic stenosis, the stethoscope is placed at the second intercostal space right of sternum; (1) location, (2) the pulmonic valve area, (3) Erb's point, (4) tricuspid valve area, and (5) mitral valve area.
Cardiac telemetry shows that a client who is up to the bathroom has converted from normal sinus rhythm with a rate of 72 beats/min to atrial fibrillation with a ventricular response rate of 100 beats/min. In what order from first to last should the nurse perform these interventions? All options must be used. 1. Assess vital signs. 2. Assist the client to the bed. 3. Initiate intravenous access. 4. Obtain a stat 12-lead electrocardiogram.
2,1,3,4. To decrease myocardial workload and promote timely intervention, the client should be assisted to the bed. Assessing vital signs provides the data needed to determine client tolerance. Early initiation of an intravenous access will enable timely medication administration if it is emergently needed. While a 12-lead electrocardiogram is needed, it can be obtained after the IV is initiated.
The nurse is preparing to measure central venous pressure (CVP). Where on the torso should the location for leveling the transducer be?
Correct location: The zero point on the CVP transducer needs to be at the level of the right atrium. The right atrium is located at the midaxillary line at the fourth intercostal space. The phlebostatic axis is determined by drawing an imaginary vertical line from the fourth intercostal space at the sternal border to the right side of the chest (A). A secondary imaginary line is drawn horizontally at the level of the midpoint between the anterior and posterior surfaces of the chest (B). The phlebostatic axis is located at the intersection of points A and B.
Which is an expected outcome when a client is receiving an IV administration of furosemide? 1. increased blood pressure 2. increased urine output 3. decreased pain 4. decreased premature ventricular contractions
2. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias.
The nurse is caring for a client who has just returned from having a percutaneous transluminal balloon angioplasty with femoral artery access. In which order, from first to last, should the nurse obtain information about the client? All options must be used. 1. vital signs and oxygen saturation 2. pedal pulses 3. color and sensation of extremity 4. catheterization site
1,2,4,3. When a client returns from having a transluminal balloon angioplasty with femoral access, the nurse should first obtain baseline vital signs and oxygen saturation to determine evidence of bleeding or decreased tissue perfusion. The nurse should next assess the pedal pulses to determine if the client has adequate peripheral tissue perfusion. Next the nurse should inspect the catheterization site and then determine color and sensation in the affected leg.
The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The nurse is confident that the client has understood the teaching when the client identifies which potential complications? Select all that apply. 1. becoming increasingly short of breath at rest 2. weight gain of 2 lb (0.9 kg) or more in 1 day 3. high intake of sodium for breakfast 4. having to sleep sitting up in a reclining chair 5. weight loss of 2 lb (0.9 kg) in 1 day
1,2,4. If the client will call the healthcare provider (HCP) when there is increasing shortness of breath, weight gain over 2 lb (0.9 kg) in 1 day, and need to sleep sitting up, this indicates an understanding of the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the HCP if he or she had consumed a high-sodium breakfast. Instead, the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.
The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take clopidogrel with food. 3. The client may bruise more easily and may experience bleeding gums. 4. Clopidogrel works by preventing platelets from sticking together and forming a clot. 5. The client should drink a glass of water after taking clopidogrel.
1,3,4. Clopidogrel is generally well absorbed and may be taken with or without food; it should be taken at the same time every day, and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of clopidogrel; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of clopidogrel; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking clopidogrel.
A client is taking clonidine for treatment of hypertension. The nurse should teach the client about which common adverse effects of this drug? Select all that apply. 1. dry mouth 2. hyperkalemia 3. impotence 4. pancreatitis 5. sleep disturbance
1,3,5. Clonidine is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.
Which is not a risk factor for the development of atherosclerosis? 1. family history of early heart attack 2. late onset of puberty 3. total blood cholesterol level > 220 mg/dL (12.2 mmol/L) 4. elevated fasting blood glucose concentration
2. Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and physical inactivity.
When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in: 1. cardiac arrhythmias. 2. hypertension. 3. seizure. 4. hypothermia.
1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.
The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. The client needs further education when the client states: 1. "I know I should not drive after taking my furosemide." 2. "I should be careful not to stand up too quickly when taking furosemide." 3. "I should take the furosemide in the morning instead of before bed." 4. "I need to be sure to also take the potassium supplement that the doctor prescribed along with my furosemide."
1. Furosemide is a diuretic often prescribed for clients with hypertension or heart failure; the drug should not affect a client's ability to drive safely. Furosemide may cause orthostatic hypotension, and clients should be instructed to be careful when changing from supine to sitting to standing position. Diuretics should be taken in the morning if possible to prevent sleep disturbance due to the need to get up to void. Furosemide is a loop diuretic that is not potassium sparing; clients should take potassium supplements as prescribed and have their serum potassium levels checked at prescribed intervals.
A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The nurse should first: 1. inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. administer oxygen via nasal cannula. 3. offer pain medication for the chest heaviness. 4. inform the healthcare provider (HCP) of the chest heaviness.
1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the HCP.
An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission, what should the nurse assess first? 1. blood pressure 2. skin breakdown 3. serum potassium level 4. urine output
1. It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.
Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision. The nurse's response should reflect the understanding that the client may be experiencing: 1. anxiety related to altered body image. 2. depression related to altered health status. 3. altered tissue perfusion. 4. lack of knowledge regarding the postoperative course.
1. Verbalized concerns from this client may stem from anxiety over the changes in the body after open-heart surgery. Although the client may experience depression related to altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in the body image. The client is not concerned about altered tissue perfusion.
A client receiving a loop diuretic should be encouraged to eat which foods? Select all that apply. 1. angel food cake 2. banana 3. dried fruit 4. orange juice 5. peppers
2,3,4. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake and peppers are low in potassium.
In teaching the client with hypertension to avoid orthostatic hypotension, the nurse should teach the client to follow which instructions? Select all that apply. 1. Plan regular times for taking medications. 2. Arise slowly from bed. 3. Avoid standing still for long periods. 4. Avoid excessive alcohol intake. 5. Avoid hot baths.
2,3. Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management, but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.
A middle-aged client being admitted to the hospital has a history of hypertension and informs the nurse that his father died from a heart attack at age 60. The client reports having "indigestion." The nurse connects the client to a cardiac monitor, which reveals eight premature ventricular contractions (PVCs) per minute. The nurse should next: 1. call the healthcare provider (HCP). 2. start an IV line. 3. obtain a portable chest radiograph. 4. draw blood for laboratory studies.
2. Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the HCP , obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.
A client experiences initial indications of dizziness after having an IV infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having: 1. palpitations. 2. tinnitus. 3. urinary frequency. 4. lethargy.
2. Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which prescription from the healthcare provider should the nurse verify before implementing? 1. Call for urine output < 30 mL/h for 2 consecutive hours. 2. Administer metoprolol 5 mg IV push. 3. Prepare for a pulmonary artery catheter insertion. 4. Titrate dobutamine to keep systolic BP > 100 mm Hg.
2. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability, and a beta-blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.
A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? 1. Serum potassium is 3.5 mEq/L (3.5 mmol/L). 2. Blood pressure is 88/46 mm Hg. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61 bpm.
2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain, and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.
A client with hypertensive emergency is being treated with sodium nitroprusside. In a dilution of 50 mg/250 mL, how many micrograms of sodium nitroprusside are in each milliliter? Round your answer to a whole number. ____________________ mcg.
200 mcg
The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used. 1. Obtain a history of which drugs the client has used recently. 2. Administer the prescribed dose of morphine. 3. Position electrodes on the chest. 4. Take vital signs.
3,4,2,1. The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? 1. Monitor the laboratory values. 2. Observe neurologic function every 15 minutes. 3. Observe the puncture site for swelling and bleeding. 4. Monitor skin warmth and turgor.
3. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.
The nurse should teach the client that signs of digoxin toxicity include: 1. rash over the chest and back. 2. increased appetite. 3. visual disturbances such as seeing yellow spots. 4. elevated blood pressure.
3. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.
A client has risk factors for coronary artery disease, including smoking cigarettes, eating a diet high in saturated fat, and leading a sedentary lifestyle. The nurse can coach this client to improve health by: 1. explaining how the risk factors lead to poor health. 2. withholding praise until the client changes the risky behavior. 3. helping the client establish a wellness vision to reduce the health risks. 4. instilling mild fear into the client about the potential outcomes of the risky health behaviors.
3. In health coaching, unlike traditional client education techniques in which the nurse provides information, the goal of coaching is to encourage the client to explore the reasons for the behavior and establish a vision for health behavior and the way he or she can make changes to improve their health behavior and reduce or eliminate health risks. When coaching a client, the nurse does not provide information, withhold praise, or instill fear.
A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin. The expected outcome of this drug is to: 1. decrease circulatory overload. 2. improve the myocardial workload. 3. prevent thrombus formation. 4. regulate cardiac rhythm.
3. Warfarin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (<20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Warfarin does not reduce circulatory load or improve myocardial workload. Warfarin does not affect cardiac rhythm.
A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse should wedge the catheter to gain information about: 1. cardiac output. 2. right atrial blood flow. 3. left end-diastolic pressure. 4. cardiac index.
3. When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowly inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end-diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area and is considered a more accurate reflection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.
Which are indications that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply. 1. distended jugular veins 2. dependent edema 3. anorexia 4. coarse crackles 5. tachycardia
4,5. Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.
Which is an expected outcome for a client on the 2nd day of hospitalization after a myocardial infarction (MI)? The client: 1. continues to have severe chest pain. 2. can identify risk factors for MI. 3. participates in a cardiac rehabilitation walking program. 4. can perform personal self-care activities without pain.
4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.
How should the nurse instruct the client with unstable angina to use sublingual nitroglycerin tablets when chest pain occurs? "Sit down and then: 1. take one tablet every 2 to 5 minutes until the pain stops." 2. take one tablet and rest for 15 minutes. Call the healthcare provider if pain persists after 15 minutes." 3. take one tablet; then if the pain persists, take additional two tablets in 5 minutes. Call the healthcare provider if pain persists after 15 minutes." 4. take one tablet. If pain persists after 5 minutes, call 911."
4. The nurse should instruct the client that correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, the client should call 911. Although some healthcare providers (HCPs) may recommend taking a second or third tablet spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take two tablets at once. Nitroglycerin acts within 2 to 3 minutes, and the client should not wait 15 minutes to take further action. The client should call 911 to obtain emergency help rather than calling the HCP.
Which client is at greatest risk for coronary artery disease? 1. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago 2. a 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/L) 3. a 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin 4. a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L)
4. The woman who is 65 years old, is overweight, and has an elevated LDL is at greatest risk. Total cholesterol >200 (11.1 mmol/L), LDL >100 (5.5 mmol/L), HDL <40 (2.2 mmol/L) in men, HDL <50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking, and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.
The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to prevent: 1. electrolyte imbalances. 2. nausea or vomiting. 3. excretion of excessive fluids accumulated during the night. 4. sleep disturbances during the night.
4. When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.
The nurse is teaching a client with hypertension about taking atenolol. The nurse should instruct the client to: 1. avoid sudden discontinuation of the drug. 2. monitor the blood pressure annually. 3. follow a 2-g sodium diet. 4. discontinue the medication if severe headaches develop.
1. Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a prescription. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.
The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? 1. Assess respiratory status. 2. Draw blood for laboratory studies. 3. Insert a Foley catheter. 4. Weigh the client.
1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.
Metoprolol is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension who has been initially treated with furosemide and ramipril. An expected therapeutic effect is: 1. decrease in heart rate. 2. lessening of fatigue. 3. improvement in blood sugar levels. 4. increase in urine output.
1. The effect of a beta-blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta-blocker. The mechanism of action does not improve blood sugar or urine output.
A client with unstable angina is scheduled to have a cardiac catheterization. The nurse explains to the client that this procedure is being used to: 1. open and dilate blocked coronary arteries. 2. assess the extent of arterial blockage. 3. bypass obstructed vessels. 4. assess the functional adequacy of the valves and heart muscle.
2. Cardiac catheterization is done in clients with angina primarily to assess the extent and the severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? 1. Prepare the client for ambulation. 2. Promote urinary and intestinal elimination. 3. Prevent thrombophlebitis and blood clot formation. 4. Decrease the likelihood of pressure ulcer formation.
3. Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.
Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which instruction would most likely help the client prevent this problem? 1. Climb the steps early in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down after climbing the stairs.
3. Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.
In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open-heart surgery, the nurse should explain that: 1. the client will remain in the ICU for 5 days. 2. the client will sleep most of the time while in the ICU. 3. noise and activity within the ICU are minimal. 4. the client will receive medication to relieve pain.
4. Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip. The nurse interprets this rhythm as: 1. atrial fibrillation. 2. ventricular tachycardia. 3. premature ventricular contractions. 4. sinus tachycardia.
4. Sinus tachycardia is characterized by normal conduction and a regular rhythm, but with a rate exceeding 100 bpm. A P wave precedes each QRS, and the QRS is usually normal.
Which measure should the nurse institute to help prevent complications associated with excessive calcium excretion following cardiac surgery to replace an aortic valve? 1. Ensure a liberal fluid intake. 2. Provide an alkaline-ash diet. 3. Prevent constipation. 4. Enrich the client's diet with dairy products.
1. In an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: 1. observe careful handwashing procedures. 2. clean the incisional area with an antiseptic. 3. use prepackaged sterile dressings to cover the incision. 4. place soiled dressings in a waterproof bag before disposing of them.
1. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful handwashing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
An older adult has chest pain and shortness of breath. The healthcare provider (HCP) prescribes nitroglycerin tablets. What should the nurse instruct the client to do? 1. Put the tablet under the tongue until it is absorbed. 2. Swallow the tablet with 120 mL of water. 3. Chew the tablet until it is dissolved. 4. Place the tablet between the cheek and gums until it disappears.
1. The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The client should place the tablet under the tongue and wait until it is absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums.
Which symptom should the nurse teach the client with unstable angina to report immediately to the healthcare provider (HCP)? 1. a change in the pattern of the chest pain 2. pain during sexual activity 3. pain during an argument 4. pain during or after a physical activity
1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.
A client is scheduled for insertion of a coronary stent with right groin access. Which teaching points should the nurse include in this client's preoperative teaching plan? Select all that apply. 1. "If you have a hearing aid, you will need to remove it prior to leaving for the procedure." 2. "If you have chest pain during this procedure, please tell the staff when or if this should occur." 3. "The stitches at your right groin will be able to be removed in 7 to 10 days following the procedure." 4. "You will be given general anesthesia and will be asleep for throughout this procedure." 5. "You will need to remain flat during the procedure and for 3 to 6 hours after the procedure." 6. "You will need to keep your right leg in a flexed position for 1 to 2 hours following the procedure."
2, 5. It is important for clients to wear hearing aids to this procedure so that they can hear the questions posed to them by the healthcare team. Chest pain often occurs when the balloon within the stent is inflated and deployed into the coronary artery. It is expected and brief but should still be reported by the client. During the procedure and for a prescribed amount of time after the procedure, the client will need to remain flat in bed with the right leg straight, not flexed, to prevent bleeding from the access site. The site is not routinely stitched. It is a puncture rather than an incision requiring sutures. The client may be given intravenous medication to help with comfort, but the client is kept awake to answer questions and to hear instructions and explanations. General anesthesia is not given.
An older adult had a myocardial infarction (MI) 4 days ago. At 0930, the client's blood pressure is 102/64 mm Hg. After reviewing the client's progress notes (see chart), the nurse should first: Nurses Progress Notes: Urinary output for the last 4 hours: 90 mL Capillary refill: > 3 seconds Blood pressure: 128/82 Extremities: Cool 1. give a fluid challenge/bolus. 2. notify the healthcare provider (HCP). 3. assist the client to walk. 4. administer furosemide as prescribed.
2. All of the 1200 hour assessments are signs of decreased cardiac output and can be an ominous sign in a client who has recently experienced an MI; the nurse should notify the HCP of these changes. Cardiac output and blood pressure may continue to fall to dangerous levels, which can induce further coronary ischemia and extension of the infarct. While the client is currently hypotensive, giving a fluid challenge/bolus can precipitate increased workload on a damaged heart and extend the myocardial infarction. Exercise or walking for this client will increase both the heart rate and stroke volume, both of which will increase cardiac output, but the increased cardiac output will increase oxygen needs especially in the heart muscle and can induce further coronary ischemia and extension of the infarct. The client is hypotensive. Although the client has decreased urinary output, this is the body's response to a decreasing cardiac output, and it is not appropriate to administer furosemide.
A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing: 1. dilated coronary arteries. 2. increased myocardial contractility. 3. decreased cardiac arrhythmias. 4. decreased electrical conductivity in the heart.
2. Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema.
A client has a history of heart failure and has been prescribed furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of: 1. hyperkalemia. 2. digoxin toxicity. 3. fluid deficit. 4. pulmonary edema.
2. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. The nurse should first: 1. increase the IV infusion rate to 150 mL/h. 2. notify the healthcare provider (HCP). 3. increase the oxygen concentration to 4 L/min. 4. administer a prescribed analgesic.
2. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the HCP should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
As an initial step in treating a client with angina, the healthcare provider (HCP) prescribes nitroglycerin tablets, 0.3 mg, given sublingually. This drug's principal effects are produced by: 1. antispasmodic effects on the pericardium. 2. causing an increased myocardial oxygen demand. 3. vasodilation of peripheral vasculature. 4. improved conductivity in the myocardium.
3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.
The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs? 1. mixed green salad with blue cheese dressing, crackers, and cold cuts 2. ham sandwich on rye bread and an orange 3. baked chicken, an apple, and a slice of white bread 4. hot dogs, baked beans, and celery and carrot sticks
3. Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic.
Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg, and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the following lab tests (see chart). What should the nurse do first? Laboratory Results Sodium: 140 mEq/L (140 mmol/L) Potassium: 6.8 mEq/L (6.8 mmol/L) BUN: 18 mg/dL (6.4 mmol/L) Creatinine: 1.0 mg/dL (76.3 μmol/L) Hemoglobin: 12 g/dL (120 g/L) Hematocrit: 37% (0.37) 1. Administer the medications. 2. Call the healthcare provider (HCP). 3. Withhold the captopril. 4. Question the metoprolol dose.
3. The nurse should withhold the dose of captopril; captopril is an ACE inhibitor, and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first? 1. Monitor daily weights and urine output. 2. Limit visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand.
4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first: 1. administer atropine 0.5 mg IV push. 2. auscultate for abnormal heart sounds. 3. prepare for transcutaneous pacing. 4. take the client's blood pressure.
4. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.
When preparing a client for a cardiac angiogram, what actions should the nurse take? Select all that apply. 1. Determine if the client has an allergy to liquid contrast material. 2. Inform the client that an intravenous infusion will be started before the procedure. 3. Remind the client to have nothing to eat or drink 8 hours before the procedure. 4. Instruct the client to remain still during the procedure. 5. Explain that the client will receive a fast-acting acting anesthetic.
1,2,3,4. When preparing the client for a cardiac angiogram, the nurse should determine if the client has an allergy to the liquid contrast medium used in the procedure. Contrast dyes contain iodine, and the administration of a dye could lead to an anaphylactic response in clients who are allergic to the dye. An intravenous infusion will be started before the procedure to administer the contrast dye. The client should not eat or drink for 8 hours prior to the procedure. The client may experience a flushing sensation, but this is a normal response and does not indicate a life-threatening reaction. The client may receive light sedation, but not an anesthetic as the client must be awake to follow instructions. The client should be instructed to remain still during the procedure.
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which are expected findings on assessment? Select all that apply. 1. decreased cardiac output 2. increased heart rate 3. vasoconstriction in skin, GI tract, and kidneys 4. decreased pulmonary perfusion 5. fluid overload
1,2,3,5. Heart failure can be a result of several cardiovascular conditions, which will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure and, therefore, cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease.
Good dental care is an important measure in reducing the risk of endocarditis. What should a teaching plan to promote good dental care in a client with mitral stenosis instruct the client to do? Select all that apply. 1. Brush the teeth at least twice a day. 2. Avoid use of an electric toothbrush. 3. Take an antibiotic prior to oral surgery. 4. Floss the teeth at least once a day. 5. Have regular dental checkups. 6. Rinse the mouth with an antibiotic mouthwash once a day.
1,4,5. Daily dental care including brushing the teeth twice a day and flossing once a day and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. The client can use a regular toothbrush; it is not necessary to avoid use of an electric toothbrush. Taking antibiotics prior to certain dental procedures is recommended only if the client has a prosthetic valve or a heart transplant. It is not necessary to use an antibiotic mouthwash.
The healthcare provider (HCP) prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. The nurse should: 1. obtain an infusion pump for the medication. 2. take the blood pressure every 4 hours. 3. monitor urine output hourly. 4. obtain serum potassium levels daily.
1. IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.
A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: 1. administer the morphine. 2. obtain a 12-lead ECG. 3. obtain the blood work. 4. prescribe the chest radiograph.
1. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: 1. acetaminophen or ibuprofen can be taken for this common side effect. 2. nitroglycerin should be avoided if the client is experiencing this serious side effect. 3. taking the nitroglycerin with a few glasses of water will reduce the problem. 4. the client should lie in a supine position to alleviate the headache.
1. Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.
The client has been managing angina episodes with nitroglycerin. Which finding indicates that the therapeutic effect of the drug has been achieved? 1. decreased chest pain 2. increased blood pressure 3. decreased blood pressure 4. decreased heart rate
1. Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerin, it is only secondary and not related to the angina the client is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerin.
A client has mitral stenosis and will have a valve replacement. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which prescription would pose the greatest health hazard to this client at this time? 1. medication therapy 2. diet modification 3. activity restrictions 4. dental care
1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprosthesis are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.
The nurse is developing a teaching plan for a client who will be starting a prescription for simvastatin 40 mg/day. What instructions should the nurse give the client? Select all that apply. 1. "Take once a day in the morning." 2. "If you miss a dose, take it when you remember it." 3. "Limit greens such as lettuce in the diet to prevent bleeding." 4. "Be sure to take the pill with food." 5. "Report muscle pain or tenderness to your healthcare provider." 6. "Continue to follow a diet that is low in saturated fats."
2, 5, 6. Simvastatin is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take simvastatin in the evening, and the nurse should instruct the client that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next scheduled dose. It is not necessary to take the pill with food. The client does not need to limit greens (limiting greens is appropriate for clients taking warfarin), but the nurse should instruct the client to avoid grapefruit and grapefruit juice, which can increase the amount of the drug in the bloodstream. A serious side effect is myopathy, and the client should report muscle pain or tenderness to the healthcare provider (HCP) .
A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. 1. Administer warfarin. 2. Check the postoperative CBC, INR, PTT, and platelet levels. 3. Confirm availability of blood products. 4. Monitor the mediastinal chest tube drainage. 5. Start a dopamine drip for a systolic BP < 100 mm Hg.
2,3,4. The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding; therefore, availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.
Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which contradiction to administering the drug? 1. age > 60 years 2. history of cerebral hemorrhage 3. history of heart failure 4. cigarette smoking
2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age > 60 years, history of heart failure, and cigarette smoking are not contraindications.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? 1. BP 110/62 mm Hg, atrial fibrillation with HR 82, bilateral basilar crackles 2. confusion, urine output 15 mL over the last 2 hours, orthopnea 3. SpO2 92 on 2 L nasal cannula, respirations 20, 1+ edema of lower extremities 4. weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise
2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.
When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal space. The nurse should further assess the client for: 1. left atrial enlargement. 2. left ventricular enlargement. 3. right atrial enlargement. 4. right ventricular enlargement.
2. A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.
Which is the most appropriate diet for a client during the acute phase of myocardial infarction? 1. liquids as desired 2. small, easily digested meals 3. three regular meals per day 4. nothing by mouth
2. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.
The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of: 1. maintaining a high-fiber diet. 2. walking 2 miles (3.2 km) every day. 3. obtaining daily weights at the same time each day. 4. remaining sedentary for most of the day.
3. Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the healthcare provider (HCP) if there has been a weight gain of 2 lb (0.91 kg) or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles (3.2 km) every day, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the HCP and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.
The nurse should teach the client who is receiving warfarin sodium that: 1. partial thromboplastin time values determine the dosage of warfarin sodium. 2. protamine sulfate is used to reverse the effects of warfarin sodium. 3. international normalized ratio (INR) is used to assess effectiveness. 4. warfarin sodium will facilitate clotting of the blood.
3. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.
Which position is best for a client with heart failure who has orthopnea? 1. semisitting (low Fowler's position) with legs elevated on pillows 2. lying on the right side (Sims' position) with a pillow between the legs 3. sitting upright (high Fowler's position) with legs resting on the mattress 4. lying on the back with the head lowered (Trendelenburg's position) and legs elevated
3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg's position.
A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: 1. heart rate irregular with S3. 2. heart rate irregular with S4. 3. heart rate irregular with aortic regurgitation. 4. heart rate irregular with mitral stenosis.
1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex, and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.
The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1,000 units per hour. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. The nurse should first: 1. don gloves and apply direct pressure over the site. 2. observe and document the bleeding. 3. notify the healthcare provider (HCP). 4. prepare protamine sulfate for intravenous administration.
1. The nurse should first don gloves and apply direct pressure over the site to stop blood loss from the femoral artery. While the nurse will later observe the site for further bleeding and record the extent of bleeding, this is not the first action that is needed. If the bleeding cannot be controlled, the healthcare provider who performed the procedure should be contacted, but first, an attempt to manually stop the bleeding with direct pressure is warranted. Protamine sulfate is the antidote for heparin sodium, but this is not an initial action to control the bleeding.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first: 1. assess for changes in vital signs. 2. draw an arterial blood gas. 3. evaluate heart sounds with the client leaning forward. 4. obtain a 12-lead electrocardiogram.
1. The nurse should first obtain vital signs as changes in the vital signs will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position and can best be heard when the client is in these positions, not with the client leaning forward. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide to treat pulmonary congestion and begins a nitroprusside drip as prescribed. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. The nurse should first assess: 1. 12-lead EKG. 2. blood pressure. 3. lung sounds. 4. urine output.
2. The nurse should immediately assess the blood pressure since nitroprusside and furosemide can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the nitroprusside dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.
An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the healthcare provider (HCP) has written a prescription to: 1. limit the amount of protein in the diet prior to the cardiac catheterization. 2. withhold the metformin prior to the cardiac catheterization. 3. administer the metformin with only a sip of water prior to the cardiac catheterization. 4. give the metformin before breakfast.
2. The nurse should verify that the HCP has requested to withhold the metformin prior to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system. The HCP may prescribe sliding scale insulin during this time if needed. Regardless of how or when the medication is administered, the medication should be withheld. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.
The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a: 1. low sodium level. 2. high glucose level. 3. high calcium level. 4. low potassium level.
4. A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.
