[M12/13] Evolve Qs

The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure? Urine output of 1500 mL on the preceding day Crackles in the lung fields Pedal edema Expectoration of yellow sputum

Crackles in the lung fields Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields.A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question? Enalapril (Vasotec) Sodium nitroprusside (Nipride) Dopamine (Intropin) Clevidipine (Butyrate)

Dopamine (Intropin) The nurse would question the prescription for dopamine. Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure, and would not be used in hypertensive emergency.Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies. Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies. Labetalol, an intravenous calcium channel blocker, is used in hypertensive emergencies when oral therapy is not feasible.

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? "Consume foods high in potassium." "Monitor for irregular pulse." "Monitor for muscle cramping." "Avoid grapefruit juice."

"Avoid grapefruit juice." The nurse teaches the client who is taking verapamil to avoid grapefruit juice. Grapefruit juice must be avoided with calcium channel blockers, such as verapamil, because it can enhance the action of the drug.Foods high in potassium would be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. Bradycardia, not irregular pulse, is a typical side effect of verapamil. Muscle cramping may occur with statins, not with calcium channel blockers.

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? "I can use an electric razor or a regular razor." "Eating foods like green beans won't interfere with my Coumadin therapy." "If I notice I am bleeding a lot, I should stop taking Coumadin right away." "When taking Coumadin, I may notice some blood in my urine."

"Eating foods like green beans won't interfere with my Coumadin therapy." Teaching about the precautions of warfarin has been effective when the client says "that eating foods like green beans won't interfere with my Coumadin therapy." Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.Warfarin "thins" the blood, so the risk for cutting oneself and bleeding is very high with the use of a regular razor. The client needs to use an electric razor. Clients must apply pressure to bleeding wounds and must seek medical assistance immediately. They do not need to discontinue warfarin therapy. Blood in the urine of a client taking warfarin therapy is not a side effect. The client must notify the primary health care provider immediately if this occurs.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? "I feel my heart beating in my abdominal area." "I just started to feel a tearing pain in my belly." "I have a headache. May I have some acetaminophen?" "I have had hoarseness for a few weeks."

"I just started to feel a tearing pain in my belly." The nurse suspects dissection of an AAA when the client says that "I just started to feel a tearing pain in my belly." Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? "I should avoid eating hamburgers." "I must cut out bacon and canned foods." "I shouldn't put the salt shaker on the table anymore." "I should avoid lunchmeats but may cook my own turkey."

"I should avoid eating hamburgers." Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content.Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? "I will call the provider if I have a cough lasting 3 or more days." "I will report to the provider weight loss of 2 to 3 pounds in a day." "I will try walking for 1 hour each day." "I should expect occasional chest pain."

"I will call the provider if I have a cough lasting 3 or more days." The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs.

Which statement by a client scheduled for a percutaneous transluminal coronary angioplasty (PTCA) indicates a need for further preoperative teaching? "I will be awake during this procedure." "I will have a balloon in my artery to widen it." "I must lie still after the procedure." "My angina will be gone for good."

"My angina will be gone for good." In this situation, further teaching is needed when the client states that angina will be gone after the PTCA. The client's angina may not be eliminated. Reocclusion is possible after PTCA.The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access. Time is necessary to allow the hole to heal and prevent hemorrhage.

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? "My leg might turn very white after the surgery." "I should be concerned if my foot turns blue." "I should report a fever or any drainage." "Warmness, redness, and swelling are expected."

"My leg might turn very white after the surgery." A need for further postoperative teaching about arterial revascularization is needed when the client says that "my leg might turn very white after the surgery." Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis.The foot turning blue is a sign of poor perfusion. Fever or drainage would indicate an infection. Warmness, redness, and swelling indicate reperfusion, which is a good sign.

A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct? "This way you will not need to have a leg incision." "The surgeon prefers this approach because it is easier." "These arteries remain open longer." "The surgeon has chosen this approach because of your age."

"These arteries remain open longer." The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts.Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.

A client with unstable angina has received education about acute coronary syndrome. Which statement indicates that the client has understood the teaching? "This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." "Angina is just a temporary interruption of blood flow to my heart." "I need to tell my wife I've had a heart attack." "Because this was temporary, I will not need to take any medications for my heart."

"This is a big warning; I must modify my lifestyle or risk having a heart attack in the next year." The statement by the client that unstable angina being a big warning and needing to alter his lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of unstable angina and/or MI.Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Unstable angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? "Elevate your legs above heart level to prevent swelling." "Inspect your legs daily for brownish discoloration around the ankles." "Walk to the point of leg pain, then rest, resuming when pain stops." "Apply a heating pad to the legs if they feel cold."

"Walk to the point of leg pain, then rest, resuming when pain stops." The teaching point the nurse include for a client with PAD is walk to the point of leg pain, rest, and then resume when pain stops. Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous occlusive disease. Application of heat must be avoided in clients with PAD due to a lack of sensation and possible burns to the legs.

During discharge planning after admission for a myocardial infarction, the client says, "I won't be able to increase my activity level. I live in an apartment, and there is no place to walk." What is the nurse's best response? "You are right. Work on your diet then." "You must find someplace to walk." "Walk around the edge of your apartment complex." "Where might you be able to walk?"

"Where might you be able to walk?" In this situation, the best response by the nurse is to ask the client where he or she might be able to walk. This calls for cooperation and participation from the client. Increased activity is imperative for this client.Telling the client to work on diet is an inappropriate response. Telling the client to find someplace to walk is too demanding to be therapeutic. Telling the client to walk around the apartment complex is domineering and will not likely achieve cooperation from the client.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? "Are you afraid you will not be able to work?" "If you control your diabetes, you can avoid amputation." "Your concerns are valid; we can review some steps to limit disease progression." "What about the situation concerns you most?"

"Your concerns are valid; we can review some steps to limit disease progression." The most therapeutic response by the nurse to this client is "Your concerns are valid; we can review some steps to limit disease progression." It is important to validate the client's concern and offer needed information.Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern. Controlling diabetes may help prevent amputation, but the nurse cannot state this with certainty. Asking the client about what concerns him the most is not as open-ended a question as the others. In addition, the client has already stated his concern.

The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize? Reduce abdominal fat. Avoid stress. Do not smoke or chew tobacco. Avoid alcoholic beverages.

Do not smoke or chew tobacco. The most important point for the nurse to emphasize when teaching a group of teens about heart disease prevention is not to smoke or chew tobacco. Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causing vasoconstriction, endothelial dysfunction, and thickening of the vessel walls. Smoking also increases carbon monoxide and decreases oxygen. Because it is highly addicting, beginning smoking in the teen years may lead to decades of exposure.Teens are not likely to experience metabolic syndrome from obesity but are very likely to use tobacco. Avoiding stress is a less modifiable risk factor, which is less likely to cause heart disease in teens. The risk of smoking outweighs the risk of alcohol use.

Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) Sharp, inspiratory chest pain Dyspnea Dizziness Extreme fatigue Anorexia

Dyspnea Dizziness Extreme fatigue

After receiving change-of-shift report about these four clients, which client should the nurse assess first? A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions The nurse would first assess the 46-year-old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic The client who just arrived in the ED and needs immediate medical evaluation of the 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic. This client's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.The 64-year-old is most stable and can be seen last. The 60-year-old and the 69-year-old would both be seen soon, but the 70-year-old client must be seen first.

An LPN/LVN is scheduled to work on the inpatient "stepdown" cardiac unit. Which client does the charge nurse assign to the LPN/LVN? A 60-year-old who was admitted today for pacemaker insertion because of third-degree heart block and who is now reporting chest pain A 62-year-old who underwent open heart surgery 4 days ago for mitral valve replacement and who has a temperature of 38.2° C A stable 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today A 69-year-old who had a stent placed 2 hours ago in the left anterior descending artery and who has bursts of ventricular tachycardia

A stable 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today The nurse will assign a stable 66-year-old client with a prescription for a nitroglycerin patch to the LPN/LVN. The LPN/LVN scope of practice includes administration of medications to stable clients.Third-degree heart block is characterized by a very low heart rate and usually requires pacemaker insertion. The skills of the RN are needed to care for this client. Fever after surgery requires collaboration with the health care provider, which is more consistent with the role of the RN. The client with a recent stent placement and having bursts of ventricular tachycardia is unstable and is showing ventricular irritability. This client will need medications and monitoring beyond the scope of practice of the LPN/LVN.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? Assess leg ulcers for evidence of infection. Administer a clonidine patch for hypertension. Obtain a request from the health care provider for a dietary consult. Develop a plan for discharge, and assess home care needs.

Administer a clonidine patch for hypertension. The action the nurse delegates to the LPN/LVN caring for a client with dark-colored toe ulcers and a BP of 190/100 mmHg is to administer a clonidine patch for hypertension. Administering medication is within the scope of practice for the LPN/LVN.The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.

The nurse is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure? Inferior wall Anterior wall Lateral wall Posterior wall

Anterior wall The client with an anterior wall MI is most carefully observed for the development of left ventricular failure. Due to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of left ventricular contraction, leading to heart failure.The client with an inferior wall MI is most likely to develop right ventricular heart failure related to an occlusion of the right coronary artery. Clients with obstruction of the circumflex artery may experience a lateral wall MI and sinus dysrhythmias or a posterior wall MI and sinus dysrhythmias.

An older adult client, 4 hours after coronary artery bypass graft (CABG), has a blood pressure of 80/50 mm Hg. What action does the nurse take? No action is required; low blood pressure is normal for older adults. No action is required for postsurgical CABG clients. Assess pulmonary artery wedge pressure (PAWP). Give ordered loop diuretics.

Assess pulmonary artery wedge pressure (PAWP). In this situation, the nurse next needs to assess pulmonary wedge pressure (PAWP). Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation. Hypotension could cause the graft to collapse.Low blood pressure is not normal in older adults or postoperative clients. The cause of hypotension must be found and treated. Further action is needed to determine additional interventions. Hypotension could be caused by hypovolemia. Giving loop diuretics increases hypovolemia.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Assess the client for peripheral edema. Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions.

Auscultate the client's posterior breath sounds. The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? Serum potassium level of 3.2 mEq/L Ejection fraction of 60% B-type natriuretic peptide (BNP) of 760 ng/dL Chest x-ray report showing right middle lobe consolidation

B-type natriuretic peptide (BNP) of 760 ng/dL A BNP of 760 pg/ml (760 ng/dL) is consistent with a diagnosis of heart failure. BNP is produced and released by the ventricles when the client has fluid overload as a result of HF. A normal BNP value is less than 0-99 picograms per milliliter (pg/mL) or 0-99 nanograms per liter (ng/L).Hypokalemia (serum potassium level of 3.2 mEq/L [3.2 mmol/L]) may occur in response to diuretic therapy for HF, but may also occur with other conditions. It is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? Heart rate 52 beats/min Blood pressure 192/102 mm Hg Report of constipation Anxiety

Blood pressure 192/102 mm Hg The problem that must be addressed immediately to prevent rupture in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.The nurse must consider the client's usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? (Select all that apply.) Blurred Vision Tachycardia Fatigue Serum digoxin level of 1.5 Anorexia

Blurred Vision Fatigue Anorexia The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur.Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

Which medication, when given in heart failure, may improve morbidity and mortality? Dobutamine (Dobutrex) Carvedilol (Coreg) Digoxin (Lanoxin) Bumetanide (Bumex)

Carvedilol (Coreg) Carvedilol when given to clients in heart failure may improve morbidity and mortality. Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure. This category of pharmacologic agents improves morbidity, mortality, and quality of life.Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion, and does not improve morbidity and mortality.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.) Chest discomfort or pain Tachycardia Expectorating thick, yellow sputum Sleeping on back without a pillow Fatigue

Chest discomfort or pain Tachycardia Fatigue When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

A client has just returned from coronary artery bypass graft surgery. For which finding does the nurse contact the surgeon? Temperature 98.2° F Chest tube drainage 175 mL last hour Serum potassium 3.9 mEq/L Incisional pain 6 on a scale of 0 to 10

Chest tube drainage 175 mL last hour Truncal obesity related to large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (89 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 45 mg/dL (1.17 mmol/L) for men or less than 55 mg/dL (1.42 mmol/L) for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome.Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? Ejection fraction is 25%. Client states that she is able to sleep on one pillow. Client was hospitalized five times last year with pulmonary edema. Client reports that she experiences palpitations.

Client states that she is able to sleep on one pillow. A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol.An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? Small amount of blood at the IV insertion site Heavy menstrual bleeding +1 pitting edema of the affected extremity Client stating that the year is 1967

Client stating that the year is 1967 The nurse becomes most concerned after a client receives t-PA for a large vein thrombus when the client states that the year is 1967. The most serious complication from thrombolytic therapy is intracerebral bleeding, manifested by changes in the level of consciousness.Thrombolytics such as t-PA dissolve clots. Even without this medication, a small amount of blood at the insertion site is not abnormal. Anticoagulants and thrombolytics may cause heavier-than-usual menstrual bleeding. Swelling is expected in the extremity with deep vein thrombosis.

Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with heart failure who is receiving dobutamine (Dobutrex) Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea Client with pericarditis who has a paradoxical pulse and distended jugular veins Client with rheumatic fever who has a new systolic murmur

Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice.The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client does the nurse see first? Client with dyspnea on exertion when ambulating to the bathroom Client with third-degree heart block on the monitor Client with normal sinus rhythm and PR interval of 0.28 second Client who refuses to take heparin or nitroglycerin

Client with third-degree heart block on the monitor The client with the third-degree heart block needs to be seen first. Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved. This type of block usually requires pacemaker insertion.A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client's uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) Hypertension Tachycardia Bounding right pedal pulses Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg

Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg Signs/symptoms of acute arterial occlusion of the right lower extremity include cold right foot, numbness and tingling of the right foot, and mottling and tingling of the right foot. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? Calls the family to lift the client's spirits Considers further assessment for depression Sedates the client to decrease myocardial oxygen demand Tells the client that things will get better

Considers further assessment for depression The nurse's best response to the client when he/she says it isn't worth it anymore and I want it all to end is to consider further assessment for depression. This client is at risk for depression because of the diagnosis of heart failure, and further assessment must be done.Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.

The nurse is concerned that a client who had myocardial infarction (MI) has developed cardiogenic shock. Which findings indicate shock? (Select all that apply.) Bradycardia Cool, diaphoretic skin Crackles in the lung fields Respiratory rate of 12 breaths/min Anxiety and restlessness Temperature of 100.4° F

Cool, diaphoretic skin Crackles in the lung fields Anxiety and restlessness The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/minute is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.

After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign? A 1-inch backup of blood in the IV tubing Facial drooping Partial thromboplastin time (PTT) 68 seconds Report of chest pressure during dye injection

Facial drooping During and after thrombolytic administration, facial drooping may indicate intracranial bleeding, including changes in neurologic status.A 1-inch (2.5 cm) backup of blood in the IV tubing may be related to IV positioning. If heparin is used, PTT reflects a therapeutic value which is 1½ to 2½ times the control. Reports of chest pressure during dye injection or stent deployment are considered an expected result of the procedure.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. Which prescription does the nurse implement first? Enalapril Heparin Furosemide Intake and output (I & O)

Furosemide While caring for a client with acute heart failure, the ED nurse Administers Furosemide first. The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion. A diuretic will promote fluid loss.Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis secondary to immobility, but will not reduce fluid excess. Although all clients with congestive heart failure need to have daily weights and I & O monitored, this is not a priority. Removing fluid volume and treating dyspnea are matters of priority.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.) Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds since last seen in the clinic Cooks food in palm oil to save money Exercises once weekly Has cut down on caffeine

Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds since last seen in the clinic Has cut down on caffeine Teaching about hypertension has been effective when the nurse notes that the client has been on a low-sodium, no-added salt diet, has lost 3 pounds (1.4 kg) since the last clinic visit, and has cut down on caffeine. Clients with hypertension need to consume low-sodium foods and would avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.Although palm oil may be cost-saving, it is higher in saturated fat than canola, sunflower, olive, or safflower oil. The goal is to exercise three times and not once weekly.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? Give the digoxin; reassess the heart rate in 30 minutes. Give the digoxin; document assessment findings in the medical record. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement.

Hold the digoxin, and obtain a prescription for a potassium supplement. The nurse needs to hold the digoxin and get a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? Ibuprofen (Motrin) Hydrochlorothiazide (HydroDIURIL) NPH insulin Levothyroxine (Synthroid)

Ibuprofen (Motrin) The nurse questions an 82-year-old client with exacerbation of heart failure if the client is taking ibuprofen. Long-term use of nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF.A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism. It does not cause HF.

Which characteristics place women at high risk for myocardial infarction (MI)? (Select all that apply.) Premenopausal Increasing age Family history Abdominal obesity Breast cancer

Increasing age Family history Abdominal obesity Increasing age is a risk factor, especially after 70 years. Family history is a significant risk factor in both men and women. Also, a large waist size and/or abdominal obesity are risk factors for both metabolic syndrome and MI.Premenopausal women are not at higher risk for MI, and breast cancer is not a risk factor for MI.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? Psychiatric disturbance High sodium intake Physical inactivity Kidney disease

Kidney disease The client who is most at risk for secondary hypertension is the client with kidney disease. Kidney disease is one of the most common causes of secondary hypertension.Psychiatric disturbance can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL Smoking Aspirin (acetylsalicylic acid [ASA]) consumption Type 2 diabetes Vegetarian diet

Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL Smoking Type 2 diabetes Risk factors that contribute to atherosclerosis-related diseases include LDL-C of 160 mg/dL (4.14 mmol/L), smoking, and type 2 diabetes. Having an LDL-C value of less than 100 mg/dL (2.59 mmol/L) is optimal. 100 to 129 mg/dL (2.59 to 3.34 mmol/L) is near or less than optimal. LDL-C 130 to 159 mg/dL (3.37 to 4.12 mmol/L) is borderline high. The client with a LDL-C of 160 mg/dL (4.14 mmol/L) is advised to modify diet and exercise. Smoking is a modifiable risk factor and needs to be avoided or terminated. Diabetes is a risk factor for atherosclerotic disease.ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. A diet high in whole grains, fruits, and vegetables is desirable to prevent atherosclerosis. Vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? Peptic ulcer disease Deep vein thrombosis (DVT) Osteoarthritis Marfan syndrome

Marfan syndrome Marfan syndrome is a risk factor for cardiovascular disorders such as AAA. Marfan syndrome is a genetic connective tissue disorder. It occurs in middle-aged and older people, peaking in adults in their 50s and 60s. Men are more commonly affected than women.Peptic ulcer disease is not a risk factor for AAA formation. AAA is an arterial problem, so DVT is not a related risk. Osteoarthritis is related to overuse of joints, and does not present a risk for AAA.

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action should be performed first? Assess coping skills. Assess for postoperative pain at the client's incision site. Monitor for dysrhythmias. Monitor mental status.

Monitor for dysrhythmias. The nurse would monitor the client's heart rate for dysrhythmias. Dysrhythmias are the leading cause of prehospital death.Assessing mental status, coping skills, or postoperative pain is not the priority for this client.

When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction? (Select all that apply.) Morphine sulfate Oxygen Nitroglycerin Naloxone Acetaminophen Verapamil (Calan, Isoptin)

Morphine sulfate Oxygen Nitroglycerin Administering oxygen will increase available oxygen for the ischemic myocardium during the acute phase of an MI. Morphine is also needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain.Naloxone is a narcotic antagonist that is used for over dosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.

Which nursing action may be delegated to a nursing assistant working on the medical unit? Determine the usual alcohol intake for a client with cardiomyopathy. Monitor the pain level for a client with acute pericarditis. Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis.

Obtain daily weights for several clients with class IV heart failure. The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first? Administers oxygen therapy Obtains the client's description of the chest discomfort Provides pain relief medication Remains calm and stays with the client

Obtains the client's description of the chest discomfort A description of the chest discomfort must be obtained first, before further action can be taken.Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first. Remaining calm and staying with the client are important but are not matters of highest priority.

Prompt pain management with myocardial infarction is essential for which reason? The discomfort will increase client anxiety and reduce coping. Pain relief improves oxygen supply and decreases oxygen demand. Relief of pain indicates that the MI is resolving. Pain medication should not be used until a definitive diagnosis has been established.

Pain relief improves oxygen supply and decreases oxygen demand. The focus of pain relief is to improve oxygen supply and to reduce myocardial oxygen demand.Chest discomfort will increase anxiety, but it may not affect coping. Relief of pain does not mean that the MI is resolving. Although it is used to be true that pain medication was not to be used for undiagnosed abdominal pain, this does not relate to MI.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? Ankle-brachial index Dye allergy Pedal pulses Gag reflex

Pedal pulses After a client with PAD has had a PTA, it is essential for the nurse to assess for pedal pulses. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring distal pulses to ensure adequate perfusion. Pulse checks must be assessed post procedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).Ankle-brachial index is a diagnostic study used to detect the presence of PAD. This is not necessary after PTA, which is an intervention to treat PAD. It is imperative to assess for dye allergy before performing PTA. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy). The femoral artery is generally the access site for PTA.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Monitor pulse oximetry and cardiac rate and rhythm. Reassure the client that his distress can be relieved with proper intervention. Place the client in high-Fowler's position with the legs down. Ask a family member to remain with the client.

Place the client in high-Fowler's position with the legs down. The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler's position with the legs down. High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest? The need to increase activities slowly at home Planning and participating in a walking program Placing a chair in the shower for independent hygiene Consultation with social worker for disability planning

Placing a chair in the shower for independent hygiene Placing a chair in the shower is an activity performed in Phase 1 cardiac rehabilitation. It begins with the acute illness and ends with discharge from the hospital. Phase 1 focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities.Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning. It consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the provider? Partial thromboplastin time (PTT) 60 seconds Platelets 32,000/mm3 White blood cells 11,000/mm3 Hemoglobin 12.2 g/dL

Platelets 32,000/mm3 When caring for a client receiving UFH, the nurse notifies the PCP of a platelet level of 32,000/mm3 (32 × 109/L). UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm3 (100 to 120 × 109/L). Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm3 (150 × 109/L).A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? Determines the client's physical limitations Encourages alternate rest and activity periods Monitors and documents heart rate, rhythm, and pulses Positions the client to alleviate dyspnea

Positions the client to alleviate dyspnea

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? Reproducible leg pain with exercise Unilateral swelling of affected leg Decreased pain when legs are elevated Pulse oximetry reading of 90%

Reproducible leg pain with exercise The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.

The nurse is caring for a client 36 hours after coronary artery bypass grafting, with a priority problem of intolerance for activity related to imbalance of myocardial oxygen supply and demand. Which finding causes the nurse to terminate an activity and return the client to bed? Pulse 60 beats/min and regular Urinary frequency Incisional discomfort Respiratory rate 28 breaths/min

Respiratory rate 28 breaths/min The activity should be terminated when the nurse notices the client's respiration rate of 28 breaths per minute. This indicates tachypnea and possibly tachycardia due to activity intolerance.Pulse 60 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L Serum potassium level of 2.8 mEq/L Serum creatinine of 1.0 mg/dL Serum magnesium level of 1.9 mEq/L

Serum potassium level of 2.8 mEq/L The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.

Which symptom reported by a client who has had a total hip replacement requires emergency action? Localized swelling of one of the lower extremities Positive Homans' sign Shortness of breath and chest pain Tenderness and redness at the IV site

Shortness of breath and chest pain Emergency action is needed when the postoperative total hip replacement client reports shortness of breath and cheat pain. Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE.Although localized swelling is a symptom of DVT, it is not emergent. Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of clients with DVT, and false-positive findings are common, so assessing for Homans' sign is not advised. Tenderness and redness at the IV site indicate phlebitis and are not emergent, but must be attended to after the emergency. INCORRECT

Which vascular assessment by the student nurse requires intervention by the supervising nurse? Measuring capillary refill in the fingertips Assessing pedal pulses by Doppler Measuring blood pressure in both arms Simultaneously palpating the bilateral carotids

Simultaneously palpating the bilateral carotids The vascular assessment by the student that needs intervention by the supervisor nurse is simultaneously palpating the bilateral carotids. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. Many clients with vascular disease have poor blood flow. Pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in both arms.

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? Friction rub auscultated at the left lower sternal border Pain aggravated by breathing, coughing, and swallowing Splinter hemorrhages Thickening of the endocardium

Splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed.Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? Chest pain brought on by exertion or stress Substernal chest discomfort occurring at rest Substernal chest discomfort relieved by nitroglycerin or rest Substernal chest pressure relieved only by opioids

Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI.Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the provider immediately? Swelling and tenseness in the affected area Incisional pain and tenderness at the surgical site Pink, mobile fingers An order for heparin infusion

Swelling and tenseness in the affected area The finding the nurse immediately reports to the PCP when caring for a postoperative embolectomy client who had an acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis is swelling and tenseness in the affected arm. Compartment syndrome may develop after an embolectomy, with swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb.Incisional pain is expected. Pink fingers and mobility are normal physical assessment findings. Heparin may be prescribed to maintain patency of the vessel after clot removal.

All of these client assignments have been made by the charge nurse. Which assignment is questionable? The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg

The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg The questionable assignment made by the charge nurse is assigning the LPN/LVN with 20 years' experience to care for a client with a headache whose BP is 210/150 mm Hg. The client with a headache and high blood pressure has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. This client must be assigned to an experienced RN, who can assess for end-organ damage and administer IV medications.A better assignment would be to assign the client with a headache to an RN and the client with PAD to the LPN/LVN. The RN with 3 years of experience has sufficient experience to provide care for a client with PE. The LPN/LVN can provide care for the client with leg ulcers, including dressing changes, if needed. The RN with 8 years of experience has sufficient knowledge to provide care for the client with PAD.

Which sign/symptom is essential for the nurse to report to the provider when caring for a client with Raynaud's phenomenon? Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. The client's extremity became white, then red temporarily. The affected extremity becomes purple and cold. The client states that the digits are painful when they are white.

The affected extremity becomes purple and cold. When caring for a client with Reynaud's phenomenon, it is essential for the nurse to report to the PCP an affected extremity that becomes purple and cold. Reynaud's phenomenon is described as painful vasospasms of arteries and arterioles in extremities, especially digits. This causes red-white-blue skin color changes on exposure to cold or stress. The cause is unknown, occurs more in women, and may be autoimmune because it is associated with many rheumatic diseases like systemic lupus erythematosus.Vasodilating drugs are administered as treatment and may lower the blood pressure, but this is not a significant drop. In severe cases, the attack lasts longer, and gangrene of the digits can occur. Pain, numbness, and cold are typical findings in Raynaud's phenomenon.

The nurse is assigned to all of these clients. Which client should be assessed first? The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago The client who would be assessed first is the client who had a PTA of the right femoral artery 30 minutes ago. This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment and can be assessed after the PTA client is seen.

After receiving change-of-shift report in the coronary care unit, which client does the nurse assess first? The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea The client with percutaneous coronary angioplasty who has a dose of heparin scheduled The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction

The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea The nurse needs to first assess the client with acute coronary syndrome with dyspnea and weight gain. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention.A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min. The client's weight decreases by 2.5 kg

The client's weight decreases by 2.5 kg The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 pounds (2.5 kg) in one day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The client ambulates around the nursing unit with a walker. The nurse monitors the client's pulse and blood pressure frequently. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when he becomes tachycardic.

The nurse obtains a bedside commode before administering furosemide. The ICU nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The risk for hypotension The potential for bradycardia Liver function tests

The risk for hypotension At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "This may be caused by a genetic trait." "Just imagine how bad it would be if you weren't in good shape."

This may be caused by a genetic trait." The nurse's best response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait.Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

To validate that a client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests? Creatine kinase-MB fraction (CK-MB) and alkaline phosphatase Homocysteine and C-reactive protein Total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol Troponin

Troponin Positive findings for troponin is the most specific cardiac marker used to determine whether an MI has occurred.Alkaline phosphatase is often elevated in liver disease. Homocysteine and C-reactive protein are markers of inflammation, which may represent risk for MI, but they are not diagnostic for MI. Elevated cholesterol levels are risks for MI, but they do not validate that an MI has occurred.

The nurse is preparing to teach a client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? (Select all that apply.) Truncal obesity Hypercholesterolemia Elevated homocysteine levels Glucose intolerance Client taking losartan (Cozaar)

Truncal obesity Hypercholesterolemia Glucose intolerance Client taking losartan (Cozaar) Truncal obesity related to large waist size (excessive abdominal fat causing central obesity)—40 inches (102 cm) or greater for men, 35 inches (89 cm) or greater for women—is a sign of metabolic syndrome. Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol)—HDL-C less than 45 mg/dL (1.17 mmol/L) for men or less than 55 mg/dL (1.42 mmol/L) for women—or taking an anticholesterol drug is a sign of metabolic syndrome. Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome. Blood pressure greater than 130/85 mm Hg or taking antihypertensive medication indicates metabolic syndrome.Although elevated homocysteine levels may predispose to atherosclerosis, they are not part of metabolic syndrome.

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? Urine output of 20 mL over 2 hours Blood pressure of 106/58 mm Hg Absent bowel sounds +3 pedal pulses

Urine output of 20 mL over 2 hours The nurse caring for a client who had an AAA repair would be most alarmed with the client's urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria.Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output (think ABCs). +3 pedal pulses is a normal physical assessment finding.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? Auscultation of crackles Pedal edema Weight loss of 6 pounds since the last visit Reports sucking on ice chips all day for dry mouth

Weight loss of 6 pounds since the last visit The clinic nurse recognizes that the client has been compliant with fluid restrictions when the client has a weight loss of 6 pounds (2.7 kg) since the last visit. Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions. Alternative methods of treating dry mouth need to be explored.