Med Success Heart Qs
The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instruction(s) should the nurse teach the client? 1. Call the health care provider (HCP) if any chest pain happens. 2. Discuss when the client can resume sexual bactivity. 3. Explain the pharmacology of nitroglycerin tablets. 4. Encourage the client to sleep with the head of the bed elevated.
2. The nurse should make sure the client is aware of when sexual activity can be safely resumed.
The client with coronary artery disease is prescribed transdermal nitroglycerin, a coronary vasodilator. Which behavior indicates the client nunderstands the discharge teaching concerning this medication? 1. The client places the medication under the tongue. 2. The client removes the old patch before placing the new. 3. The client applies the patch to a hairy area. 4. The client changes the patch every 36 hours.
2. This behavior indicates the client understands the discharge teaching.
The nurse identifies the concept of tissue perfusion as a client problem. Which is an antecedent of tissue perfusion? 1. The client has a history of coronary artery disease (CAD). 2. The client has a history of diabetes insipidus (DI). 3. The client has a history of chronic obstructive pulmonary disease (COPD). 4. The client has a history of multiple fractures from a motor-vehicle accident.
1. CAD narrows the arteries of the heart, causing the tissues not to be perfused, especially when an embolus or a thrombus occurs.
A client with acute chest pain is receiving LV. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply. D 1. Reduces myocardial oxygen consumption. D 2. Promotes reduction in respiratory rate. D 3. Prevents ventricular remodeling. D 4. Reduces blood pressure and heart rate. D 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 The Client with Cardiac Health Problems 333 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.
86. The nurse is working with a group of new graduates on a medical-surgical unit. Which should the nurse explain about completing first morning rounds on clients? 1. Perform a "down and dirty" assessment on each client soon after receiving report. 2. Determine which client should have a bath and inform the unlicensed assistive personnel. 3. Give all the clients a wet wash to wash the face and a toothbrush and toothpaste. 4. Pick up any paper on the floor and get the room ready for morning physician rounds.
1. "Down and dirty" rounds include assessing each client for the main focus of the client's admission or any new issue that is reported from the shift report and assessing all lines and tubes going into or coming out of the client. Once this is done the nurse knows then that the client is stable and a full head- to-toe assessment can be done at a later time.
81. The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first? 1. Notify the health care provider (HCP). 2. Assess what the client ate at the last meal. 3. Request a STAT 12 lead electrocardiogram. 4. Administer furosemide IVP.
1. "Has developed" indicates a new issue; the nurse should notify the HCP of the assessment findings, which indicate that the client has developed heart failure.
The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.
1. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.
The nurse has received shift report. Which client should the nurse assess first? 1. The client diagnosed with coronary artery disease complaining of severe indigestion. 2. The client diagnosed with congestive heart failure who has 3+ pitting edema. 3. The client diagnosed with atrial fibrillation whose apical rate is 110 and irregular. 4. The client diagnosed with sinus bradycardia bwho is complaining of being constipated.
1. A complaint of indigestion could be cardiac chest pain. The nurse should assess this client because of the diagnosis of CAD and the word "severe" in the option
The home health nurse is assigned a client diagnosed with heart failure. Which should the nurse implement? Select all that apply. 1. Request a dietary consult for a sodium restricted diet. 2. Instruct the client to elevate the feet during the day. 3. Teach the client to weigh every morning wearing the same type of clothing. 4. Assess for edema in dependent areas of the body. 5. Encourage the client to drink at least 3,000 mL of fluid per day. 6. Have the client repeat back instructions to the nurse.
1. A dietitian can assist the nurse in explaining the sodium restrictions to the client as well as hidden sources of sodium. 2. This will help the client's body to return excess fluid to the heart for removal from the body by the kidneys. 3. The client should weigh himself/herself every morning in the same type of clothing (gown, underwear, jeans, etc.) and report a weight gain of 3 pounds in a week to the HCP. 4. The nurse should not assess for edema in the feet and lower legs, but if the client is in bed the lowest part of the body may be in the sacral area. Whichever area is dependent is where the nurse should look for edema. 6. Whenever the nurse is instructing a client, the nurse should determine if the client heard and understood the instructions. Having the client repeat the instructions is one way of determining "hearing." Having the client return demonstrate is a method of determining understanding.
Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct the client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to a counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.
1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. 2. Walking will help increase collateral circulation. 4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.
The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds.
1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade.
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub.
1. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider.
A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 Llminute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given LV. The nurse should first: D 1. Administer the morphine. D 2. Obtain a 12-lead ECG. D 3. Obtain the blood work. D 4. Order 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.
The nurse is functioning in the role of medication nurse during a code. Which should the nurse implement when administering amiodarone for ventricular tachycardia? 1. Mix the medication in 100 mL of fluid and administer rapidly. 2. Push the amiodarone directly into the nearest IV port and raise the arm. 3. Question the physician's order because it is not ACLS recommended. 4. Administer via an IV pump based on mg/kg/min.
1. Amiodarone is administered during a code rapidly after being mixed in 100 mL of fluid.
The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the healthcare provider to order for this client? 1. Amiodarone. 2. Atropine. 3. Digoxin. 4. Adenosine.
1. Amiodarone suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias.
A client is admitted with a myocardial infarction and new onset 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: D 1. Heart rate irregular with S3. D 2. Heart rate irregular with S4. D 3. Heart rate irregular with aortic regurgitation. D 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 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 assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take? 1. Wait until the machine discharges. 2. Shout "all clear" and don't touch the bed. 3. Make sure the client is all right. 4. Increase the joules and redischarge.
1. Cardioversion involves the delivery of a timed electrical current. The electrical impulse discharges during ventricular depolarization and, therefore, there might be a short delay. The nurse should wait until it discharges.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first: D 1. Assess for changes in vital signs. D 2. Draw an arterial blood gas. D 3. Evaluate heart sounds with the client leaning forward. D 4. Obtain a 12 Lead electrocardiogram.
1. 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. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function
4. Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure. 2. Activity intolerance. 3. Powerlessness. 4. Anticipatory grieving.
1. Medical client problems indicate the nurse and the physician must collaborate to care for the client; the client must have medications for heart failure.
The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge? 1. Carry your nitroglycerin tablets in a brown bottle. 2. Swallow a nitroglycerin tablet at the first sign of angina. 3. If one nitroglycerin tablet does not work in 10 minutes, take another. 4. Nitroglycerin tablets have a fruity odor if they are potent.
1. Nitroglycerin tablets are dispensed in small brown bottles to preserve the potency. The client should not change the tablets to another container.
The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct the client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.
1. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity.
The client's telemetry reading shows a P wave before each QRS complex and the rate is 78.Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.
1. The P wave represents atrial contraction, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.
The client comes to the emergency department saying, "I am having a heart attack." Which question is most pertinent when assessing the client? 1. "Can you describe your chest pain?" 2. "What were you doing when the pain started?" 3. "Did you have a high-fat meal today?" 4. "Does the pain get worse when you lie down?"
1. The chest pain for an MI usually is described as an elephant sitting on the chest or a belt squeezing the substernal midchest, often radiating to the jaw or left arm.
The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Monitor the client's blood pressure and apical rate every four (4) hours. 2. Place the client on intake and output every shift. 3. Require the client to sleep with the head of the bed elevated. 4. Teach the patient to perform Buerger Allen exercises daily. 5. Determine if the client is on an antiplatelet or anticoagulant medication. 6. Assess the client's neurological status every shift and prn.
1. The client should be monitored for any cardiovascular changes. 2. The client should be monitored for the development of heart failure as a result of increased strain on the heart from the atria not functioning as they should. 5. Clients who have been diagnosed with atrial fibrillation are at risk for developing emboli from the stasis of blood in the atria. If an emboli breaks loose from the lining of the atria then it can travel to the lungs (right) or to the brain (left). 6. Clients who have been diagnosed with atrial fibrillation are at risk for developing emboli from the stasis of blood in the atria. If an emboli breaks loose from the lining of the atria then it can travel to the lungs (right) or to the brain (left).
The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."
1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.
The client has just had pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position.
1. The nurse should monitor the vital signs for any client who has just undergone surgery. 2. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds allows assessment for cardiac failure. 3. The pericardial fluid is documented as output. 4. Evaluating the client's cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardiocentesis.
Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure? 1. The potassium level is 3.2 mEq/L. 2. The digoxin level is 1.2 mcg/mL. 3. The client's apical pulse is 64. 4. The client denies yellow haze.
1. The potassium level is 3.2 mEq/L.
Which meal would indicate the client understands the discharge teaching concerning the recommended diet for coronary artery disease? 1. Baked fish, steamed broccoli, and garden salad. 2. Enchilada dinner with fried rice and refried beans. 3. Tuna salad sandwich on white bread and whole milk. 4. Fried chicken, mashed potatoes, and gravy.
1. The recommended diet for CAD is low fat, low cholesterol, and high fiber. The diet described is a diet that is low in fat and cholesterol.
The nurse is told in report the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur? 1. Second intercostal space, right sternal notch. 2. Erb's point. 3. Second intercostal space, left sternal notch. 4. Fourth intercostal space, left sternal border.
1. The second intercostal space, right sternal notch, is the area on the chest where the aorta can best be heard opening and closing
The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? 1. Discuss the order with the health-care provider. 2. Take the client's apical pulse rate before administering. 3. Check the client's potassium level before giving the medication. 4. Determine if a digoxin level has been drawn.
1. This dosage is 10 times the normal dose for a client with CHF. This dose is potentially lethal.
The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."
1. This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.
The nurse assessing the client with pericardial effusion at 1600 notes the apical pulse is 72 and the BP is 138/94. At 1800, the client has neck vein distention, the apical pulse is 70, and the BP is 106/94. Which action would the nurse implement first? 1. Stay with the client and use a calm voice. 2. Notify the health-care provider immediately. 3. Place the client left lateral recumbent. 4. Administer morphine intravenous push slowly.
1. This is a medical emergency; the nurse should stay with the client, keep him calm, and call the nurses' station to notify the health-care provider. Cardiac output declines with each contraction as the pericardial sac constricts the myocardium.
The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer the client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery.
1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health.
The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.
1. Ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted. 3. Defibrillation is the treatment of choice for ventricular fibrillation. 4. The crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation. 5. Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias.
The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.
2. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? D 1. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. D 2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. D 3. Sp02 92 on 2 liters nasal cannula, respirations 20, 1 + edema of lower extremities. D 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.
Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.
2. Any abnormal electrical activity of the heart causes decreased cardiac output.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.
2. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor.
The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select all that apply. 1. Obtain a midstream urine specimen. 2. Attach the telemetry monitor to the client. 3. Start a saline lock in the right arm. 4. Draw a basal metabolic panel (BMP). 5. Request an order for a STAT 12-lead ECG.
2. Anytime a nurse suspects cardiac problems, the electrical conductivity of the heart should be assessed. 3. Emergency medications for heart problems are primarily administered intravenously, so starting a saline lock in the right arm is appropriate. 5. A 12-lead ECG evaluates the electrical conductivity of the heart from all planes.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.
2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain
The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.
2. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention.
Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus (PE). 2. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis.
2. Bacteria enter the bloodstream from invasive procedures, and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys, or peripheral tissues.
The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges.
2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify
What is the priority problem in the client diagnosed with congestive heart failure? 1. Fluid volume overload. 2. Decreased cardiac output. 3. Activity intolerance. 4. Knowledge deficit.
2. Decreased cardiac output is responsible for all the signs/symptoms associated with CHF and eventually causes death, which is why it is the priority problem.
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Mid epigastric pain and pyrosis. 2. Diaphoresis and cool, clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.
2. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.
The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept? 1. The client has a large abdomen and a positive tympanic wave. 2. The client has paroxysmal nocturnal dyspnea. 3. The client has 2+ glucose in the urine. 4. The client has a comorbid condition of myocardial infarction.
2. Dyspnea occurring at night when the client is in a recumbent position indicates that the cardiac muscle is not able to compensate for extra fluid returning to the heart during sleep.
Which interventions should the nurse discuss with the client diagnosed with coronary artery disease? Select all that apply. 1. Instruct the client to stop smoking. 2. Encourage the client to exercise three (3) days a week. 3. Teach about coronary vasodilators. 4. Prepare the client for a carotid endarterectomy. 5. Eat foods high in monosaturated fats.
2. Exercising helps develop collateral circulation and decrease anxiety; it also helps clients to lose weight. 3. Clients with coronary artery disease are usually prescribed nitroglycerin, which is the treatment of choice for angina.
Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.
2. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication.
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? D 1. Serum potassium is 3.5 mEq/L. D 2. Blood pressure is 88/46. D 3. ST elevation is present on the electrocardiogram. D 4. Heart rate is 61.
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.
The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family history of carditis?" 4. "What over-the-counter (OTC) medications do you take?"
2. Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of people who develop it.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.
2. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain).
Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."
2. The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.
The nurse is administering morning medications. Which medication should be administered first? 1. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and whohas 2+ edema of the feet. 2. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast. 3. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL. 4. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.
2. The client intends on eating breakfast and this is a scheduled medication for before meals.
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.
2. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.
The telemetry monitor tech notifies the nurse of the strip shown below. Which should the nurse implement first? 1. Instruct the unlicensed assistive personnel (UAP) to check the client. 2. Go to the client's room and assess the client personally 3. Have the monitor tech check the client using a different lead. 4. Call for the Code Blue team and perform cardiopulmonary resuscitation.
2. The nurse must determine the situation personally; this could be artifact or ventricular fibrillation.
The nurse is caring for a client who goes intoventricular tachycardia. Which intervention should the nurse implement first? 1. Call a code immediately. 2. Assess the client for a pulse. 3. Begin chest compressions. 4. Continue to monitor the client.
2. The nurse must first determine if the client has a pulse. Pulseless ventricular tachycardia is treated as ventricular fibrillation. Stable ventricular tachycardia is treated with medications.
The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first? 1. "Do you have the money to buy your medication?" 2. "Does the medication give unwanted side effects?" 3. "Did you quit taking the medications because you don't feel bad?" 4. "Can you tell me why you stopped taking the medication?"
2. This is a mild way of introducing the subject of side effects to a client not wishing to admit the medication causes unwanted effects. It opens the door to more probing assessment questions. The nurse should bring up the subject in order to allow the client to be forthcoming with the issues of why he is not taking his medication.
3. Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? 1. Keep the client in the supine position with the legs elevated. 2. Discuss a heart transplant, which is the definitive treatment. 3. Prepare the client for coronary artery bypass graft. 4. Teach the client to take a calcium channel blocker in the morning.
2. Without a heart transplant, this client will end up in end-stage heart failure. A transplant is the only treatment for a client with dilated cardiomyopathy
A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an LV. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? mL/hour.
24 mL/hour
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client was diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.
3. A new graduate should be able to complete a pre-procedure checklist and get this client to the catheterization laboratory.
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first? 1. The client with three (3) unifocal PVCs in one (1) minute. 2. The client diagnosed with coronary artery disease who wants to ambulate. 3. The client diagnosed with mitral valve prolapse with an audible S3. 4. The client diagnosed with pericarditis who is in normal sinus rhythm.
3. An audible S3 indicates the client is developing left-sided heart failure and needs to be assessed immediately
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.
3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors.
5. The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client? 1. Do not lift or carry more than 23 kg. 2. Have someone drive the car for the rest of your life. 3. Carry the cell phone on the opposite side of the ICD. 4. Avoid using the microwave oven in the home.
3. Cell phones may interfere with the functioning of the ICD if they are placed too close to it
The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse question? 1. Furosemide IVP to a client with a potassium level of 3.6 mEq/L. 2. Digoxin orally to a client diagnosed with rapid atrial fibrillation. 3. Enalapril orally to a client whose BP is 86/64 and apical pulse is 65. 4. Morphine IVP to a client complaining of chest pain and who is diaphoretic
3. Enalapril, an ACE inhibitor, will lower the blood pressure even more. The nurse should hold the medication and notify the HCP that the medication is being held.
The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."
3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.
The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement? 1. Notify the health-care provider. 2. Document that the pericarditis has resolved. 3. Ask the client to lean forward and listen again. 4. Prepare to insert a unilateral chest tube.
3. Having the client lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard.
The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.
3. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the monitor
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.
3. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.
2. Which preprocedure information should be taught to the female client having an exercise stress test in the morning? 1. Wear open-toed shoes to the stress test. 2. Inform the client not to wear a bra. 3. Do not eat anything for four (4) hours. 4. Take the beta blocker one (1) hour before the test.
3. NPO decreases the chance of aspiration in case of emergency. In addition, if the client has just had a meal, the blood supply will be shunted to the stomach for digestion and away from the heart, perhaps leading to an inaccurate test result.
The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."
3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain.
The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays (CXRs)?" 3. "Are you sexually active?" 4. "Have you had any weight change?"
3. Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual activity
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram (ECG). 3. Have the client sit down immediately. 4. Assess the client's vital signs.
3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.
A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do? D 1. Put the tablet under the tongue until it is absorbed. D 2. Swallow the tablet with 120 mL of water. D 3. Chew the tablet until it is dissolved. D 4. Place the tablet between his cheek and gums.
3. The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The nitroglycerin tablet will be absorbed fastest if the client chews the tablet.
The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.
3. The client is symptomatic and will require a pacemaker.
Which client would most likely be misdiagnosed for having a myocardial infarction? 1. A 55-year-old Caucasian male with crushing chest pain and diaphoresis. 2. A 60-year-old Native American male with anelevated troponin level. 3. A 40-year-old Hispanic female with a normal electrocardiogram. 4. An 80-year-old Peruvian female with a normal CK-MB at 12 hours.
3. The clients who are misdiagnosed concerning MIs usually present with atypical symptoms. They tend to be female, be younger than 55 years old, be members of a minority group, and have normal electrocardiograms.
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer amiodarone , an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.
3. The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular fibrillation. If the client's heart is beating, the nurse would then administer lidocaine.
The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer.
3. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider
The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation (CPR).
3. The nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol.
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move the legs. 4. Take no action concerning the UAP's behavior.
3. The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring.
The nurse has received report when the telemetry technician notifies the nurse of the telemetry readings. Which client should the nurse assess first?
3. This is complete heart block with bradycardia, a potentially life-threatening situation. The nurse should assess this client first and make interventions accordingly.
The telemetry reading is below. Which should the nurse implement? 1. Take the client's apical pulse and pressure 2. Prepare to administer amiodarone IVPB 3. Continue to monitor 4. Place oxygen on the client via nasal cannula
3. This strip indicates normal sinus rhythm; there is no need for further action based on the strip. The nurse should continue to monitor the client
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).
3. Troponin is the enzyme that elevates within 1 to 2 hours.
The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40 ̊F. 4. Wear open-toed shoes when ambulating.
3. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside.
Which nursing diagnosis would be priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function.
4. Activity intolerance is priority for the client with myocarditis, an inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.
Which population is at a higher risk for dying from a myocardial infarction? 1. Caucasian males. 2. Hispanic females. 3. Asian males. 4. African American females.
4. African American females are 35% more likely to die from coronary artery disease than any other population. This population has significantly higher rates of hypertension and it occurs at a younger age. The higher risk of death from an MI is also attributed to a delay in seeking emergency care—an average of 11 hours.
The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first? 1. Tell the UAP to go take the client's vital signs. 2. Ask the UAP to have the telemetry nurse read the strip. 3. Notify the client's health-care provider. 4. Go to the room and assess the client's chest pain.
4. Assessment is the first step in the nursing process and should be implemented first; chest pain is priority
Which laboratory data confirm the diagnosis of congestive heart failure? 1. Chest x-ray (CXR). 2. Liver function tests. 3. Blood urea nitrogen (BUN). 4. Beta-type natriuretic peptide (BNP).
4. BNP is a hormone released by the heart muscle in response to changes in blood volume and is used to diagnose and grade heart failure.
The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.
4. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements (deep inspiration, coughing), changes in body position, and swallowing.
The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse? 1. Bilateral peripheral pulses 2+. 2. The pulse oximeter reading is 96%. 3. The urine output is 240 mL in the last four (4) hours. 4. Cool, clammy, diaphoretic skin.
4. Cold, clammy skin is an indicator of cardiogenic shock, which is a complication of MI and warrants immediate intervention.
The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess? 1. CK-MB. 2. Troponin. 3. BNP. 4. Potassium.
4. Hyperkalemia will cause a peaked T wave; therefore, the nurse should check these laboratory data.
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client.
4. If any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. Therefore, the nurse should shout "all clear."
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 is the highest priority for nursing management of this client at this time? D 1. Monitor daily weights and urine output. D 2. Permit unrestricted visitation by family and friends. D 3. Provide client education on medications and diet. D 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 client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.
4. Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia.
To what area should the nurse place the stethoscope to best auscultate the apical pulse? 1. A 2. B 3. C 4. D
4. The best place to auscultate the apical pulse is over the mitral valve area, which is the fifth intercostal space, midclavicular line.
The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is priority? 1. Sleep, rest, activity. 2. Comfort. 3. Oxygenation. 4. Perfusion.
4. The cardiac muscle is not perfused when there is a narrowing of the arteries caused by CAD or when an embolus or a thrombus occludes the artery. Adequate perfusion will supply oxygen to the cardiac muscle, allow for increased activity, and decrease pain.
The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first? 1. Call a Code Blue. 2. Assess the telemetry reading. 3. Take the client's apical pulse. 4. Have the client sit down.
4. The client began to have a problem during physical exertion. Stopping the exertion should be the first action taken by the nurse.
The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement Indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."
4. The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first? 1. Notify the health care provider. 2. Call a rapid response team (RRT). 3. Determine the telemetry monitor reading. 4. Push the Code Blue button.
4. The first action is to immediately notify the code team and initiate CPR per protocol.
The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first: D 1. Administer Atropine 0.5 mg LV. push. D 2. Auscultate for abnormal heart sounds. D 3. Prepare for transcutaneous pacing. D 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.
According to the 2010 American Heart Association Guidelines, which steps of cardiopulmonary resuscitation for an adult suffering from a cardiac arrest should the nurse teach individuals in the community? Rank in order of performance. 1. Place the hands over the lower half of the sternum. 2. Look for obvious signs of breathing. 3. Begin compressions at a ratio of 30:2. 4. Call for and AED immediately. 5. Position the victim on the back.
In order of performance: 5, 2, 4, 1, 3 5.The victim is positioned on the back for assessment and for the rescuer to be able to begin cardiopulmonary resuscitation. 2. Although we now perform a quick look to determine if the victim is breathing there is no longer a "look, listen, feel" step. The victim may not be breathing at all or may be having agonal respirations. 4. For adults the rescuer should immediately call for an AED or 911. Research has proven the faster that defibrillation is performed the better the chance of survival for the victim. 1. Compressions are initiated immediately because the victim will have some residual oxygen in the lungs. Breathing is not initiated unless there is a barrier device available. 3. The compression rate is 30:2.
