Med Surg 26-28

The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment questions, asked by the nurse, are appropriate? Select all that apply.

"Do you smoke?", "Have you recently drunk a caffeinated beverage?"

The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question, asked by the nurse, is most important?

"How do you prepare your food?"

The nurse is instructing on home care after placement of an automatic implanted cardioverter defibrillator (AICD). Which statement, made by the client, needs clarification by the nurse?

"I need to stay away from microwaves."

A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic?

"Spike" on the rhythm strip

A client is admitted to the hospital with a diagnosis of heart failure, and the physician orders a BNP level. What results would indicate to the nurse that the client is in moderate heart failure?

675 pg/mL

The nurse is assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment?

A client with atrial dysrhythmias

A patient has been admitted after the insertion of a pacemaker because of bradycardia. She asks what third-degree heart block is, and the nurse replies:

A defect in AV junction slows and impairs conduction of impulses from the SA node to the ventricles.

The licensed practical nurse is setting up the room for a client arriving at the emergency department with ventricular arrhythmias. The nurse is most correct to place which of the following in the room for treatment?

A defibrillator

A female client, aged 82 years, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine?

A possible adverse effect of blood pressure medicine is dizziness when you stand.

The nurse is evaluating the types of medications prescribed for a client's hypertension. Which of the following medication classifications establishes an action on vasoconstrictive hormones in the blood stream?

ACE inhibitor

Which ethnic background would the nurse screen for hypertension at an early age?

African American population

The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart?

Altered patterns frequently result in decrease in cardiac output.

The nurse is in the mall and observes a client slump to the floor. The nurse assesses the client and notes no pulse. The nurse calls for assistance to others in the mall and requests which piece of equipment?

An automatic external defibrillator

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?

Anticoagulant

A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?

Assess for elevated blood urea nitrogen levels.

A client presents to the emergency department via ambulance with a heart rate of 210 atrial beats/minute with a ventricular rate of 110 beats/minute. The cardiac monitor displays a sawtooth waveform pattern. The nurse would anticipate a diagnosis of?

Atrial flutter

You are teaching a health class at the local YMCA. What body system would you explain regulates arterial blood pressure?

Autonomic nervous system

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?

BP and pulse measurements every 15 to 30 minutes

The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor of the client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record?

Bigeminy

Two clients in cardiac rehabilitation are discussing the differences between scheduled cardioversion and unexpected defibrillation. Which difference will the nurse confirm?

Cardioversion uses less electrical energy.

The nurse is caring for a client in the hospital with chronic heart failure that has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?

Class III (Moderate)

The client has been hospitalized for congestive heart failure three times in the last 4 months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse's immediate course of action would be to:

Collect more information to identify his reasons for noncompliance.

A pacemaker is the treatment of choice for what cardiac dysrhythmia?

Complete heart block

A client has just been diagnosed with prehypertension. What would the nurse instruct this client to do to restore his blood pressure below hypertensive levels?

Decrease sodium intake.

Which of the following does the nurse recognize as the therapeutic goal of radiofrequency catheter ablation for a client with cardiac dysrhythmias?

Destruction of errant tissue

The nurse obtains a blood pressure of 136/86 mm Hg on morning assessment of a client with history of hypertension. Which pressure is of most concern when considering ventricular relaxation?

Diastolic pressure

The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?

Echocardiogram

The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?

Experiences exertional dyspnea when walking 3 feet; states, "I cannot catch my breath."

You are caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client?

Fluttering

You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure may experience?

Gradual unexplained weight gain

A client, newly prescribed a low-sodium diet due to hypertension, is asking for help with meal choices. The client provides four meal choices, which are favorites. Which selection would be best?

Green pepper stuffed with diced tomatoes and chicken

The nurse instructs the client with heart failure to weight themselves at the same time each day using the same scale. When should the client contact the physician?

If the weight gain is more than 2 lb in 24 hours.

You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client?

Immediate defibrillation

The nurse is providing instruction to a group of new nurses orienting on the unit, highlighting the benefits of the automatic implanted cardioverter defibrillator (AICD). While pointing at a diagram of the heart, at which location would the nurse identify the placement of the electrical lead?

In the right ventricle near the septal wall

The nurse is caring for a client with a resting heart rate of 120 beats/minute. Which nursing intervention would be the highest priority in plan of care?

Instruct to sit on the edge of the bed before rising.

The staff educator is teaching a class in dysrhythmias. What statement is correct for defibrillation?

It is used to eliminate ventricular dysrhythmias.

The nurse is caring for a client who is newly diagnosed with hypertension. The client states, "I do not understand what is causing my blood pressure to continue to rise." Which information does the nurse recognize as the key structure in regulating arterial blood pressure?

Kidney

A client with a recent myocardial infarction is on a cardiac monitor and begins to show some dysrhythmias. The physician will probably prescribe which intravenous medication?

Lidocaine

The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?

Lie very still at intermittent times during the test.

The nurse is caring for a client with malignant hypertension. What would be an appropriate nursing intervention for this client?

Monitor the blood pressure (BP) every few minutes by applying an automatic BP recording machine.

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?

Morphine sulfate

The nurse is caring for a client with long-standing hypertension. As a client advocate, which instruction is most helpful in preventing further complications?

Obtain a regular appointment with eye doctor.

The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake?

Offer small, frequent feedings.

You are working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders?

Older adults are at increased risk for toxicity.

The nurse in an oncology clinic notes that the client being treated has hypertension. What tumor is a predisposing condition for secondary hypertension?

Pheochromocytoma

The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix?

Potassium level of 3.1

What disease processes contribute to chronic heart failure? Select all that apply.

Pulmonary insufficiency, Tachydysrhythmias, Renal failure

The nurse is caring for a client on the cardiac unit. The licensed practical nurse on the previous shift reported the following vital signs/assessment information: temperature, 100.6° F; pulse, 56 beats/minute; respirations 24 breaths/minute; blood pressure, 116/60 mm Hg; pulse oximetry reading, 95%; and with 2+ edema noted in the lower extremities. Prior to administering the prescribed antidysrhythmic medication, the nurse should reassess which of the following?

Pulse

Which of the following is the nurse most correct to recognize as a direct effect of client hypertension?

Renal dysfunction resulting from atherosclerosis

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?

Respiratory rate of 20 breaths/minute

The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse pressing the discharge button?

Shouts, "All clear"

The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety?

Sit on the edge of the chair and rise slowly.

The nurse is caring for a client with hypertension. The nurse is correct to realize that a 24-hour urine is ordered to determine if the cause of hypertension is related to the dysfunction of which of the following?

The adrenal gland

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are difficult to remove.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

The development of left-sided heart failure

The nurse is caring for a client with essential hypertension. The nurse reviews lab work and assesses kidney function. Which action of the kidney would the nurse evaluate as the body's attempt to regulate high blood pressure?

The kidney excretes sodium and water.

The licensed practical nurse is co-assigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated?

The registered nurse administering atropine sulfate intravenously

The nurse is obtaining a health history from a client with blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering the blood pressure. Which medication classification is used initially in treatment of hypertension?

Thiazide diuretic

The nurse is caring for a client who is ordered Hyperstat IV to decrease blood pressure. Which nursing consideration is a priority?

Use an automatic blood pressure recording machine.

A nurse is assessing the blood pressure of a large adult client diagnosed with primary hypertension. To ensure an accurate blood pressure reading, the nurse follows which standard of care? Select all that apply.

Use the large adult blood pressure cuff, Document the results immediately after the reading is completed, Place the cuff midway between the acromion and olecranon process.

The student nurse is caring for a client with heart failure. Diuretics have been ordered. What method might be used with a debilitated patient to help the nurse evaluate the client's response to diuretics?

Using a urinary catheter

Which of the following medications does the nurse anticipate administering to a client preparing for cardioversion?

Versed

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Withhold the medication and notify the physician of the heart rate.

A 53-year-old patient with a history of dysrhythmias has an order for a Holter monitor. The nurse would explain that Holter monitoring:

is a portable electrocardiographic device.

A patient has heart failure. His physician's orders include complete bed rest. The nurse knows that this order means he:

must remain quiet as possible, with any task requiring physical effort being done for him.