MED SURG CARDIOVASCULAR
What is the most important information the nurse can share with a client who is just diagnosed with hypertension?
"Continue with long-term follow-up care."
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect?
"I have trouble breathing when I walk rapidly."
A client reports foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. Which client statement indicates to the nurse that further teaching is needed?
"I will elevate my foot."
The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement?
"I will maintain complete bed rest."
A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse?
"In case of too slow of a heart rate, the epicardial leads are attached to a pacemaker to maintain a normal rate."
An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response?
"The higher-risk population is composed of African-American men and women."
A client's arterial blood gas report indicates that pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L (20 mmol/L). Which client should the nurse consider is most likely to exhibit these results?
A 24-year-old with diabetic ketoacidosis
A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider?
A diastolic blood pressure that remains greater than 90 mm Hg
A client with angina pectoris is scheduled for a stress echocardiogram. What should the nurse tell the client that an echocardiogram is?
A noninvasive approach to assess cardiovascular status
A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding?
Absence of breath sounds on auscultation
A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client?
Absence of breath sounds over the affected area
A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client?
Ambulate early and frequently
A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." Which action should the nurse take?
Call the rapid response team.
The nurse observes a client collapse while walking down the hallway and establishes unresponsiveness. What should the nurse do first?
Check for a carotid pulse
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?
Constriction of the peripheral vessels increases the force of flow.
A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse?
Decreased force of contraction
A client is receiving whole-body radiation for Hodgkin disease. Which side effect should the nurse expect as a result of this therapy?
Decreased number of erythrocytes
A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next?
Give naloxone intravenous push med (IVP) per protocol.
A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client?
Hematoma formation
A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client?
Hoarseness
A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse?
Identifying the concerns and helping the client explore feelings
A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority?
Immediate defibrillation
A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information?
Mechanical ventilation may be required next.
A nurse reviews the laboratory test results of a client with emphysema who is recovering from a myocardial infarction. The nurse obtains the client's vital signs and performs a physical assessment. Which prescribed medication should the nurse consider the priority at this time?
Metoprolol
An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time?
Monitor for cardiovascular irregularities.
A client had a ventricular demand pacemaker inserted. What is the priority nursing intervention immediately after the procedure?
Monitor the heart rate and rhythm.
A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical?
Pain when exercising and thickening of the toenails
The nurse is providing information about blood pressure to an unlicensed health care worker and recalls that the factor that has the greatest influence on diastolic blood pressure is what?
Peripheral vascular resistance
A client is prescribed prolonged bed rest after surgery. The nurse expects which complication to possibly occur secondary to a compromised circulation from the calf veins?
Pulmonary embolism
The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding?
Subcutaneous emphysema
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance?
Suction as needed
A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, what condition does the nurse recall that homeless persons are at risk for?
Tuberculosis
Which assessment finding is considered the earliest sign of decreased tissue oxygenation?
Unexplained restlessness
The spouse of a client who had emergency coronary artery bypass surgery asks why there is a dressing on the client's left leg. How should the nurse explain the dressing?
"A vein in the leg was used to bypass the coronary artery."
A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response?
"Cover your cough with your forearm."
A client being treated for uncontrolled hypertension and chest pain calls out to the nurse and reports a nosebleed. Upon entry to the client's room, the nurse immediately applies pressure. Which action should the nurse take next?
Assess the client's blood pressure.
The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately?
Assess the client's pulse
The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care?
Coughing and deep breathing every hour
Which statement is true regarding the Hering-Breuer reflex?
Prevents overdistension of the lungs
A client in the emergency department is diagnosed with atrial fibrillation. Initially the primary healthcare provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm?
The vagus nerve is stimulated.
A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen?
To increase oxygen concentration to heart cells
A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic?
Activated partial thromboplastin time (APTT) is double the control value
The nurse is providing instructions to a client on how to reduce the dietary intake of sodium. Which information should the nurse include in the instructions?
Avoid carbonated beverages
The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively?
Maintaining a reduced blood pressure
A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances?
Plan for maximum periods of rest
A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury?
Quality and depth of respirations
After flushing a client's left forearm saline lock (SL) with normal saline, the client begins to report a painful and burning sensation at the insertion site. Which is the most appropriate action for the nurse to take?
Remove the angiocatheter and saline lock and restart the SL in another site.
A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer?
Supplemental oxygen
A nurse is teaching a client with Hodgkin disease about responses to whole-body radiation. Which clinical indicator increase should the nurse include in the teaching session?
Susceptibility to infection
When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, what should the nurse caution the client to avoid?
Using a heating pad to warm the extremities
A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How does the preceptor evaluate the suitability of the instructions given to the client by the orientee?
Appropriate; oral intake after the procedure may result in aspiration
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique?
Arterial oxygen saturation
A healthcare provider prescribes epoetin subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first?
Assess the client's readiness to learn
A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit, the client's vital signs remained stable for 1 hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first?
Check the dressing on the incision
Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing?
Eustachian tubes
A nurse is caring for a client with first degree atrioventricular (AV) block. Which information will the nurse consider when planning care?
Every P wave is conducted to the ventricles.
A client who is receiving methotrexate for acute lymphocytic leukemia (ALL) develops a temperature of 101° F (38.3° C). The nurse notifies the primary healthcare provider. Aspirin 650 mg every 4 hours as needed for temperature equal to or greater than 101° F (38.3° C) is prescribed. What should the nurse do regarding this prescription?
Express concern about the type of antipyretic prescribed.
A prescribed blood transfusion of packed red blood cells was started five minutes ago. Now the client is complaining of chest pain, flank pain, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 100.8° F (38.2° C), and the client seems less alert. What should the nurse suspect?
Hemolytic reaction
A client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period?
Hoarseness and airway obstruction may result from laryngeal nerve damage.
A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses?
Hypovolemic shock
After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method?
Incentive spirometry
A client is admitted with a higher than expected red blood cell (RBC) count. What physiologic alteration does the nurse expect will result from this clinical finding?
Increased blood viscosity
The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition?
Increased pressure within the circulatory system
A client had a total knee replacement several days ago and has been receiving warfarin sodium therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the healthcare provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. Which is the next action the nurse should take?
Maintain the client on bed rest until the healthcare provider reviews the laboratory results
The left foot of a client with a history of intermittent claudication becomes increasingly cyanotic and numb. Gangrene of the left foot is diagnosed, and because of the high level of arterial insufficiency, an above-the-knee amputation (AKA) is scheduled. Which response by the client best demonstrates emotional readiness for the surgery?
Participates in learning perioperative care
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain?
Presence of a cough and pulmonary secretions
Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing?
Promotes elimination of CO2
The nurse is interpreting an electrocardiogram rhythm. What part of the electrical pattern represents ventricular contraction?
QRS interval
A client sustains multiple internal injuries in a motor vehicle accident. While performing the client's initial assessment, the nurse identifies that the client's blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What most likely has caused this drop in blood pressure?
Reduction in the circulating blood volume
The client's heart monitor shows a regular rhythm made up of wide and bizarre-looking QRS complexes and no P waves. The rate is 40 beats per minute. How should the nurse interpret these findings?
Sinoatrial (SA) and atrioventricular (AV) nodes fail to initiate an impulse.
Metoprolol is prescribed for a client. Which condition in the client's electronic medical record will cause the nurse to question the prescription?
Sinus bradycardia
A nurse reviews the plan of care for a client who is recovering from the acute phase of left ventricular failure. Which dietary restriction will the nurse expect to be included in the plan?
Sodium
A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions?
Sputum is free of acid-fast bacteria.
A nurse is caring for a client with a myocardial infarction. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart?
Strength of contractions
Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon?
The client's intraarterial pressure may compromise the graft's viability.
The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip?
Third degree AV block (complete heart block)
A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction?
This prevents further fluid accumulation, which increases the workload of the heart.
A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what?
Tissue necrosis
A nurse is developing a health teaching plan for clients with pacemakers. Which activity should the nurse teach these clients to avoid?
Touring a power plant
An older adult with peripheral vascular disease has stopped smoking, and the client's children want to make the home environment safe. What should the home healthcare nurse emphasize when providing instructions?
Use measures that can prevent thermal injuries
A client with liver dysfunction reports bleeding gums. In addition, the nurse observes small facial hemorrhagic lesions. What should the nurse conclude that the client needs?
Vitamin K
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take?
Wear a particulate respirator when caring for the client
While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record?
Wheezes
A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The mother shares that she is 4 weeks pregnant and questions as to whether this pregnancy will result in a child with hemophilia. What is the best response by the nurse?
With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the gender of the child.
A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding?
"Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."
A client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required?
"I have to take his blood pressure every day in the arm with the fistula."
A healthcare provider prescribes thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?
Ask the healthcare provider if an elastic bandage can be used in place of the stockings.
A client presents to the emergency department with weakness, dizziness, and difficulty breathing. The nurse performs an electrocardiogram (ECG) and notices this arrhythmia. Which arrhythmia is the client exhibiting?
Atrial fibrillation (AF)
A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client?
Diminished breath sounds
An electrocardiogram is prescribed for a client complaining of chest pain. The nurse recognizes which as an early finding of an infarcted area of the heart?
Elevated ST segments
A healthcare provider makes the diagnosis that an obese client has primary hypertension. Which priority information should the nurse include when preparing a teaching plan for this client?
Foods recommended on a low-calorie and low-sodium diet
A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have?
Fracture of the nose
A client is receiving a 2-gram sodium diet. The family members ask whether they can bring snacks from home. Which food item will the nurse suggest?
Fresh orange wedges
The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect?
Improved hemoglobin and hematocrit levels
A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client?
Improving ventilation
A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do?
Inhale completely and then blow out as hard and as fast as possible through the mouthpiece.
During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment?
Pulsating abdominal mass
During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record?
Resonance
One week after admission to the cardiac care unit, a client displays an outburst of anger and tells the nurse to get out of the room. Which is the most appropriate nursing action?
Return when the client has calmed down.
When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider?
Severe shortness of breath
