Med Surg: Cardiovascular ATI Practice A
A nurse in an emergency room is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse look out for?
A) Confusion B) Friction rub C) Hypertension D) Dry skin Correct Answer A Rationales: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status. The nurse should expect to hear a friction rub during cardiac auscultation on a client who has pericarditis. The nurse should monitor a client who has a bradydysrhythmia for hypotension. The nurse should monitor a client who has a bradydysrhythmia for diaphoresis.
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?
A) Hemoglobin 14.4 g/dL B) History of peripheral arterial disease C) Urine output 200 mL/4 hr D) Previous allergic reaction to shellfish Correct Answer d Rationales A hemoglobin level of 14.4 g/dL is within the expected reference range. This procedure involves access through large arteries or veins into the heart and is not affected by peripheral arterial disease. An output of 200 mL in 4 hr is within the expected reference range. The contrast medium used is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine.
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds?
A) Increase the heparin infusion flow rate by 2 mL/hr. B) Continue to monitor the heparin infusion as prescribed. C) Request a prothrombin time (PT). D) Stop the heparin infusion. Correct Answer: A Rationales An aPTT of 96 seconds indicates excessive heparin. Therefore, the nurse should not increase the heparin infusion. An aPTT of 96 seconds indicates excessive heparin. Therefore, the nurse should take corrective action. The nurse should monitor PT for a client who is taking an oral anticoagulant. However, it is not necessary to request a PT before taking any corrective action. MY ANSWER The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
A) "I can't get rid of these hiccups." B) "I feel dizzy when I stand." C) "My incision site stings." D) "I have a headache." Correct Answer: A Rationales: Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation. Dizziness is not a complication of the insertion procedure and is expected initially as the client adjusts to the pacemaker. Pain or stinging at the incision site is not a complication of the insertion procedure. However, the client should monitor the pacemaker insertion site for manifestations of infection. Headache is not a complication of the insertion procedure. However, it might be related to other disease processes.
A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?
A) Explore the client's family history of peripheral vascular disease. B) Note the presence or absence of pain at the ulcer site. C) Inquire about the presence or absence of claudication. D) Ask if the client has had a recent infection. Correct Answer: C Rationales: Family history is important, but it does not help to differentiate between arterial and venous ulcers. Both arterial and venous ulcers cause varying degrees of pain or discomfort. Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not. Both arterial and venous ulcers have the potential to become infected. Claudication definition: a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?
A) "My arthritis is really bothering me because I haven't taken my aspirin in a week." B) "My blood pressure shouldn't be high because I took my blood pressure medication this morning." C)"I took my warfarin last night according to my usual schedule." D)"I will check my blood sugar because I took a reduced dose of insulin this morning." Correct Answer: C Rationales: The provider might have the client discontinue over-the-counter medications, such as aspirin, prior to surgery to reduce the risk of bleeding. The provider might instruct the client to administer medications to treat high blood pressure to reduce the risk of hypertension. Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding. The provider might instruct a client who takes insulin to take a reduced dose in the morning of surgery to regulate blood glucose.
A nurse is providing teaching for a client who is 2 days postop following a heart transplant. Which of the following statements should the nurse include in the teaching?
A) "You might no longer be able to feel chest pain." B) "Your level of activity intolerance will not change." C) "After 6 months, you will no longer need to restrict your sodium intake." D) "You will be able to stop taking immunosuppressants after 12 months." Correct Answer: A Rationales: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart. The client's activity tolerance should gradually improve as the healing process progresses. The client will need to permanently maintain a diet that is restricted in sodium and fat. The client will remain on immunosuppressants for the remainder of his life to help prevent rejection of the heart.
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition?
A) Absence of adventitious breath sounds B) Presence of a nonproductive cough C)Decrease in respiratory rate at rest D) SaO2 86% on room air Correct Answer: Rationales: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving. A moist, productive cough usually accompanies pulmonary edema. However, the presence of a nonproductive cough does not indicate that the problem is resolving. The respiratory rate usually decreases while at rest. It is not an indicator of effective treatment. This value is below the expected reference range. It is not an indicator of effective treatment.
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse.
A) Aortic B) Pulmonic C) Tricuspid D) Mitral A is incorrect. The nurse should inspect this location to assess for pulsations of the aortic area of the heart, which is located in the second intercostal space to the right of the sternum. B is incorrect. The nurse should inspect this location to assess for pulsations of the pulmonic area of the heart, which is located in the second intercostal space to the left of the sternum. C is incorrect. The nurse should inspect this location to assess for pulsations of the tricuspid area of the heart, which is located in the fifth intercostal space to the left of the sternal border. D is correct. Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line.
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teachings?
A) Apply the new patch to the same site as the previous patch. B) Place the patch on an area of skin away from skin folds and joints. C)Keep the patch on 24 hr per day. D) Replace the patch at the onset of angina. Correct Answer is B. Rationales: Rotating the patch site can prevent skin irritation. The client should apply the patch to an area of intact skin that has enough room for the patch to fit smoothly. The client should have a patch-free interval of 10 to 12 hr per day to prevent tolerance to the medication. The nurse should emphasize that nitroglycerin patches offer ongoing prevention of angina attacks. The patches do not treat angina attacks because they do not take effect immediately.
A nurse is assessing a client who has a history of DVT and is receiving warfarin. The nurse should identify which of the following findings indicates the medication is effective?
A) Hemoglobin 14 g/dL B) Minimal bruising of extremities C) Decreased blood pressure D) INR 2.0 Correct Answer: d Rationales: The nurse should recognize that a hemoglobin level of 14 g/dL is within the expected reference range. However, this is not evidence of effective warfarin therapy. The nurse should recognize that minimal bruising or no bruising is desired. However, this is not evidence of effective warfarin therapy. The nurse should recognize that decreased blood pressure is a manifestation of bleeding, which is an adverse effect of warfarin. The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?
A) Increased abdominal girth B) Weak peripheral pulses C) Jugular venous neck distention D) Dependent edema Correct Answer: B Rationales: Increased abdominal girth is a finding related to systemic congestion resulting from right-sided heart failure. Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. Jugular venous neck distention is a finding related to systemic congestion resulting from right-sided heart failure. Dependent edema is a finding related to systemic congestion resulting from right-sided heart failure.
A nurse in an emergency department is caring for a client who has a blood pressure of 254/139. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?
A) Initiate seizure precautions. B) Tell the client to report vision changes. C) Elevate the head of the client's bed. D) Start a peripheral IV. Correct Answer C Rationales The nurse should initiate seizure precautions because the client is at risk for seizures. However, this is not the first action the nurse should take. The nurse should tell the client to report vision changes because the client is at risk for blurred vision. However, this is not the first action the nurse should take. The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation. The nurse should initiate an IV to provide access for medication administration to reduce the client's blood pressure. However, this is not the first action the nurse should take.
A nurse is caring for a client who was admitted for treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and irregular heart rate. Which of the following actions should the nurse take first?
A) Obtain client's current weight. B) Review serum electrolyte values. C) Determine the time of the last digoxin dose. D) Check the client's urine output. Correct Answer: B Rationales: The nurse should obtain the client's current weight to determine fluid loss from diuretic therapy. However, the nurse should take another action first. Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia. The nurse should determine the time of the last digoxin dose in order to evaluate when the next dose is due. However, the nurse should take another action first. The nurse should check the client's urine output to determine fluid loss from diuretic therapy. However, the nurse should take another action first.