Med-Surg I: ATI Practice Cardiovascular

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."

a. "I can't get rid of these hiccups. This indicates that the pacemaker may be stimulating the chest wall or diaphragm. Dizziness is expected after the procedure. Stinging at the insertion site is not a result of the procedure but continue to monitor for infection. Headaches could explain another disease process.

A nurse is assessing a patient who has pulmonary edema related to heart failure. Which of the following indicates effective treatment of this 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

a. Absence of adventitious breath sounds

A nurse is assessing a client who has left-sided HF. Which of the following should the nurse expect to find? a. Increased abdominal girth b. Weak peripheral pulses c. JVD d. Dependent edema

b. Weak peripheral pulses All other findings are associated with right-sided HF.

A nurse is in the ER assessing a client with bradydysrhythmia. Which of the following findings should the nurse monitor for? a. Confusion b. Friction rub c. Hypertension d. Dry skin

a. Confusion The client may be confused due to impaired perfusion. Friction rub can be heard in a client with pericarditis but not in this client. Hypotension is an expecting finding of bradydysrhythmia. This client should be monitored for diaphoresis.

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? a. Dyspnea on exertion b. Tracheal deviation c. Pericardial rub d. Weight loss

a. Dyspnea on exertion Tracheal deviation is a finding of tension pneumothorax. Pericardial rub is a finding of pericarditis. Weight gain is an expected finding of dilated cardiomyopathy, not weight loss.

A nurse is caring for a client who has HF and is experiencing A-Fib. The nurse should plan to monitor for and report which of the findings to the provider? a. Slurred speech b. Irregular pulse c. Dependent edema d. Persistent fatigue

a. Slurred speech The client is at risk of developing an embolus and this finding can indicate blood supply to the brain is interrupted. All other findings are expected for this PT.

A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? a. Client with hypothyroidism b. Client with diabetes mellitus c. Client whose daily caloric intake includes 25% of fat d. Client who consumes two 12 oz. bottles of beer a day

b. Client with diabetes mellitus

A nurse is caring for a client who has a BP of 254/139. The nurse recognizes 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 bed d. Start a peripheral IV

c. Elevate the head of the bed This reduces blood pressure and promotes oxygen to prevent organ damage and is what the nurse should do FIRST.

A nurse is assessing a client who has a leg ulcer and history of diabetes mellitus. The nurse should use which of the following focused assessments to differentiate between an arterial ulcer and venous stasis ulcer? a. Explore family history regarding PAD b. Note the presence or absence of pain c. Inquire about the presence or absence of claudication d. Ask if the client has had a recent infection

c. Inquire about the presence or absence of claudication Those with arterial leg ulcers will experience claudication, those with venous ulcers do not.

A nurse is caring for a post-op. client 1 hr following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? a. Serosanguineous drainage on dressing b. Severe pain with coughing c. Urine output 20 mL/hr d. Increase in temp. from 98.2 F to 99.5 F

c. Urine output 20 mL/hr Urine output less than 30 mL/hr is a manifestation of shock. Serosanguineous drainage is expected. Coughing after an aortic aneurysm repair is painful. Temp. is within expected range.

A nurse is caring for a client who has had chest pain with onset 24 hrs ago. The nurse should recognize which of the following is diagnostic of MI? a. Myoglobin b. C-reactive protein c. Creatinine kinase - MB d. Homocysteine

c. Creatinine kinase - MB This biomarker is specific to myocardium

A nurse is caring for a client being treated for HF and was prescribed furosemide. The nurse should plan to monitor for which of the following adverse effects? a. Shortness of breath b. Lightheadedness c. Dry cough d. Metallic taste

b. Lightheadedness This can result from a drop in BP.

A nurse is teaching a client who's been prescribed a transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? a. Apply the new patch to the same site as the old patch. b. Place the patch on an area away from skin folds and joints. c. Keep the patch on 24 hrs a day. d. Replace the patch at the onset of angina.

b. Place the patch on an area away from skin folds and joints. It's important to rotate the skin patch to prevent irritation. The client should be patch-free 10-12 hrs/day to prevent tolerance to the medication. The patch offers prevention of attacks but does not treat attacks.

A nurse is caring for a client who was admitted for tx. of left-sided HF with IV loop diuretics and digitalis therapy. The client is experiencing weakness and irregular HR. 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

b. Review serum electrolyte values Weakness and irregular HR show that the client is at a great risk for electrolyte imbalances, an adverse effect of loop diuretics. This is what the nurse should do FIRST, the other actions come next.

A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hrs. Which of the following client statements indicates a need for further teaching? a. "My arthritis is really bothering me because I haven't taken my aspirin in a week." b. "My BP shouldn't be high because I took my medication this morning." c. "I took my warfarin last night according to my usual schedule." d. "I Will check my blood sugar since I took a reduced dose of insulin this morning."

c. "I took my warfarin last night according to my usual schedule." Clients scheduled for CABG should not take anticoagulants several days before the surgery.

A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements requires the nurse to contact the provider for possible rescheduling? a. "I'm still hungry after the bowl of cereal I ate at 7 am." b. "I didn't take my heart pills this morning because my doctor told me not to." c. "I've had chest pain a couple times since i saw my doctor last week." d. "I smoked a cigarette this morning to calm my nerves about the procedure."

d. "I smoked a cigarette this morning to calm my nerves about the procedure." Smoking before this test can change the outcome and place the client at an additional risk.

A nurse is assessing a client who has a history of deep vein thrombosis and is receiving warfarin. Which of the following indicates the medication is effective? a. Hemoglobin 14 g/dL b. Minimal bruising of extremities c. Decreased BP d. INR 2.0

d. INR 2.0 An INR of 2.0-3.0 is a measurement of effective warfarin therapy.

A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider? a. Hgb 14.4 g/dL b. History of PAD c. Urine output 2000mL/4 hr d. Previous allergic reaction to shellfish

d. Previous allergic reaction to shellfish

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? a. Ventricular depolarization b. Guillan-Barre syndrome c. Myelodysplastic syndrome d. Valvular disease

d. Valvular disease Often occurs as a result of inflammation and infection of the endocardium.