NCLEX-PN Cardiac

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action?

The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.

claudication

a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.

Hemostasis

The stoppage of bleeding or hemorrhage.

The nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse should plan to maintain bed rest for this client in which position?

After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period. The client may turn from side to side. The client is placed in the supine position and the head of the bed is not elevated to more than 30 degrees to keep the affected leg straight at the groin and prevent arterial occlusion. Bathroom privileges are not allowed during the immediate postcatheterization period. For the high-Fowler's position, the head of the bed is elevated 90 degrees

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings?

An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.

The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside?

CAD causes obstruction to blood flow through one or more major coronary arteries, cutting off oxygen and nutrients to the cardiac cells, and resulting in chest pain. Providing oxygen to the client is important to help decrease pain and prevent its recurrence. A bedside commode and ECG machine may be helpful but are not the priority. A rolling shower chair has no value for this client because the client should be able to walk and shower if pain free and an activity prescription allows it.

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which?

Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission?

Chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. It is a first-generation sulfonylurea. Insulin does not cause or aggravate fluid retention. Acarbose is a miscellaneous oral hypoglycemic agent.

A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client?

During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.

The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen (Tylenol) usually prescribed to be taken before the administration of the topical nitrate?

Headache occurs as a side effect of nitrates. Acetaminophen may be given before nitrates to prevent headaches or to minimize the discomfort from the headaches. Option 2 is incorrect. Options 3 and 4 are unrelated to the data in the question.

A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home?

Medication therapy is an essential part of the therapeutic regimen for treating heart failure. The client must have a clear understanding of which medications to take and when. Options 1 and 3 can be carried out with the assistance of someone else. Option 2 may not be realistic for this client.

The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA?

Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine, or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not specifically related to an abdominal aortic aneurysm.

Cardioversion is a medical procedure done to restore a normal heart rhythm for people who have certain types of abnormal heartbeats (arrhythmias). Cardioversion is most often done by sending electric shocks to your heart through electrodes placed on your chest

Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin?

Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle. Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which?

Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection?

Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A β-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis. Options 1, 2, and 4 are incorrect.

A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs/symptoms?

Rheumatic heart disease can occur as a result of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting for the presence of sore throat and fever. The other options are unrelated to this problem and indicate possible yeast infection, skin lesions, and urinary tract infection, respectively.

A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first?

Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.

A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action?

The best initial action is to rule out chest pain of cardiac origin to eliminate a cardiovascular etiology related to the client's complaint. If the pain is left untreated and the pain is caused by myocardial ischemia or infarction (MI), the client could suffer a devastating cardiac injury. Furthermore, the nurse does this because a female presenting with an MI is more likely to display atypical clinical indicators, including fatigue and dyspnea. After instituting measures to rule out a cardiac problem, the nurse completes the client assessment by auscultating the heart and lungs and by reviewing the medical record. After a cardiac problem is ruled out, the nurse can administer an analgesic if prescribed.

The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of taking which measure?

The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next?

The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?

The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse?

The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may also radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief.

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading

To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. The use of the other positions listed would result in false low or false high readings.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the nurse best describe this type of anginal pain?

Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. The data in the question is characteristic of a type of angina pain, and therefore, nonanginal pain is incorrect.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?

Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 4 describes the Trendelenburg's test findings, which are indicative of varicose veins. In the test, the health care provider has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client?

Fluid overload can cause complications for the client with heart failure. Therefore, the nurse evaluates the client's fluid balance to forestall activation of harmful compensatory mechanisms and deterioration of other organ systems that increasing total body fluid can cause. This is the nurse's priority because balancing the client's fluid status has the broadest range of potential benefits for the client, including improving oxygenation. The vital signs, serum electrolytes, and electrocardiogram are important assessments, yet remain secondary in importance to fluid status because they are items that are affected by fluid balance

The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care?

Immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. Placing the client in the Fowler's position increases the risk of hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. Flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. The regularly scheduled medications are needed to treat acute and chronic conditions

The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client?

Standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen program to prevent straining and constipation, and maintaining fluid and electrolyte balance. Increasing fluids to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease.