NURS271: Perfusion PrepU

A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse?

"I should expect a low-grade fever and swelling at the site for the next week." Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.

The nurse is caring for a female client who has had 25 mg of oral hydrochlorothiazide added to her medication regimen for the treatment of hypertension (HTN). Which of the following instructions should the nurse give the patient?

"Increase the amount of fruits and vegetables you eat." Thiazide diuretics cause loss of sodium, potassium, and magnesium. The patient should be encouraged to eat fruits and vegetables which are high in potassium. Diuretics cause increased urination; the patient should not take the medication prior to going to bed. Thiazide diuretics to not cause dry mouth or nasal congestion. Postural hypotension (side effect) may be potentiated by alcohol.

A nurse is preparing a client for a scheduled Adenocard (adenosine) stress test. Which of the following statements by the client indicates a need for further teaching?

"My wife is bringing me a cup of coffee to drink before the test." Caffeine must be avoided for 4 hours prior to the stress test. If caffeine is ingested, the test must be rescheduled. All other statements are true.

The nurse is providing education about the nutrient content of the Therapeutic Lifestyle Changes (TLC) diet to a community group. Which of the following will the nurse include? Choose all that apply.

- Carbohydrates should make up 50% to 60% of the total calories. - Dietary fiber should be 20 to 30 grams per day. - Protein should make up approximately 15% of total calories.

A nurse is caring for a client with orthostatic hypotension. Which of the following are symptoms of orthostatic hypotension? Select all that apply.

- Dizziness - Syncope - Nausea - Weakness Symptoms of orthostatic hypotension are those related to decreased cerebral perfusion, such as dizziness, syncope, weakness, blurred vision, and marked changes in blood pressure and heart rate. It may also cause nausea. Skin rash is not symptom of orthostatic hypotension.

The nurse is interviewing a client who is complaining of chest pain. Which of the following questions related to the client's history are most important to ask? Select all that apply.

- How would you describe your symptoms? - Are you allergic to any medications or foods? - How did your mother die? During initial assessment, the nurse should obtain important information about the client's history that focuses on a description of the symptoms before and during admission, family medical history, prescription and nonprescription drug use, and drug and food allergies.

A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.

- Hyperlipidemia - Obesity - Tobacco use Modifiable risk factors for coronary artery disease include hyperlipidemia, tobacco use, hypertension, diabetes mellitus, metabolic syndrome, obesity, and physical inactivity. Nonmodifiable risk factors include family history, advanced age, gender, and race.

The nurse is responsible for recognizing significant data when developing nursing diagnoses. The following significant data would indicate a health problem may exist: (Select all that apply.)

- The client has a blood pressure reading of 150/90 mm Hg. - During assessment, the client is sweating and short of breath. - The client only answers yes or no questions. The subjective and objective data that would be considered significant in this scenario are elevated blood pressure, sweating and shortness of breath, and client responses. Individually, each of these data may not be considered abnormal. However, as a cluster they may indicate that a problem exists. The other findings are within normal range and do not signify a problem at this time.

It is appropriate for the nurse to recommend smoking cessation for patients with hypertension because nicotine ...

... increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. The nurse recommends smoking cessation for patients with hypertension because nicotine raises the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. Reduced oral fluids decrease the circulating blood volume.

A client is experiencing an irregular heartbeat. The client asks the nurse how a heartbeat occurs. The nurse explains the conduction system of the heart beginning with the sinoatrial node (SA node). Place the conduction sequence of the heart in order beginning with the SA node. Use all options.

1) Purkinje fibers 2) AV node 3) Atrial cell stimulation 4) Bundle of His 5) Bundle branches

The nurse is assessing the cardiovascular status of a client who was found unresponsive in a lobby area. Following transfer of the client, the family asks how blood circulates through the body. The nurse is most correct to state the proper circulation as which? Place the pattern of circulation in the correct order beginning in the right atrium. Use all options.

1) Right atrium 2) Pulmonary vein 3) Right ventricle 4) Left ventricle 5) Pulmonary artery 6) Left atrium 7) Aorta

On his return to the cardiac step-down unit after his diagnostic procedure, a client awaits the report from his cardiologist. As the client's nurse, you review the process of measuring ejection fraction and explain to the client that it measures the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55% Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.

A nurse is performing CPR on a patient who is in cardiac arrest. What action would the nurse perform second?

Activate the emergency response system. The victim is first checked for unresponsiveness. Once this is established, the emergency response system is activated. An AED is secured next, followed by initiating CPR with the CAB sequence.

Primary or essential hypertension accounts for about 95% of all hypertension diagnoses—with an unknown etiology. Secondary hypertension accompanies specific conditions that create hypertension as a result of tissue damage. Which of the following conditions contribute to secondary hypertension?

Arterial vasoconstriction Secondary hypertension may accompany any primary condition that affects fluid volume or renal function or causes arterial vasoconstriction.

A patient complains about chest pain and heavy breathing when exercising or when stressed. Which of the following is a priority nursing intervention for the patient diagnosed with coronary artery disease?

Assess chest pain and administer prescribed drugs and oxygen The nurse assesses the patient for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing the blood pressure or the physical history does not clearly indicate that the patient has CAD. The nurse does not administer aspirin without the physician's prescription.

The nurse plays an important role in monitoring and managing potential complications in the patient who has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which of the following respiratory complications?

Atelectasis Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.

The nurse caring for a patient with a dysrhythmia understands that the P wave on an electrocardiogram (ECG) represents what phase of the cardiac cycle?

Atrial depolarization The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. The T wave represents ventricular repolarization. The ST segment represents early ventricular repolarization, and lasts from the end of the QRS complex to the beginning of the T wave.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?

Blood pressure increase of 20 mm Hg Criteria for termination of the weaning process includes: heart rate increase of 20 beats per minute, and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

Which of the following is a key diagnostic indicator of heart failure (HF)?

Brain natriuretic peptide (BNP) The BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of HF. A BUN, creatinine, and CBC are included in the initial workup.

The nurse is caring for a patient with a medical history of sickle cell anemia. The nurse understands this predisposes the patient to which of the following possible renal or urologic disorders?

Chronic kidney disease A medical history of sickle cell anemia predisposes the patient to the development of chronic kidney disease. The other disorders are not associated with the development of sickle cell anemia.

The nurse is caring for an infant diagnosed with a congenital heart disease. Which of the following concerns should be a priority for the nurse to address with the parents when discussing the child's condition?

Congestive heart failure (CHF) Parents of children with congenital heart disease need information about congestive heart failure because congestive heart failure is generally the first consequence seen in a child with congenital heart disease. In addition to often being the primary diagnosis, it can also remain an ongoing complication. Kidney failure, eating concerns, and intermittent elevated temperature may inevitably present as complications, but not initially.

When treating hypertensive emergencies, the nurse identifies the most appropriate route of administration for antihypertensive agents as being which of the following?

Continuous IV infusion The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the sublingual and IM routes as their absorption and dynamics are unpredictable. The oral route would not have as quick an onset as a continuous IV infusion.

The nurse is assessing a client with peripheral arterial disease who had a femoral-popliteal bypass. Which finding indicates improved arterial blood supply to the lower extremity?

Decrease in muscle pain when walking With increased blood supply to the leg there should be less or absent claudication (cramping pain in leg with walking). Pulses should be palpable with improved blood supply. Edema is associated with venous disease. Pallor with elevation and dependent rubor are symptoms of peripheral arterial disease.

A patient has a high magnesium level. Identify how hypermagnesemia affects cardiac function.

Decreases myocardial contractility Hypermagnesemia can cause depression of myocardial contractility and excitability heart block and asystole. Hypomagnesemia predisposes patient to atrial or ventricular tachycardias.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed in the initial workup.

Dysrhythmias can be fatal to a client during the acute phase following a myocardial infarction. The nurse understands that the primary cause of this event is due to which of the following?

Effects on depolarization and repolarization of the myocardial cells Dysrhythmias during the acute phase occur because the affected areas are electrically unstable due to the shifting of electrolytes and accumulation of lactic acid, which affect the depolarization and repolarization of the myocardial cells. Arterial spasms can be a cause of MI, not a result. Leukocytosis does occur after a MI but not the cause of dysrhythmias. Scar tissue formation takes weeks to form and does not occur in the acute phase.

Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue?

Endocardium The inner layer, the endocardium, is composed of a thin, smooth layer of endothelial cells. Folds of endocardium form the heart valves. The middle layer, the myocardium, consists of muscle tissue and is the force behind the heart's pumping action. The pericardium is a saclike structure that surrounds and supports the heart. The outer layer, the epicardium, is composed of fibrous and loose connective tissue.

A nurse is teaching about lifestyle modifications to a group of clients with known hypertension. Which of the following statements would the nurse include in the education session?

Engage in aerobic activity at least 30 minutes/day most days of the week. Recommmended lifestye modifications to prevent and manage hypertension include maintaining a normal body mass index (about 24; greater than 25 is considered overweight), maintaining a waist circumference of less than 40 inches for men and 35 inches for women, limiting alcohol intake to no more than 2 drinks for men and 1 drink for women per day, and engaging in aerobic activity at least 30 minutes per day most days of the week.

An 80-year-old male client who has been informed by his physician that he has arteriosclerosis is confused by what this means. The nurse explains that arteriosclerosis is a:

Expected part of the aging process. Arteriosclerosis is loss of elasticity or hardening of the arteries that accompanies the aging process. While arteriosclerosis is a contributing factor to vascular occlusive disease, it is a term that refers to a loss of elasticity or hardening of the arteries that accompanies the aging process. Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Hyperlipidemia, or high levels of blood fat, triggers atherosclerotic changes.

Identify which of the following as an age-related change associated with conduction system of the heart?

Heart block Age-related changes to the conduction system may include bradycardia and heart block. Age-related changes to the heart valves include the presence of a murmur or thrill.

The lab values of a patient diagnosed with coronary artery disease (CAD) have just come back from the lab. His low-density lipoprotein (LDL) level is 112 mg/dL. This lab value is indicative of which of the following?

High LDL level If the LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered to be high. The goal is to decrease the LDL level below 100 mg/dL.

When the postcardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which of the following electrolyte imbalances?

Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, and cardiac arrest. Signs and symptoms of hypokalemia include signs of digitalis toxicity and dysrhythmias (U wave, AV block, flat or inverted T waves). Signs of hyperkalemia include: mental confusion, restlessness, nausea, weakness, paresthesias of extremities, dysrhythmias (tall, peaked T waves; increased amplitude, widening QRS complex; prolonged QT interval). Signs and symptoms of hypomagnesemia include: paresthesias, carpopedal spasm, muscle cramps, tetany, irritability, tremors, hyperexcitability, hyperreflexia, cardiac dysrhythmias (prolonged PR and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. After the procedure the nurse performs which of the following interventions?

Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. During the recovery period, the client must have the head of the bed elevated 45 degrees to avoid aspiration. The nurse should restrict food and fluids until the return of the gag reflex and the client is fully awake and alert.

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for receiving oxygenated blood from the lungs?

Left atrium The left atrium receives oxygenated blood from the lungs. The left ventricle pumps that blood to all the cells and tissues of the body. The right atrium receives deoxygenated blood from the venous system. The right ventricle pumps that blood to the lungs to be oxygenated.

Which of the following is the hallmark of systolic heart failure?

Low ejection fraction (EF) A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the patient's symptoms.

The results of which serologic test should the nurse have on the medical record before a client is started on tissue plasminogen activator or alteplase recombinant?

Partial thromboplastin time The baseline values of the client's partial thromboplastin time, bleeding time, and prothrombin time should be obtained. Potassium levels do not indicate a client's coagulation time. The Lee-White clotting time or baseline fibrin split product does not need to be established before starting tissue plasminogen activator or alteplase.

The nurse receives a telephone call from a client with an implanted pacemaker who reports that his pulse is 68 beats per minute, but his pacemaker rate is set at 72 beats per minute. The best response by the nurse is which of the following?

Please come to the clinic right away so that we may interrogate the pacemaker to see if it is malfunctioning." A client experiencing pacemaker malfunctioning may develop bradycardia as well as signs and symptoms of decreased cardiac output. The client should check the pulse daily and report immediately any sudden slowing or increasing of the pulse rate. This may indicate pacemaker malfunction.

A 48-year-old female client presents to the ED with a myocardial infarction. Prior to administering a prescribed thrombolytic agent, the nurse must interview the client to determine if she has which of the following absolute contraindications to thrombolytic therapy?

Prior to intracranial hemorrhage History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. An allergy to iodine, shellfish, radiographic dye, and latex are of primary concern before a cardiac catheterization but not a known contraindication for thrombolytic therapy. Administration of a thrombolytic agent with heparin increases risk of bleeding; the primary healthcare provider usually discontinues the heparin until thrombolytic treatment is completed.

Which of the follow arteries carries deoxygenated blood?

Pulmonary artery The pulmonary artery is the only artery carrying deoxygenated blood. Oxygenated blood returns to the left atrium via the pulmonary veins. The left coronary artery, right coronary artery, and left anterior descending artery do not carry deoxygenated blood.

When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as the

Pulmonary artery wedge pressure When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client?

Pulmonary congestion When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure (Pulmonary congestion, pedal edema , nausea, JVD).

A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems?

Pulmonary embolism Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction where emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

During an initial assessment of a client diagnosed with Raynaud's phenomenon, the nurse notes a sudden color change from pink to white in the fingers. The nurse should first assess:

Radial pulse Decreased perfusion from vasospasm induces color changes in the extremity. The degree of decreased perfusion should be assessed by taking the radial pulse. Color changes progressively to blue with cyanosis and then red when reperfusion occurs. The SpO2 requires adequate perfusion for accuracy. A blood pressure will cause further constriction and reduction of perfusion in the extremity.

The nurse is caring for a client newly diagnosed with secondary hypertension. Which of the following conditions contributes to the development of secondary hypertension?

Renal disease Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoietin alfa [Epogen]), and coarctation of the aorta. High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attacks, strokes, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension.

When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for angina, the nurse should plan to include which instructions?

See if rest relieves the chest pain before using the nitroglycerin. Decreased activity may relieve chest pain; sitting will prevent injury should the nitroglycerin lower BP and cause fainting. The client should expect to feel dizzy or flushed or to develop a headache following sublingual nitroglycerin use. The client should place one nitroglycerin tablet under the tongue if 2-3 minutes of rest fails to relieve pain. Clients may take up to three nitroglycerin tablets within 5 minutes of each other to relieve angina. However, they should call 911 if the three tablets fail to resolve the chest pain.

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm?

Severe back pain Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe back pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.

Which of the following dysrhythmias are common in older patients?

Sinus bradycardia Sinus bradycardia is a common dysrhythmia in older patients. Sinus tachycardia, atrial fibrillation, and ventricular tachycardia are not common dysrhythmias in older patients.

A client with gestational hypertension is likely to exhibit:

Sudden weight gain, headaches, and double vision Gestational hypertension is defined as a blood pressure of 140/90 or higher for the first time after 20 weeks' gestation, without proteinuria. Clients may exhibit the following symptoms along with high blood pressure: Headache, double vision, edema, nausea, or sudden weight gain. Vaginal bleeding and uterine contractions aren't associated with gestational hypertension. if proteinuria is present, the client's diagnoses will now be preeclampsia.

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 The 24-hour urine collection specimen is ordered to determine dysfunction of the adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are not evaluated by a 24-hour urine.

Your client has just been diagnosed with a dysrhythmia. The client asks you to explain normal sinus rhythm. What would you explain is the characteristic of normal sinus rhythm?

The sinoatrial (SA) node initiates the impulse. The characteristics of normal sinus rhythm are heart rate between 60 and 100 beats/minute, the SA node initiates the impulse, the impulse travels to the AV node in 0.12 to 0.2 second, the ventricles depolarize in 0.12 seconds or less, and each impulse occurs regularly.

The nurse is reevaluating a patient 2 hours following a percutaneous transluminal coronary angioplasty (PTCA) procedure. Which of the following assessment findings may indicate the patient is experiencing a complication of the procedure?

Urine output of 40 mL Complications that may occur following a PTCA include myocardial ischemia, bleeding and hematoma formation, retroperitoneal hematoma, arterial occlusion, pseudoaneurysm formation, arteriovenous fistula formation, and acute renal failure. The urine output of 40 mL over a 2-hour period may indicate acute renal failure. The patient is expected to have a minimum urine output of 30 mL per hour. Dried blood at the insertion site is a finding warranting no acute intervention. A serum potassium level of 4.0 mEq/L is within normal range. The heart rate of 100 bmp is within the normal range and indicates no acute distress.

How do you assess left ventricle hypertrophy?

Ventricular hypertrophy can be assessed by echocardiography.