Perfusion

Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The parent asks the nurse what type of test this is and why it is done. Which response would the nurse provide?

"Electrical activity in the baby's heart is recorded, then printed on graph paper."

Which client statement indicates understanding of the side effects of nitroglycerin ointment?

"I may experience a headache."

Which explanation will the nurse give when a client asks about what causes varicose veins?

"Incompetent valves of superficial veins."

Which instruction would the nurse include in a teaching plan for nitroglycerin patches?

"Remove a previous patch before applying the next one."

The nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include?

"You will need to apply them in the morning before you lower your legs from the bed to the floor."

The parent of an infant with heart failure questions the necessity of weighing the baby every morning. Which would the nurse say that this daily information is important in determining?

Fluid retention

Which is involved in the postprocedure nursing care of a child after left- side cardiac catheterization?

Monitoring the insertion site for bleeding

Which medication may be used to treat postpartum hemorrhage?

Methylergonovine

Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma?

Moist, red, and raised above the skin surface

Which information is important for the nurse to include in the discharge teaching plan for a client prescribed atenolol 20 mg by mouth four times a day?

Avoid abruptly discontinuing the medication.

Within which period of time would a nurse advise the client to anticipate pain relief will begin when nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina?

1 to 3 minutes

How far would the nurse depress the lower sternum when performing cardiac compression on an adult client?

2 to 2.4 inches (5-6 cm)

Which is the minimum heart rate of a 14-year-old? Record your answer

60

Which client seen at a health fair will be most at risk for hypertension?

62-year-old African American man

Which range of heart rate is acceptable for a preschooler?

80 to 110

Which heart rate is the maximum normal for a 16-year-old? Record

90

Which assessment would the nurse include in the plan of care for a postpartum client with large, painful varicose veins?

Assessing for signs of thrombophlebitis

Which factor is unique to vascular dementia when comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type ?

Abrupt onset of symptoms

How would the nurse describe heart failure to a client?

An inability of the heart to pump blood in proportion to metabolic needs

Which client response indicates to the nurse that a vasodilator medication is effective?

Blood pressure changes from 154/90 to 126/72 mm Hg

Which body system is affected by excessive use of amphetamine/dextroamphetamine?

Cardiac

The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy

Causes local vasoconstriction, preventing edema and muscle spasms

The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. Which is the next nursing action?

Changing the maternal position

Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid?

Circulatory collapse

Which activity would the nurse expect to cause the most distress when assessing a client with heart failure for activity tolerance?

Climbing a flight of stairs to the bedroom

Which comorbidity is associated Down syndrome?

Congenital heart disease

Which rationale will prompt the nurse to ask the provider for a different form of metformin when an older adult asks that extended-release metformin be crushed because it is difficult to swallow?

Extended-release formulations are designed to be released slowly and crushing the tablet will prevent this from occurring.

Which clotting factor would a nurse explain is deficient to the parents of a child newly diagnosed with hemophilia A?

Factor VIII

Which Korotkoff sound represents the diastolic blood pressure in an adolescent?

Fifth

Which response indicates that a beta blocker prescribed for persistent ventricular tachycardia is working effectively?

Decreased heart rate

Which medication would a nurse suspect is the cause of severe nausea and a heartbeat that is irregular and slow in a client who takes multiple medications?

Digoxin

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities?

Duplex venous Doppler

Which teratogenic effect is seen because of lithium?

Ebstein anomaly

Which nursing intervention would the nurse implement when providing postoperative care for a client who had a below-the-knee amputation?

Elevate residual leg slightly while keeping the knee joint straight for first 24 hours.

Which action would the nurse suggest when a client reports feeling faint and lightheaded upon rising to a standing position after a discectomy and fusion surgery?

Have the client sit on the edge of the bed so the nurse can hold the client upright.

Which factor would the nurse identify as the cause of the pain experienced by a client who is experiencing acute coronary syndrome?

Heart muscle ischemia

Which assessment after administration of diltiazem to a client with supraventricular tachycardia (SVT) and a heart rate of 170 beats/minute indicates that the medication was effective?

Heart rate of 98 beats/minute

Which assessment parameter is used to determine the severity of blood loss in a client with an upper gastrointestinal (UGI) bleed? Select all that apply. One, some, or all responses may be correct.

HematocritHemoglobinPlatelet countOxygen saturationBlood urea nitrogen (BUN)

Which term would the nurse use to document a drop in blood pressure when a client moves rapidly from a lying to a standing position?

Orthostatic hypotension

Which oxytocic medication may help control uterine bleeding postdelivery and promote milk ejection?

Oxytocin

Which response indicates that sublingual nitroglycerin prescribed for a client with unstable angina is effective?

Pain subsides as a result of arteriole and venous dilation.

Which assessment finding is a late sign of heart failure?

Peripheral edema

Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage?

Peripheral vasoconstriction

Which action will the nurse take when a client who had a myocardial infarction complains of feeling dizzy fifteen minutes after receiving 15 mg of morphine sulfate for chest pain?

Place the client in the supine position and take the vital signs.

Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery?

Prevent clot formation

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all thatapply. One, some, or all responses may be correct.

Providing oxygenAssessing vital signsObtaining a 12-lead EKGDrawing blood for cardiac enzymes Auscultating heart sounds Administering nitroglycerin

Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin?

Relief of anginal pain

Which instruction will the nurse teach the client who had a femoropopliteal bypass graft and is receiving clopidogrel postoperatively?

Report any occurrence of multiple bruises.

Which autoimmune disease can result in damage to the heart?

Rheumatic fever

Which action will the nurse take during administration of blood products to ensure the client's safety?

Stay with client during first 15 minutes of infusion.

Several minutes after the start of a red blood cell infusion, the client reports itching. The nurse observes hives on the client's chest. Which action would the nurse take?

Stop the transfusion.

Which information would be used to determine the cause of premature atrial contractions (PACs) observed on a client's EKG? Select all that apply. One, some, or all responses may be correct.

Stress level Tobacco use Caffeine intake Electrolyte levels Home medications

The nurse assessed a client's pulse rate and recorded the score as 3+. Which descriptor reflects the strength of the pulse?

Strong

Which action would the nurse take to determine a client's pulse pressure?

Subtract the diastolic from the systolic reading.

Which cardiovascular adverse effect would the nurse associate with the use of clomiphene?

Tachycardia

Which assessment finding after an open reduction and internal fixation (ORIF) of a fractured hip would cause the nurse to suspect and monitor for signs and symptoms of a fat embolism?

Tachycardia and petechiae over the chest

While assessing a client for the dorsalis pedis pulse, the nurse documents the reading as 1+. Which conclusion can be inferred from this finding?

The pulse strength is barely palpable.

Which adverse effect can be seen in a female client with gonadotropin deficiency and who is undergoing hormone replacement therapy?

Thrombosis

Which physiological process causes temperature elevation after a client has had a myocardial infarction?

Tissue necrosis and inflammation

Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours?

To prevent development of pressure injuries

For which purpose would enoxaparin 40 mg subcutaneously daily be prescribed for a client who had abdominal surgery?

To provide prophylaxis against postoperative thrombus formation

Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization?

To visualize the disease process in the coronary arteries

Which pulse site would the nurse use to perform the Allen test?

Ulnar

A client had surgery on the shoulder, and the nurse is to obtain a brachial pulse. Where on the illustration would the nurse indicate to best obtain the brachial pulse rate?

b

Which instruction would the nurse include when teaching the client about sublingual nitroglycerin?

"Common side effects include headache and low blood pressure."

Which complication would the nurse consider in a client who just had a total hip replacement and is experiencing restlessness and changes in mentation?

Hypovolemic shock

Which nursing action is important when transfusing packed red blood cells to a client with a diagnosis of anemia?

Monitoring the client's response, particularly within the first 10 minutes

While assessing a client's vascular system, the nurse finds a diminished and barely papable pulse strength. Which documentation would the nurse utilize in this situation?

1+

Which blood pressure is optimal for an adolescent?

110/65 mm Hg

Which example would be a normal blood pressure of a 12-year-old client?

110/65 mm Hg

The mean arterial pressure (MAP) for a client who has a blood pressure of 180/95 mm Hg is 123 mm Hg

123

Which client conditions does the nurse associate with bluish-colored mucous membranes? Select all that apply. One, some, or all responses may be correct.

Methemoglobinemia Cardiopulmonary disease

The nurse understands which antihypertensive medication is contraindicated in lactating women?

Atenolol

Which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client?

Atherosclerotic plaques within arteries

Which electrical activity of the cardiac conduction system is reflected in the P wave?

Atrial depolarization

Which instructions would the nurse share with the client being discharged after rhinoplasty?

Avoid items that may trigger sneezing.

Which pain relief medication would the nurse expect to find in the plan of care of a client with a myocardial infarction admitted to the cardiac intensive care unit?

Morphine

Which nursing intervention is correct for a client with venous insufficiency?

Elevate the client's legs above heart level.

To prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care?

Encourage early mobility.

Which action would the nurse take to prevent venous thrombus formation after abdominal surgery?

Encourage the client to ambulate multiple times daily.

Which item would the client with palpitations from premature heartbeats be taught to avoid?

Energy drinks

Which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease?

Esophageal pain may imitate the symptoms of a heart attack.

How frequently will the nurse plan to assess the blood pressure when a client is admitted to the postanesthesia care unit after surgery?

Every 10 to 15 minutes

A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP), has an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor?

Hemorrhage

Which type of shock is associated with a ruptured abdominal aneurysm?

Hypovolemic shock

Which immunoglobulin crosses the placenta?

IgG

The weight of a 3-month-old infant with tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate weight gain?

Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse

How would anxiety affect outcomes for a client with heart failure?

Increases the cardiac workload

A child who has iron-deficiency anemia tells the school nurse, "I get dizzy in gym class." Which explanation is most likely for the development of this symptom?

Insufficient cerebral oxygenation

Which cytokine stimulates the liver to produce fibrinogen and protein C?

Interleukin-6

Which action would the nurse take when performing external cardiac compression?

Interlock the fingers with the heel of 1 hand on the sternum and the heel of the other on top of it.

Which explanation would the nurse nurse give regarding purpose of early ambulation to a client who had surgery the previous day?

Keep blood from pooling in the legs to prevent clots

Which direction will the nurse include in the teaching plan for a client with lower extremity arterial disease (LEAD)?

Seeking professional treatment for any minor injuries to the extremities

Which complication will occur as the result of administering sildenafil to a client who takes isosorbide dinitrate?

Severe hypotension

Which signs and symptoms are observed in the human body with a decrease in body temperature? Select all that apply. One, some, or all responses may be correct.

Shivering Contraction of blood vessels

Which condition would the nurse conclude that the client is experiencing when the monitor shows a PQRST wave for each beat, indicates a rate of 120 beats per minute, and the rhythm is regular?

Sinus tachycardia

Which therapeutic effect is associated with digoxin prescribed to a client with heart failure?

Slows and strengthens cardiac contractions

In what order does normal cardiac conduction occur through the heart?

The cardiac cycle begins with an impulse generated from a small concentrated area of pacemaker cells high in the right atria called the sinus or sinoatrial node. The impulse quickly reaches the AV node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The electrical impulse then is conducted rapidly through the bundle of His to the ventricles via the left and right bundle branches. The bundle branches divide into smaller and smaller branches, finally

Identify the primary causes of adrenal insufficiency. Select all that apply. One, some, or all responses may be correct.

Tuberculosis Acquired immunodeficiency syndrome (AIDS)

Information about which vitamin would be included when teaching a client with atrial fibrillation about a new prescription for warfarin?

Vitamin K

Which term describes the inheritance pattern of hemophilia A?

X-linked recessive trait

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

Yellow