252 Test 4 Combined sets

12. A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this? A) To prevent bacterial endocarditis B) To prevent hospital-acquired pneumonia C) To minimize the need for antibiotic use during the procedure D) To decrease the need for surgical asepsis

A Feedback: Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after the following invasive procedures, such as bronchoscopy. Gentamicin would not be given to prevent pneumonia, to avoid antibiotic use during the procedure, or to decrease the need for surgical asepsis.

19. An older adult patient has been diagnosed with aortic regurgitation. What change in blood flow should the nurse expect to see on this patient's echocardiogram? A) Blood to flow back from the aorta to the left ventricle B) Obstruction of blood flow from the left ventricle C) Blood to flow back from the left atrium to the left ventricle D) Obstruction of blood from the left atrium to left ventricle

A Feedback: Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of blood from the left atrium to left ventricle.

39. A cardiac surgery patient's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action? A) Prepare to assist with pericardiocentesis. B) Reposition the patient into a prone position. C) Administer a dose of metoprolol. D) Administer a bolus of normal saline.

A Feedback: Cardiac tamponade requires immediate pericardiocentesis. Beta-blockers and fluid boluses will not relieve the pressure on the heart and prone positioning would likely exacerbate symptoms.

29. The cardiac nurse is caring for a patient who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding? A) Decreased ejection fraction B) Decreased heart rate C) Ventricular hypertrophy D) Mitral valve regurgitation

A Feedback: DCM is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. The ventricles have elevated systolic and diastolic volumes, but a decreased ejection fraction. Bradycardia and mitral valve regurgitation do not typically occur in patients with DCM.

11. A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease? A) Recognizing and promptly treating streptococcal infections B) Prophylactic use of calcium channel blockers in high-risk populations C) Adhering closely to the recommended child immunization schedule D) Smoking cessation

A Feedback: Group A streptococcus can cause rheumatic heart fever, resulting in rheumatic endocarditis. Being aware of signs and symptoms of streptococcal infections, identifying them quickly, and treating them promptly, are the best preventative techniques for rheumatic endocarditis. Smoking cessation, immunizations, and calcium channel blockers will not prevent rheumatic heart disease.

36. The nurse on the hospital's infection control committee is looking into two cases of hospital-acquired infective endocarditis among a specific classification of patients. What classification of patients would be at greatest risk for hospital-acquired endocarditis? A) Hemodialysis patients B) Patients on immunoglobulins C) Patients who undergo intermittent urinary catheterization D) Children under the age of 12

A Feedback: Hospital-acquired infective endocarditis occurs most often in patients with debilitating disease or indwelling catheters and in patients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy. Patients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis. Patients on immunoglobulins, those who need in and out catheterization, and children are not at increased risk for nosocomial infective endocarditis.

26. A patient has been diagnosed with a valvular disorder. The patient tells the nurse that he has read about numerous treatment options, including valvuloplasty. What should the nurse teach the patient about valvuloplasty? A) "For some patients, valvuloplasty can be done in a cardiac catheterization laboratory." B) "Valvuloplasty is a dangerous procedure, but it has excellent potential if it goes well." C) "Valvuloplasty is open heart surgery, but this is very safe these days and normally requires only an overnight hospital stay." D) "It's prudent to get a second opinion before deciding to have valvuloplasty."

A Feedback: Some valvuloplasty procedures do not require general anesthesia or cardiopulmonary bypass and can be performed in a cardiac catheterization laboratory or hybrid room. Open heart surgery is not required and the procedure does not carry exceptional risks that would designate it as being dangerous. Normally there is no need for the nurse to advocate for a second opinion.

32. A patient has been living with dilated cardiomyopathy for several years but has experienced worsening symptoms despite aggressive medical management. The nurse should anticipate what potential treatment? A) Heart transplantation B) Balloon valvuloplasty C) Cardiac catheterization D) Stent placement

A Feedback: When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Valvuloplasty, stent placement, and cardiac catheterization will not address the pathophysiology of cardiomyopathy.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

ANS: A A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics

ANS: A African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."

ANS: A Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A "drink" is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman's size does not matter.

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

ANS: A Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?"

ANS: A As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the client's disease is worsening. The other questions are useful, but not as important.

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the client's respiratory status. b. Draw blood to assess the client's serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications.

ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.

14. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."

ANS: A Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How should the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." How should the nurse respond? a. "Would you like to talk more about this?" b. "You are lucky to have such a devoted daughter." c. "It is normal to feel as though you are a burden." d. "Would you like to meet with the chaplain?"

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client's concerns and do not allow the nurse to obtain more information to provide client-centered care.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."

ANS: A Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

Before giving a dose of digoxin (Lanoxin), the nurse checked an infant's apical heart rate and it was 114 bpm. What should the nurse do next? a. Administer the dose as ordered. b. Hold the medication until the next dose. c. Wait and recheck the apical heart rate in 30 minutes. d. Notify the physician about the infant's heart rate.

ANS: A Feedback A The infant's heart rate is above the lower limit for which the medication is held. The dose can be given. p. 1084

What is the nurse's first action when planning to teach the parents of an infant with a CHD? a. Assess the parents' anxiety level and readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.

ANS: A Feedback Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing level of anxiety is often needed before new information can be processed. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents' knowledge and readiness. p. 1085

Which drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Captopril (Capoten) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Chlorothiazide (Diuril)

ANS: A Feedback Capoten is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide is a diuretic. p. 1083

A beneficial effect of administering digoxin (Lanoxin) is that it a. Decreases edema b. Decreases cardiac output c. Increases heart size d. Increases venous pressure

ANS: A Feedback Digoxin improves cardiac output, which will lead to decreased edema although it is not a diuretic. It does not increase heart size or increase venous pressure. p. 1083

What intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.

ANS: A Feedback Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Digoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid. p. 1084

A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? a. Polycythemia b. Infection c. Dehydration d. Anemia

ANS: A Feedback Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Infection, dehydration, and anemia are not clinical consequences of cyanosis. p. 1088

In which situation is there a risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling born with Turner syndrome

ANS: A Feedback The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turner syndrome, have a higher incidence of CHD. A family history is not a risk factor. p. 1081

What should the nurse include in discharge teaching as the highest priority for the child with a cardiac dysrhythmia? a. CPR instructions b. Repeating digoxin if the child vomits c. Resting if dizziness occurs d. Checking the child's pulse after digoxin administration

ANS: A Feedback This could potentially be life-saving for the child. The parents and significant others in the child's life should have CPR training. The digoxin dose is not repeated if the child vomits. Dizziness is a symptom the child should be taught to report to adults so that the physician can be notified. It is not the priority intervention. The child's pulse should be counted before the medication is given. The dose is withheld if the pulse is below the parameters set by the physician. p. 1108

Which CHD results in increased pulmonary blood flow? a. Ventricular septal defect b. Coarctation of the aorta c. Tetralogy of Fallot d. Pulmonary stenosis

ANS: A Feedback Ventricular septal defect causes a left-to-right shunting of blood, thus increasing pulmonary blood flow. Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal to distal aorta. The defects associated with tetralogy of Fallot result in a right-to-left shunting of blood, thus decreasing pulmonary blood flow. Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery. Pulmonary blood flow is decreased. p. 1094 | Table 46.3

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count

ANS: A Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

ANS: A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

A client is taking warfarin (Coumadin) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."

ANS: A Many foods and drugs interfere with warfarin, St. John's wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.

A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the client's chart as the only action.

ANS: A Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this client's readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider.

15. A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone (Cordarone) daily to prevent PACs."

ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Blood pressure above the normal range b. Bounding pedal pulses c. Night blindness d. Reflux disease

ANS: A Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

ANS: A The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use? a. Standard Precautions b. Bleeding precautions c. Reverse isolation d. Contact isolation

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions should be used. Bleeding precautions or reverse or contact isolation is not necessary.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

ANS: A The first step is to assess the reason behind the client's fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like "drugs are safer today" do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

13. A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

The patient asks the nurse to explain the sinoatrial node in the heart. The nurse's best response would be, "The sinoatrial node a. provides the heart with the stimulation to beat in a normal rhythm." b. protects the heart from atherosclerotic changes." c. provides the heart with oxygenated blood." d. protects the heart from infection."

ANS: A The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

ANS: A There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

ANS: A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the client's lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

ANS: A This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client's ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

17. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

ANS: A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

19. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

ANS: A, B, C Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, B, C If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.

ANS: A, B, C When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the client's feelings.

3. A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer

ANS: A, B, D Acute pericarditis is most commonly associated acute exacerbations of systemic connective tissue disease, including SLE; with Dressler's syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure ulcers do not increase clients' risk for acute pericarditis.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale

ANS: A, B, D Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

ANS: A, B, D The Heart Failure Core Measure Set includes discharge instructions on diet, activity, medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is usually prescribed for clients who experience a myocardial infarction. Although the nurse may consult the social worker or case manager for additional resources, this is not part of the Core Measures.

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

ANS: A, B, D The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"

ANS: A, B, D To ensure safety upon discharge, the nurse should assess for structural barriers to functional ability, such as stairs. The nurse should also assess the client's available social support, which may include family, friends, and home health services. The client's ability to adhere to medication and treatments, including daily weights, should also be reviewed. The other questions do not address the client's safety upon discharge.

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night

ANS: A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.

2. A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

ANS: A, B, E, F A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is on the high side of normal and the serum creatinine level is normal.

A child has a total cholesterol level of 180 mg/dL. What dietary recommendations should the nurse make to the child and the child's parents? Select all that apply. a. Replace whole milk for 2% or 1% milk. b. Increase servings of red meat. c. Increase servings of fish. d. Avoid excessive intake of fruit juices. e. Limit servings of whole grain.

ANS: A, C, D Feedback Correct A low-fat diet includes using nonfat or low-fat dairy products, limiting red meat intake, and increasing intake of fish, vegetables, whole grains, and legumes. Incorrect Children should avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats. p. 1115

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) a. "Reposition the client every 2 hours." b. "Teach the client to perform deep-breathing exercises." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning." e. "Place the client on oxygen if the client becomes short of breath."

ANS: A, C, D The UAP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The UAP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess the need for and provide oxygen therapy.

A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

ANS: A, C, D, E The Joint Commission's Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.

A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

ANS: A, C, E A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

ANS: A, C, E Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations.

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

ANS: A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

1. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 liters of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."

ANS: A, D, E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client should be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day.

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? a. "Walk until you become short of breath, and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."

ANS: B A client who has heart failure should be taught to conserve energy. Gathering all supplies needed for a chore at one time decreases the amount of energy needed. The client should not walk until becoming short of breath because he or she may not make it back home. Pushing a cart takes less energy than pulling or lifting. Although walking after dinner may help the client, the nurse should teach the client to complete activities when he or she has the most energy. This is usually in the morning.

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.

ANS: B All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client's feelings of control.

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.

ANS: B An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

ANS: B Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

ANS: B Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

ANS: B Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

3. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

2. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

ANS: B A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline.

ANS: B Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures.

The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student states, "Central perfusion a. is monitored only by the physician." b. involves the entire body." c. is decreased with hypertension." d. is toxic to the cardiac system."

ANS: B Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the body's ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "You should balance weight loss with consuming necessary nutrients." c. "A nutritionist will provide you with information about your new diet." d. "If you exercise more frequently, you won't need to change your diet."

ANS: B Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

ANS: B Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." How should the nurse respond? a. "This is a routine surgery and the risk of death is very low." b. "Would you like to speak with a chaplain prior to surgery?" c. "Tell me more about your concerns about the surgery." d. "What support systems do you have to assist you?"

ANS: C The nurse should discuss the client's feelings and concerns related to the surgery. The nurse should not provide false hope or push the client's concerns off on the chaplain. The nurse should address support systems after addressing the client's current issue.

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

ANS: B Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the client's manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a. "I'll be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by my dentist in 2 weeks." c. "I must avoid eating foods high in vitamin K, like spinach." d. "I must use an electric razor instead of a straight razor to shave."

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy should be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

4. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.

The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Educate parents on daily low-dose aspirin regime. b. Prepare to administer indomethacin. c. Administer next dose of enalapril early. d. Position infant in the knee-chest position.

ANS: B Feedback B The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard throughout both systole and diastole. p. 1093 | Table 46.3

An adolescent being seen by the nurse practitioner for a sports physical is identified as having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The initial treatment of secondary hypertension initially involves: a. Weight control and diet b. Treating the underlying disease c. Administration of digoxin d. Administration of beta-adrenergic receptor blockers

ANS: B Feedback Identification and treatment of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are non-pharmacologic treatments for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. Beta-adrenergic receptor blockers may be indicated in the treatment of secondary hypertension, but the main focus is on identifying and treating the underlying cause. p. 1114

The nurse discovers a heart murmur in an infant 1 hour after birth. She is aware that fetal shunts are closed in the neonate at what point? a. When the umbilical cord is cut b. Within several days of birth c. Within a month after birth d. By the end of the first year of life

ANS: B Feedback In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several days to complete. With the neonate's first breath, gas exchange is transferred from the placenta to the lungs. The separation of the fetus from the umbilical cord does not contribute to the establishment of neonatal circulation. p. 1079

In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. B) There is an uncontrolled increase in cardiac output. C) Blood pressure regulation becomes irregular. D) The patient experiences tachycardia and a bounding pulse.

Ans: A Feedback: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.

Before preparing a teaching plan for the parents of an infant with ductus arteriosus, it is important that the nurse understands this condition. Which statement best describes patent ductus arteriosus? a. Patent ductus arteriosus involves a defect that results in a right-to-left shunting of blood in the heart. b. Patent ductus arteriosus involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. c. Patent ductus arteriosus is a stenotic lesion that must be surgically corrected at birth. d. Patent ductus arteriosus causes an abnormal opening between the four chambers of the heart.

ANS: B Feedback Patent ductus arteriosus is failure of the fetal shunt between the aorta and the pulmonary artery to close. Patent ductus arteriosus allows blood to flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. Patent ductus arteriosus is not a stenotic lesion. Patent ductus arteriosus can be closed both medically and surgically. Atrioventricular defect occurs when fetal development of the endocardial cushions is disturbed, resulting in abnormalities in the atrial and ventricular septa and the atrioventricular valves. p. 1093 | Table 46.3

Which strategy is appropriate when feeding the infant with congestive heart failure? a. Continue the feeding until a sufficient amount of formula is taken. b. Limit feeding time to no more than 30 minutes. c. Always bottle feed every 4 hours. d. Feed larger volumes of concentrated formula less frequently.

ANS: B Feedback The infant with congestive heart failure may tire easily, so the feeding should not continue beyond 30 minutes. If inadequate amounts of formula are taken, gavage feedings should be considered. The infant is fed smaller volumes of concentrated formula every 3 hours. p. 1085

A lipid profile has been ordered for a patient who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results? A) As close to the end of the day as possible B) After a meal high in fat C) After a 12-hour fast D) Thirty minutes after a normal meal

Ans: After a 12-hour fast Feedback: Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for the lipid profile should be obtained after a 12-hour fast.

The primary nursing intervention to prevent bacterial endocarditis is a. Institute measures to prevent dental procedures. b. Counsel parents of high-risk children about prophylactic antibiotics. c. Observe children for complications, such as embolism and heart failure. d. Encourage restricted mobility in susceptible children.

ANS: B Feedback The objective of nursing care is to counsel the parents of high-risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Observing children for complications should be done, but maintaining good oral health and prophylactic antibiotics is important. Restricted mobility may or may not be necessary. p. 1105

A child had an aortic stenosis defect surgically repaired 6 months ago. Which antibiotic prophylaxis is indicated for an upcoming tonsillectomy? a. No antibiotic prophylaxis is necessary. b. Amoxicillin is taken orally 1 hour before the procedure. c. Oral penicillin is given for 7 to 10 days before the procedure. d. Parenteral antibiotics are administered for 5 to 7 days after the procedure.

ANS: B Feedback The standard prophylactic agent is amoxicillin given orally 1 hour before the procedure. Antibiotic prophylaxis is indicated for the first 6 months after surgical repair. Antibiotic prophylaxis is not given for 7 to 10 days nor is it given parenterally. p. 1105

What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? a. Recheck the infant's blood pressure. b. Alert the physician. c. Withhold oral feeding. d. Increase the oxygen rate.

ANS: B Feedback These are signs of early congestive heart failure, and the provider should be notified. Rechecking the blood pressure is not necessary. Withholding the infant's feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms, but medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the provider is the priority nursing action. p. 1084

12. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? A) Monitor her blood pressure daily B) Assess her radial pulses daily C) Monitor her weight daily D) Monitor her bowel movements

Ans: C Monitor her weight daily Feedback: To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.

A patient has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the patient for this test, what action should the nurse perform? A) Keep the patient NPO for at least 6 hours prior to the test. B) Establish peripheral IV access. C) Limit the patient's activity for 2 hours before the test. D) Teach the patient to perform incentive spirometry.

Ans: Establish peripheral IV access. Feedback: An IV is necessary if contrast is to be used to enhance the images of the CT. The patient does not need to fast or limit his or her activity. Incentive spirometry is not relevant to this diagnostic test.

10. A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The physician's choice of antibiotics would be primarily based on what diagnostic test? A) Echocardiography B) Blood cultures C) Cardiac aspiration D) Complete blood count

B Feedback: To help determine the causative organisms and the most effective antibiotic treatment for the patient, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. "Cardiac aspiration" is not a diagnostic test.

22. After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98° F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2° F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the client's heart rate.

8. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure.

ANS: B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.

ANS: B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the client's perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. The nurse's primary concern is to monitor for a. mental alertness. b. perfusion. c. pain. d. reaction to medications.

ANS: B Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

ANS: B The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.

10. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I should participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."

ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

21. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.

ANS: B The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

ANS: B The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

ANS: B The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the client's medications.

ANS: B The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's discharge teaching? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection. The medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in heart rate.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

ANS: B Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

As a nurse working in the newborn nursery, you notice an infant who is having circumoral cyanosis. Which CHD do you suspect the child may have? Select all that apply. a. Patent ductus arteriosus (PDA) b. Tetralogy of Fallot c. Pulmonary atresia d. Transposition of the great arteries e. Ventricular septal defect

ANS: B, C, D Feedback Correct: Tetralogy of Fallot is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Pulmonary atresia is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Transposition of the great arteries is a cyanotic lesion with increased pulmonary blood flow. Incorrect: PDA is failure of the fetal shunt between the aorta and the pulmonary artery to close. PDA is not classified as a cyanotic heart disease. Prostaglandin E1 is often given to maintain ductal patency in children with cyanotic heart diseases. VSD is the most common type of cardiac defect. The VSD is a left-to-right shunting defect; however, it may be accompanied by other defects. pp. 1193-1197 | Table 46.3

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

ANS: B, C, D The three E's of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) a. Weight gain b. Night sweats c. Cardiac murmur d. Abdominal bloating e. Osler's nodes

ANS: B, C, E Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise and fatigue, anorexia and weight loss, cardiac murmur, and Osler's nodes on palms of the hands and soles of the feet. Abdominal bloating is a manifestation of heart transplantation rejection.

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

ANS: B, C, E Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

ANS: B, D, E Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

ANS: B, D, E In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

ANS: B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client's blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

7. A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority. x

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

ANS: C A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the client's fluid status. Neurologic changes would take priority.

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How should the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question.

6. A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." How should the nurse respond? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "The provider has prescribed an antacid for you to take every morning." c. "What do you understand about what happened to you?" d. "When did you start experiencing this indigestion?"

ANS: C Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain.

11. A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

16. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

ANS: C Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."

ANS: C Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

The nurse is admitting a child who has been diagnosed with Kawasaki disease. What is the most serious complication for which the nurse should assess in Kawasaki disease? a. Cardiac valvular disease b. Cardiomyopathy c. Coronary aneurysm d. Rheumatic fever

ANS: C Feedback Coronary artery aneurysms are seen in 20% to 25% of children with untreated Kawasaki disease. Cardiac valvular disease can occur in rheumatic fever. Cardiomyopathies are diseases of the heart muscle, which can occur as a result of congenital heart disease, coronary artery disease, or other systemic disease. Rheumatic fever is not a complication of Kawasaki disease. p. 1111

A nurse is teaching an adolescent about primary hypertension. Which statement made by the adolescent indicates an understanding of primary hypertension? a. Primary hypertension should be treated with diuretics as soon as it is detected. b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise.

ANS: C Feedback Primary hypertension in children may be treated with weight reduction and exercise programs. Primary hypertension is usually treated with weight reduction and exercise. If ineffective, pharmacologic intervention may be needed. An exercise program in conjunction with weight reduction can be effective in managing primary hypertension in children. p. 1113

A nurse is conducting a class for nursing students about fetal circulation. Which statement is accurate about fetal circulation and should be included in the teaching session? a. Oxygen is carried to the fetus by the umbilical arteries. b. Blood from the inferior vena cava is shunted directly to the right ventricle through the foramen ovale. c. Pulmonary vascular resistance is high because the lungs are filled with fluid. d. Blood flows from the ductus arteriosus to the pulmonary artery.

ANS: C Feedback Resistance in the pulmonary circulation is very high because the lungs are collapsed and filled with fluid. Oxygen and nutrients are carried to the fetus by the umbilical vein. The inferior vena cava empties blood into the right atrium. The direction of blood flow and the pressure in the right atrium propel most of this blood through the foramen ovale into the left atrium. Most of the blood in the pulmonary artery flows though the ductus arteriosus into the descending aorta. p. 1079

Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

ANS: C Feedback The atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. The other three diseases do not result in increased pulmonary blood flow. p. 1093 | Table 46.3

When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm b. The left arm c. All four extremities d. Both arms while the child is crying

ANS: C Feedback When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease p. 1091 | Table 46.2

A patient was diagnosed with hypertension. The patient asks the nurse how this disease could have happened to them. The nurse's best response is "Hypertension a. happens to everyone sooner or later. Don't be concerned about it." b. can happen from eating a poor diet, so change what you are eating." c. can happen from arterial changes that impede the blood flow." d. happens when people do not exercise, so you should walk every day."

ANS: C Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to everyone. Changing the patient's diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

ANS: C In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."

ANS: C Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem.

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.

ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.

A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, "Perfusion a. is a normal function of the body, and I don't have to be concerned about it." b. is monitored by the physician, and I just follow orders." c. is monitored by vital signs and capillary refill." d. varies as a person ages, so I would expect changes in the body."

ANS: C The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

ANS: C The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.

20. A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first.

A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if what condition occurs? Select all that apply. a. Respiratory rate of 36 at rest b. Appetite slowly increasing c. Temperature above 37.7° C (100° F) d. New, frequent coughing e. Turning blue or bluer than normal

ANS: C, D, E Feedback Correct: The parents should be instructed to notify the physician after their infant's cardiac surgery for a temperature above 37.7° C; new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. Incorrect: A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly. p. 1104 | Patient-Centered Teaching Box

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. "A good abrasive pumice stone will keep my feet soft." b. "I'll always wear shoes if I can buy cheap flip-flops." c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best."

ANS: C, D, E Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and won't offer much protection against injury.

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

ANS: D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

ANS: D All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the client's chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

ANS: D Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

ANS: D Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.

A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. The nurse knows that the patient should be observed for a. tissue ischemia. b. brain malformations. c. intestinal blockage. d. cardiac dysthymia.

ANS: D Cardiac dysthymia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."

ANS: D Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

The nurse is admitting a child to the hospital for a cardiac workup. What is the first step in a cardiac assessment? a. Percussion b. Palpation c. Auscultation d. History and inspection

ANS: D Feedback The assessment should begin with the least threatening interventions—the history and inspection. Assessment progression includes inspection, auscultation, and palpation because each step includes more touching. p. 1089

Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.

ANS: D Feedback The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure. p. 1092

The nurse caring for a child diagnosed with acute rheumatic fever should assess the child for a. Sore throat b. Elevated blood pressure c. Desquamation of the fingers and toes d. Tender, warm, inflamed joints

ANS: D Feedback Arthritis, characterized by tender, warm, erythematous joints, is one of the major manifestations of acute rheumatic fever in the first 1 to 2 weeks of the illness. The child may have had a sore throat previously associated with a group A beta-hemolytic streptococcal infection a few weeks earlier. A sore throat is not a manifestation of rheumatic fever. Hypertension is not associated with rheumatic fever. Desquamation of the fingers and toes is a manifestation of Kawasaki syndrome. p. 1109

A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic? a. Place the infant in a knee-chest position. b. Administer oxygen. c. Administer morphine sulfate. d. Calm the infant.

ANS: D Feedback Calming the crying infant is the first response. An infant with unrepaired tetralogy of Fallot who is crying and agitated may eventually lose consciousness. Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. This should be done after calming the infant. Administering oxygen is indicated after placing the infant in a knee-chest position. Administering morphine sulfate calms the infant and depresses respirations. It may be indicated sometime after the infant has been calmed. p. 1088

A common, serious complication of rheumatic fever is a. Seizures b. Cardiac dysrhythmias c. Pulmonary hypertension d. Cardiac valve damage

ANS: D Feedback Cardiac valve damage is the most significant complication of rheumatic fever. The other three are not common complications of rheumatic fever. p. 1109

Which statement suggests that a parent understands how to correctly administer digoxin? a. "I measure the amount I am supposed to give with a teaspoon." b. "I put the medicine in the baby's bottle." c. "When she spits up right after I give the medicine, I give her another dose." d. "I give the medicine at 8 in the morning and evening every day."

ANS: D Feedback For maximum effectiveness, the medication should be given at the same time every day. The maintenance dose is given in two divided doses daily. To ensure the correct dosage, the medication should be measured with a syringe. To prevent toxicity, the parent should not repeat the dose without contacting the child's physician. p. 1083

Nursing care for the child in congestive heart failure includes a. Counting the number of saturated diapers b. Putting the infant in the Trendelenburg position c. Removing oxygen while the infant is crying d. Organizing care to provide rest periods

ANS: D Feedback Nursing care should be planned to allow for periods of undisturbed rest. Diapers must be weighed for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be administered during stressful periods such as when the child is crying if needed. p. 1084

For what reason might a newborn infant with a cardiac defect, such as coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? a. To decrease inflammation b. To control pain c. To decrease respirations d. To improve oxygenation

ANS: D Feedback Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent. This will improve oxygenation. It is not given for inflammation, pain, or to decrease respirations. p. 1089 | p. 1091 | Table 46.3

What is the most common causative agent of bacterial endocarditis? a. Staphylococcus albus b. Streptococcus hemolyticus c. Staphylococcus albicans d. Streptococcus viridans

ANS: D Feedback S. viridans and S. aureus are the most common causative agents in bacterial (infective) endocarditis. The others are not common causative agents. p. 1104

Which statement made by a parent indicates understanding of restrictions for a child after cardiac surgery? a. "My child needs to get extra rest for a few weeks." b. "My son is really looking forward to riding his bike next week." c. "I'm so glad we can attend religious services as a family this coming Sunday." d. "I am going to keep my child out of daycare for 6 weeks."

ANS: D Feedback Settings where large groups of people are present should be avoided for 4 to 6 weeks after discharge, including day care and other public places such as churches. The child should resume his regular bedtime and sleep schedule after discharge. Due to fatigue, the child may initially need some naps during the day. p. 1104 | Patient-Centered Teaching Box

Which information should be included in the nurse's discharge instructions for a child who underwent a cardiac catheterization earlier in the day? a. Pressure dressing is changed daily for the first week. b. The child may soak in the tub beginning tomorrow. c. Contact sports can be resumed in 2 days. d. The child can return to school on the third day after the procedure.

ANS: D Feedback The child can return to school on the third day after the procedure. It is important to emphasize follow-up with the cardiologist. p. 1092

What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities

ANS: D Feedback The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities. Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation. p. 1091 | Table 46.2

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.

1. A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a. Apply an ice pack to the client's chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

ANS: D Pain from acute pericarditis may worsen when the client lays supine. The nurse should position the client in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain.

18. A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble sleeping at night." How should the nurse respond? a. "I will consult the provider to prescribe a sleep study to determine the problem." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."

ANS: D The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of pushing the client's issues off on a chaplain or psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

ANS: D The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D The vasodilating effects of isosorbide mononitrate frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.

9. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

The nurse is caring for a child with Kawasaki disease. The child weighs 33 pounds. When initiating aspirin therapy, what dose does the nurse prepare to administer? a. 75 mg orally once a day b. 81 mg orally twice a day c. 200 mg three times a day d. 375 mg orally four times a day

ANS: D When initiating aspiring for Kawasaki disease, it is started at the anti-inflammatory dose of 80 to 100 mg/kg divided into four doses a day. This child weighs 15 kg so 100 mg 15 kg = 1500 mg. Divided into four doses is 375 mg four times a day. 75 mg once a day is the maintenance dose used for antiplatelet aggregate purposes. 81 mg a day is the adult antiplatelet aggregate dose. p. 1111

The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? A) Lactated Ringer's B) Albumin C) Dextran D) 3% NaCl

Ans: A Feedback: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer's and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.

The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A) Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock. B) Inform the patient's family immediately that the patient will likely not survive to allow the family time to make plans and move forward. C) Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to normal life. D) Protect the patient's airway, optimize intravascular volume, and initiate the early rehabilitation process.

Ans: A Feedback: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Informing the patient's family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues.

A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patient's care? A) Communicate clearly and frequently with the patient's family. B) Taper down interventions slowly when the prognosis worsens. C) Transfer the patient to a subacute unit when recovery appears unlikely. D) Ask the patient's family how they would prefer treatment to proceed.

Ans: A Feedback: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the patient's care, for the family to see, touch, and talk to the patient. The onus should not be placed on the family to guide care, however. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The patient would not be transferred to a subacute unit.

The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The nurse understands that the patient's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? A) Dysrhythmias B) Increase in blood pressure C) Increase in heart rate D) Decrease in oxygen demands

Ans: A Feedback: Cardiogenic shock occurs when the heart's ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenic shock include angina pain and dysrhythmias. Cardiogenic shock does not cause increased blood pressure, increased heart rate, or a decrease in oxygen demands.

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B) The patient is in the progressive stage of shock. C) The patient will stabilize and be released by tomorrow. D) The patient is in the irreversible stage of shock.

Ans: A Feedback: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described "fight or flight" response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patient's chance of survival is low and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patient's plan of care while the patient is ventilated? A) Performing frequent oral care B) Maintaining the patient in a supine position C) Suctioning the patient every 15 minutes unless contraindicated D) Administering prophylactic antibiotics, as ordered

Ans: A Feedback: Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.

The ICU nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock. What nursing action should be prioritized at this point during care? A) Providing information and support to family members B) Preparing the family for a long recovery process C) Educating the patient regarding the use of supportive fluids D) Facilitating the rehabilitation phase of treatment

Ans: A Feedback: Providing information and support to family members is a critical role of the nurse. Most patients with MODS do not recover, so the rehabilitation phase of recovery is not a short-term priority. Educating the patient about the use of supportive fluids is not a high priority.

13. You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient? A) Hypothermia B) Bradycardia C) Coffee ground emesis D) Pain

Ans: A Feedback: Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the patient for cardiovascular overload and pulmonary edema when large volumes of IV solution are administered. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.

14. The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? A) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema D) Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions

Ans: A Feedback: When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patient's response. Reviewing medications, performing a focused cardiovascular assessment, and providing patient education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema are not the priorities for administration of IV vasoactive drugs. Vital signs are taken on a frequent basis when monitoring administration of IV vasoactive drugs, vasoactive medications should be administered through a central venous line, and early discharge instructions would be inappropriate in this time of crisis.

The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The nurse should know that vasoactive medications should be administered in what way? A) Through a central venous line B) By a gravity infusion IV set C) By IV push for rapid onset of action D) Mixed with parenteral feedings to balance osmosis

Ans: A Feedback: Whenever possible, vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.

A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response? A) "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia" B) "To detect and treat bradycardia, which is an excessively slow heart rate" C) "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently" D) "To shock your heart if you have a heart attack at home"

Ans: A "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia" Feedback: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia.

The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient? A) A beta-adrenergic blocker B) An antiplatelet aggregator C) A calcium channel blocker D) A nonsteroidal anti-inflammatory drug (NSAID)

Ans: A A beta-adrenergic blocker Feedback: Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.

A cardiac patient's resistance to left ventricular filling has caused blood to back up into the patient's circulatory system. What health problem is likely to result? A) Acute pulmonary edema B) Right-sided HF C) Right ventricular hypertrophy D) Left-sided HF

Ans: A Acute pulmonary edema Feedback: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.

A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A) Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B) Administer atropine as a continuous infusion until symptoms resolve. C) Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D) Administer atropine 1.0 mg sublingually.

Ans: A Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. Feedback: Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed options are inappropriate.

The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF? A) An S3 heart sound B) Pleural friction rub C) Faint breath sounds D) A heart murmur

Ans: A An S3 heart sound Feedback: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.

A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patient's health history creates a heightened risk of intracardiac thrombi? A) Atrial fibrillation B) Infective endocarditis C) Recurrent pneumonia D) Recent surgery

Ans: A Atrial fibrillation Feedback: Intracardiac thrombi are especially common in patients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.

The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the step-down unit should prioritize what assessment? A) Cardiac monitoring B) Monitoring the implanted device signal C) Pain assessment D) Monitoring the patient's level of consciousness (LOC)

Ans: A Cardiac monitoring Feedback: Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device.

The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? A) Confusion and bradycardia B) Uncontrolled diuresis and tachycardia C) Numbness and tingling in the extremities D) Chest pain and shortness of breath

Ans: A Confusion and bradycardia Feedback: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention? A) Defibrillation B) ECG monitoring C) Implantation of a cardioverter defibrillator D) Angioplasty

Ans: A Defibrillation Feedback: Any type of VT in a patient who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia.

The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document? A) ECG to compare time of onset of VT and onset of device's shock B) ECG so physician can see what type of dysrhythmia the patient has C) Patient's level of consciousness (LOC) at the time of the dysrhythmia D) Patient's activity at time of dysrhythmia

Ans: A ECG to compare time of onset of VT and onset of device's shock Feedback: If the patient has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.

A patient with a diagnosis of HF is started on a beta-blocker. What is the nurse's priority role during gradual increases in the patient's dose? A) Educating the patient that symptom relief may not occur for several weeks B) Stressing that symptom relief may take up to 4 months to occur C) Making adjustments to each day's dose based on the blood pressure trends D) Educating the patient about the potential changes in LOC that may result from the drug

Ans: A Educating the patient that symptom relief may not occur for several weeks Feedback: An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.

The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards, the nurse should anticipate the administration of what medication? treatment is what? A) Epinephrine 1 mg IV push B) Lidocaine 100 mg IV push C) Amiodarone 300 mg IV push D) Sodium bicarbonate 1 amp IV push

Ans: A Epinephrine 1 mg IV push Feedback: Epinephrine should be administered as soon as possible after the first unsuccessful defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and licocaine are given if ventricular dysrhythmia persists.

The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patient's sensorium and LOC. Why is the assessment of the patient's sensorium and LOC important in patients with HF? A)HF ultimately affects oxygen transportation to the brain. B) Patients with HF are susceptible to overstimulation of the sympathetic nervous system. C) Decreased LOC causes an exacerbation of the signs and symptoms of HF. D) The most significant adverse effect of medications used for HF treatment is altered LOC.

Ans: A HF ultimately affects oxygen transportation to the brain. Feedback: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular.

A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? A) In a high Fowler's position B) On the left side-lying position C) In a flat, supine position D) In the Trendelenburg position

Ans: A In a high Fowler's position Feedback: Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.

The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient? A) Insertion of an implantable cardioverter defibrillator B) Insertion of an implantable pacemaker C) Administration of a calcium channel blocker D) Administration of a beta-blocker

Ans: A Insertion of an implantable cardioverter defibrillator Feedback: In patients with severe left ventricular dysfunction and the possibility of life-threatening dysrhythmias, placement of an implantable cardioverter defibrillator (ICD) can prevent sudden cardiac death and extend survival. A pacemaker, a calcium channel blocker, and a beta-blocker are not medical interventions that may extend the survival of the patient with left ventricular dysfunction.

The nurse is providing patient education prior to a patient's discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist? A) Know how to recognize and prevent orthostatic hypotension. B) Weigh yourself weekly at a consistent time of day. C) Measure everything you eat and drink until otherwise instructed. D) Limit physical activity to only those tasks that are absolutely necessary.

Ans: A Know how to recognize and prevent orthostatic hypotension. Feedback: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.

The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do? A) Maintain firm contact between paddles and patient skin. B) Apply a layer of water as a conducting agent. C) Call "all clear" once before discharging the defibrillator. D) Ensure the defibrillator is in the sync mode.

Ans: A Maintain firm contact between paddles and patient skin. Feedback: When defibrillating an adult patient, the nurse should maintain good contact between the paddles and the patient's skin to prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. "Clear" should be called three times before discharging the paddles.

Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following? A) Perform at least 100 chest compressions per minute. B) Pause to allow a colleague to provide a breath every 10 compressions. C) Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D) Perform high-quality chest compressions as rapidly as possible.

Ans: A Perform at least 100 chest compressions per minute. Feedback: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitator's goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10 compressions to allow for a breath or for full vital signs monitoring.

A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurse's best action? A) Rapidly assess the patient's cardiopulmonary status. B) Arrange for an ECG. C) Increase the height of the patient's bed. D) Manage the patient's anxiety.

Ans: A Rapidly assess the patient's cardiopulmonary status. Feedback: Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions may be appropriate and necessary.

The nurse is caring for a patient who has had a biventricular pacemaker implanted. When planning the patient's care, the nurse should recognize what goal of this intervention? A) Resynchronization B) Defibrillation C) Angioplasty D) Ablation

Ans: A Resynchronization Feedback: Biventricular (both ventricles) pacing, also called resynchronization therapy, may be used to treat advanced heart failure that does not respond to medication. This type of pacing therapy is not called defibrillation, angioplasty, or ablation therapy.

A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela? A) Stroke B) Myocardial infarction (MI) C) Hemorrhage D) Peripheral edema

Ans: A Stroke Feedback: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D. A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min

Ans: A The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia. The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis; this type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia; this client may be seen after the client with aortic stenosis.

A patient the nurse is caring for has a permanent pacemaker implanted with the identification code beginning with VVI. What does this indicate? A) Ventricular paced, ventricular sensed, inhibited B) Variable paced, ventricular sensed, inhibited C) Ventricular sensed, ventricular situated, implanted D) Variable sensed, variable paced, inhibit

Ans: A Ventricular paced, ventricular sensed, inhibited Feedback: The identification of VVI indicates ventricular paced, ventricular sensed, inhibited.

A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? A) Blood pressure B) Level of consciousness (LOC) C) Assessment for nausea D) Oxygen saturation

Ans: A Blood pressure Feedback: Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.

A patient is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurse's responsibility in the care of the patient's pacemaker? A) Monitoring for pacemaker malfunction or battery failure B) Determining when it is appropriate to remove the pacemaker C) Making necessary changes to the pacemaker settings D) Selecting alternatives to future pacemaker use

Ans: A Monitoring for pacemaker malfunction or battery failure Feedback: Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The other listed actions are physician responsibilities.

The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A) Recognize that the view of the electrical current changes in relation to the lead placement. B) Recognize that the electrophysiological conduction of the heart differs with lead placement. C) Inform the technician that the ECG equipment has malfunctioned. D) Inform the physician that the patient is experiencing a new onset of dysrhythmia.

Ans: A Recognize that the view of the electrical current changes in relation to the lead placement. Feedback: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment malfunction or dysrhythmias.

The patient has a homocysteine level ordered. What aspects of this test should inform the nurse's care? Select all that apply. A) A 12-hour fast is necessary before drawing the blood sample. B) Recent inactivity can depress homocysteine levels. C) Genetic factors can elevate homocysteine levels. D) A diet low in folic acid elevates homocysteine levels. E) An ECG should be performed immediately before drawing a sample.

Ans: A 12-hour fast is necessary before drawing the blood sample, Genetic factors can elevate homocysteine levels, A diet low in folic acid elevates homocysteine levels Feedback: Genetic factors and a diet low in folic acid, vitamin B6, and vitamin B12 are associated with elevated homocysteine levels. A 12-hour fast is necessary before drawing a blood sample for an accurate serum measurement. An ECG is unnecessary and recent inactivity does not influence the results of the test.

While auscultating a patient's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in what patient? A) An older adult B) A 20-year-old patient C) A patient who has undergone valve replacement D) A patient who takes a beta-adrenergic blocker

Ans: A 20-year-old patient Feedback: S3 represents a normal finding in children and adults up to 35 or 40 years of age. In these cases, it is called a physiologic S3. It is an abnormal finding in a patient with an artificial valve, an older adult, or a patient who takes a beta blocker.

The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? A) A change in position from standing to sitting B) A heart rate of 54 bpm C) A pulse oximetry reading of 94% D) An increase in preload related to ambulation

Ans: A heart rate of 54 bpm Feedback: Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm. An increase in preload will lead to an increase in stroke volume. A pulse oximetry reading of 94% does not indicate hypoxemia, as hypoxia can decrease contractility. Transitioning from standing to sitting would more likely increase rather than decrease cardiac output.

When hemodynamic monitoring is ordered for a patient, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a patient who has such a device in place, the nurse should check which of the following components? Select all that apply. A) A transducer B) A flush system C) A leveler D) A pressure bag E) An oscillator

Ans: A transducer, A flush system, A pressure bag Feedback: To perform hemodynamic monitoring, a CVP, pulmonary artery, or arterial catheter is introduced into the appropriate blood vessel or heart chamber. It is connected to a pressure monitoring system that has several components. Included among these are a transducer, a flush system, and a pressure bag. A pressure monitoring system does not have a leveler or an oscillator.

A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patient's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply. A) Blood urea nitrogen (BUN) level B) Urine specific gravity C) Alkaline phosphatase level D) Creatinine level E) Serum albumin level

Ans: A, B, D Feedback: Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid-base imbalances, and a loss of the renal-hormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function.

The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A) Facilitate the presence of friends and family whenever possible. B) Teach the patient about the harmful effects of anxiety on cardiac function. C) Provide supplemental oxygen, as needed. D) Provide validation of the patient's expressions of anxiety. E) Administer benzodiazepines two to three times daily.

Ans: A, C, D Facilitate the presence of friends and family whenever possible, Provide supplemental oxygen, as needed, Provide validation of the patient's expressions of anxiety Feedback: The nurse should empathically validate the patient's sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.

The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? A) Improve functional status B) Prevent endocarditis. C) Extend survival. D) Limit physical activity. E) Relieve patient symptoms.

Ans: A, C, E Improve functional status, Extend survival, Relieve patient symptoms Feedback: The overall goals of management of HF are to relieve the patient's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.

The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply. A) Drop in systolic blood pressure of ≥40 mm Hg from baselines B) Hypotension that responds to bolus fluid resuscitation C) Exaggerated response to vasoactive medications D) Serum lactate >4 mmol/L E) Mean arterial pressure (MAP) of ˂65 mm Hg

Ans: A, D, E Feedback: Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or mean arterial pressure (MAP) <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.

A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply. A) Anaphylactic B) Hypovolemic C) Cardiogenic D) Septic E) Neurogenic

Ans: A, D, E Feedback: The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.

The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best response? A) "Taking an aspirin every day is an easy way to help restore the normal function of your heart." B) "An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks." C) "Taking an aspirin every day is a simple way to make your blood penetrate your heart more freely." D) "An aspirin a day eventually helps your blood carry more oxygen that it would otherwise."

Ans: An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks. Feedback: An aspirin a day is a common nonprescription medication that improves outcomes in patients with CAD due to its antiplatelet action. It does not affect oxygen carrying capacity or perfusion. Aspirin does not restore cardiac function.

The nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. The nurse is aware that afterload influences a patient's stroke volume. The nurse recognizes that afterload is increased when there is what? A) Arterial vasoconstriction B) Venous vasoconstriction C) Arterial vasodilation D) Venous vasodilation

Ans: Arterial vasoconstriction Feedback: Arterial vasoconstriction increases the systemic vascular resistance, which increases the afterload. Venous vasoconstriction decreases preload thereby decreasing stroke volume. Venous vasodilation increases preload.

The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurse's most recent assessment reveals that CVP is 7 mm Hg. What is the nurse's most appropriate action? A) Arrange for continuous cardiac monitoring and reposition the patient. B) Remove the CVP catheter and apply an occlusive dressing. C) Assess the patient for fluid overload and inform the physician. D) Raise the head of the patient's bed and have the patient perform deep breathing exercise, if possible.

Ans: Assess the patient for fluid overload and inform the physician. Feedback: The normal CVP is 2 to 6 mm Hg. Many problems can cause an elevated CVP, but the most common is due to hypervolemia. Assessing the patient and informing the physician are the most prudent actions. Repositioning the patient is ineffective and removing the device is inappropriate.

A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boy's mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock? A) Rapid onset of acute hypertension B) Rapid onset of respiratory distress C) Rapid onset of neurologic compensation D) Rapid onset of cardiac arrest

Ans: B Feedback: Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur if prompt treatment is not provided.

A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.

Ans: B Feedback: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.

An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize? A) Establishing central venous access and beginning fluid resuscitation B) Establishing a patent airway and beginning cardiopulmonary resuscitation C) Establishing peripheral IV access and administering IV epinephrine D) Performing a comprehensive assessment and initiating rapid fluid replacement

Ans: B Feedback: If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. As well, a patent airway is an immediate priority. Epinephrine is not withheld pending IV access and fluid resuscitation is not a priority.

6. A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? A) Anaphylactic shock B) Neurogenic shock C) Septic shock D) Hypovolemic shock

Ans: B Feedback: Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention? A) Reviewing the cause of shock and prioritizing the patient's psychosocial needs B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C) Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive D) Promoting the patient's coping skills in an effort to better deal with the physiologic changes accompanying shock

Ans: B Feedback: Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.

The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What would be the main challenge in meeting this patient's elevated energy requirements during prolonged rehabilitation? A) Loss of adipose tissue B) Loss of skeletal muscle C) Inability to convert adipose tissue to energy D) Inability to maintain normal body mass

Ans: B Feedback: Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the patient's recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this patient.

An adult patient has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse? A) Providing supervision to home health aides in providing necessary patient care B) Assisting the patient and family to identify and mobilize community resources C) Providing ongoing medical care during the family's rehabilitation phase D) Reinforcing the importance of continuous assessment with the family

Ans: B Feedback: The home care nurse reinforces the importance of continuing medical care and helps the patient and family identify and mobilize community resources. The home health nurse is part of a team that provides patient care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the patient and family, not just the family. The nurse performs continuous and ongoing assessment of the patient; he or she does not just reinforce the importance of that assessment.

A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? A) The drug should be discontinued immediately after blood pressure increases. B) The drug dose should be tapered down once vital signs improve. C) The patient should have arterial blood gases drawn every 10 minutes during treatment. D) The infusion rate should be titrated according the patient's subjective sensation of adequate perfusion.

Ans: B Feedback: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every10-minute draws are not the norm.

New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to explain depolarization. What would be the best answer by the preceptor? A) "Depolarization is the mechanical contraction of the heart muscles." B) "Depolarization is the electrical stimulation of the heart muscles." C) "Depolarization is the electrical relaxation of the heart muscles." D) "Depolarization is the mechanical relaxation of the heart muscles."

Ans: B "Depolarization is the electrical stimulation of the heart muscles." Feedback: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole.

A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurse's nutritional teaching plan has been effective? A) "I will have a ham and cheese sandwich for lunch." B) "I will have a baked potato with broiled chicken for dinner." C) "I will have a tossed salad with cheese and croutons for lunch." D) "I will have chicken noodle soup with crackers and an apple for lunch."

Ans: B "I will have a baked potato with broiled chicken for dinner." Feedback: The patient's choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response? A) "Cardioversion is done on a beating heart; defibrillation is not." B) "The difference is the timing of the delivery of the electric current." C) "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D) "Cardioversion is always attempted before defibrillation because it has fewer risks."

Ans: B "The difference is the timing of the delivery of the electric current." Feedback: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the patient's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first.

A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A) Right-sided heart failure B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock

Ans: B Acute pulmonary edema Feedback: Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.

A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this patient? A) Chest pain B) Bleeding at the implantation site C) Malignant hyperthermia D) Bradycardia

Ans: B Bleeding at the implantation site Feedback: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.

A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A) Decrease SA node conduction B) Control ventricular heart rate C) Improve oxygenation D) Maintain anticoagulation

Ans: B Control ventricular heart rate Feedback: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.

A patient is scheduled for catheter ablation therapy. When describing this procedure to the patient's family, the nurse should address what aspect of the treatment? A) Resetting of the heart's contractility B) Destruction of specific cardiac cells C) Correction of structural cardiac abnormalities D) Clearance of partially occluded coronary arteries

Ans: B Destruction of specific cardiac cells Feedback: Catheter ablation destroys specific cells that are the cause or central conduction route of a tachydysrhythmia. It does not "reset" the heart's contractility and it does not address structural or vascular abnormalities.

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient's diagnosis? A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea

Ans: B Distended neck veins Feedback: Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.

The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? A) Place gel pads over the apex and posterior chest for better conduction. B) Ensure no one is touching the patient at the time shock is delivered. C) Continue to ventilate the patient via endotracheal tube during the procedure. D) Allow at least 3 minutes between shocks.

Ans: B Ensure no one is touching the patient at the time shock is delivered. Feedback: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads, or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the patient's skin to prevent leaking. Second, ensure that no one is in contact with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the patient. Ventilation should be stopped during defibrillation.

When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize? A) Core body temperature B) Heart rate and rhythm C) Blood pressure D) Oxygen saturation level

Ans: B Heart rate and rhythm Feedback: For patients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed.

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? A) Monitor liver function studies B) Monitor for hypotension C) Assess the patient's vitamin D intake D) Assess the patient for hyperkalemia

Ans: B Monitor for hypotension Feedback: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum? A) Skin turgor B) Potassium level C) White blood cell count D) Peripheral pulses

Ans: B Potassium level Feedback: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.

The nurse's comprehensive assessment of a patient who has HF includes evaluation of the patient's hepatojugular reflux. What action should the nurse perform during this assessment? A) Elevate the patient's head to 90 degrees. B) Press the right upper abdomen. C) Press above the patient's symphysis pubis. D) Lay the patient flat in bed.

Ans: B Press the right upper abdomen. Feedback: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.

The nurse is caring for a patient with refractory atrial fibrillation who underwent the maze procedure several months ago. The nurse reviews the result of the patient's most recent cardiac imaging, which notes the presence of scarring on the atria. How should the nurse best respond to this finding? A) Recognize that the procedure was unsuccessful. B) Recognize this as a therapeutic goal of the procedure. C) Liaise with the care team in preparation for repeating the maze procedure. D) Prepare the patient for pacemaker implantation.

Ans: B Recognize this as a therapeutic goal of the procedure. Feedback: The maze procedure is an open heart surgical procedure for refractory atrial fibrillation. Small transmural incisions are made throughout the atria. The resulting formation of scar tissue prevents reentry conduction of the electrical impulse. Consequently, scar formation would constitute a successful procedure. There is no indication for repeating the procedure or implanting a pacemaker.

The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics? A) Avoid drinking fluids for 2 hours after taking the diuretic. B) Take the diuretic in the morning to avoid interfering with sleep. C) Avoid taking the medication within 2 hours consuming dairy products. D) Take the diuretic only on days when experiencing shortness of breath.

Ans: B Take the diuretic in the morning to avoid interfering with sleep. Feedback: Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient's nighttime rest. Discussing the timing of medication administration is especially important for elderly patients who may have urinary urgency or incontinence. The nurse would not teach the patient about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.

Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with heart failure who is receiving dobutamine (Dobutrex) B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea C. Client with pericarditis who has a paradoxical pulse and distended jugular veins D. Client with rheumatic fever who has a new systolic murmur

Ans: B The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the RN.

The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI C) The patient admitted with malignant hypertension D) The patient admitted following a stroke

Ans: B The patient admitted following an MI Feedback: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.

The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient? A) Implanted pacemaker B) Trancutaneous pacemaker C) ICD D) Asynchronous defibrillator

Ans: B Trancutaneous pacemaker Feedback: If a patient suddenly develops a bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief.

The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A) Apply the paddles directly to the patient's skin. B) Use a conducting medium between the paddles and the skin. C) Always use a petroleum-based gel between the paddles and the skin. D) Any available liquid can be used between the paddles and the skin.

Ans: B Use a conducting medium between the paddles and the skin. Feedback: Use multifunction conductor pads or paddles with a conducting medium between the paddles and the skin (the conducting medium is available as a sheet, gel, or paste). Do not use gels or pastes with poor electrical conductivity.

A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply. A) Hypovolemia B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema E) Hypoglycemia

Ans: B, C, D Feedback: Fluid replacement complications can occur, often when large volumes are administered rapidly. Therefore, the nurse monitors the patient closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.

The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply. A)Platelet level B) Fluid status C) Cardiac rhythm D) Action of medications E) Sputum volume

Ans: B, C, D Fluid status, Cardiac rhythm, Action of medications Feedback: The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.

The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock? A) Elevated systolic blood pressure B) Elevated mean arterial pressure (MAP) C) Shallow, rapid respirations D) Bradycardia

Ans: C Feedback: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.

The acute care nurse is providing care for an adult patient who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock? A) Increased hunger B) Decreased thirst C) Decreased urinary output D) Increased capillary perfusion

Ans: C Feedback: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.

The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic shock? A) Hypertension B) Cool, moist skin C) Bradycardia D) Signs of sympathetic stimulation

Ans: C Feedback: In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions? A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B) Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C) Promoting communication with the patient and family along with addressing end-of-life issues D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea

Ans: C Feedback: Promoting communication with the patient and family is a critical role of the nurse with a patient in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patient's wishes. Many cases of MODS result in death and the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the patient.

The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient? A) Anaphylaxis B) Decreased oxygen consumption C) Abdominal compartment syndrome D) Decreased serum osmolality

Ans: C Feedback: Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are administered. The scenario does not describe an antigen-antibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur.

The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patient's nutritional needs. What physiologic process contributes to these increased nutritional needs? A) The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP) B) The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements D) The increase in GI peristalsis during shock and the resulting diarrhea

Ans: C Feedback: Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock? A) Aggressive hypoglycemic control B) Administration of hypertonic IV fluids C) Early provision of nutritional support D) Aggressive antibiotic therapy

Ans: C Feedback: Nutritional support is necessary for all patients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many patients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in patients with septic shock.

The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states? A) Third spacing of fluid B) Dysrhythmias C) Tachycardia D) Gastric hypermotility

Ans: C Feedback: Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.

The nurse in a rural nursing outpost has just been notified that she will be receiving a patient in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the best choice for fluid replacement for this patient is what? A) 5% albumin because it is inexpensive and is always readily available B) Dextran because it increases intravascular volume and counteracts coagulopathy C) Whatever fluid is most readily available in the clinic, due to the nature of the emergency D) Lactated Ringer's solution because it increases volume, buffers acidosis, and is the best choice for patients with liver failure

Ans: C Feedback: The best fluid to treat shock remains controversial. In emergencies, the "best" fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume. There is no consensus regarding whether crystalloids or colloids, such as dextran and albumin, should be used; however, with crystalloids, more fluid is necessary to restore intravascular volume. Albumin is very expensive and is a blood product so it is not always readily available for use. Dextran does increase intravascular volume, but it increases the risk for coagulopathy. Lactated Ringer's is a good solution choice because it increases volume and buffers acidosis, but it should not be used in patients with liver failure because the liver is unable to covert lactate to bicarbonate.

The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patient's medical history, what is a potential primary cause of the patient's heart failure? A) Endocarditis B) Pleural effusion C) Atherosclerosis D) Atrial-septal defect

Ans: C Atherosclerosis Feedback: Atherosclerosis of the coronary arteries is the primary cause of HF. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of HF.

During a patient's care conference, the team is discussing whether the patient is a candidate for cardiac conduction surgery. What would be the most important criterion for a patient to have this surgery? A) Angina pectoris not responsive to other treatments B) Decreased activity tolerance related to decreased cardiac output C) Atrial and ventricular tachycardias not responsive to other treatments D) Ventricular fibrillation not responsive to other treatments

Ans: C Atrial and ventricular tachycardias not responsive to other treatments Feedback: Cardiac conduction surgery is considered in patients who do not respond to medications and antitachycardia pacing. Angina, reduced activity tolerance, and ventricular fibrillation are not criteria.

The nurse is planning discharge teaching for a patient with a newly inserted permanent pacemaker. What is the priority teaching point for this patient? A) Start lifting the arm above the shoulder right away to prevent chest wall adhesion. B) Avoid cooking with a microwave oven. C) Avoid exposure to high-voltage electrical generators. D) Avoid walking through store and library antitheft devices.

Ans: C Avoid exposure to high-voltage electrical generators. Feedback: High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows patients to safely use most household electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so patients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function.

The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure? A) Jugular vein distention B) Right upper quadrant pain C) Bibasilar fine crackles D) Dependent edema

Ans: C Bibasilar fine crackles Feedback: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication? A) Pulmonary edema B) Pericardiocentesis C) Cardiac tamponade D) Pericarditis

Ans: C Cardiac tamponade Feedback: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiological process.

The nurse is caring for a patient who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? A) Increased blood pressure B) Bounding peripheral pulses C) Changes in level of consciousness D) Skin flushing

Ans: C Changes in level of consciousness Feedback: The nurse conducts a physical assessment to confirm the data obtained from the history and to observe for signs of diminished cardiac output (CO) during the dysrhythmic event, especially changes in level of consciousness. Blood pressure tends to decrease with lowered CO and bounding peripheral pulses are inconsistent with this problem. Pallor, not skin flushing, is expected.

The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs? A) Loop diuretic and antiplatelet aggregator B) Loop diuretic and calcium channel blocker C) Combination of hydralazine and isosorbide dinitrate D) Combination of digoxin and normal saline

Ans: C Combination of hydralazine and isosorbide dinitrate Feedback: A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.

A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the patient's care? A) Ablate the area causing the dysrhythmia. B) Freeze hypersensitive cells. C) Diagnose the dysrhythmia. D) Determine the nursing plan of care.

Ans: C Diagnose the dysrhythmia. Feedback: A patient may undergo an EP study in which electrodes are placed inside the heart to obtain an intracardiac ECG. This is used not only to diagnose the dysrhythmia but also to determine the most effective treatment plan. However, because an EP study is invasive, it is performed in the hospital and may require that the patient be admitted.

An adult patient with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A) PP interval and RR interval are irregular. B) PP interval is equal to RR interval. C) Fewer QRS complexes than P waves D) PR interval is constant.

Ans: C Fewer QRS complexes than P waves Feedback: In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes are not consistent with this diagnosis.

The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient? A) Maintain a resting heart rate below 70 bpm. B) Maintain adequate control of chest pain. C) Maintain adequate cardiac output. D) Maintain normal cardiac structure.

Ans: C Maintain adequate cardiac output. Feedback: For patient safety, the most appropriate goal is to maintain cardiac output to prevent worsening complications as a result of decreased cardiac output. A resting rate of less than 70 bpm is not appropriate for every patient. Chest pain is more closely associated with acute coronary syndrome than with dysrhythmias. Nursing actions cannot normally influence the physical structure of the heart.

The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? A) Pericarditis B) Cardiomyopathy C) Pulmonary edema D) Right ventricular hypertrophy

Ans: C Pulmonary edema Feedback: As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patient's hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.

The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action? A) Lay the patient flat. B) Notify the family of the patient's critical state. C) Stay with the patient. D) Update the physician.

Ans: C Stay with the patient. Feedback: Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to relieve dyspnea. The family should be informed, but this is not the priority action.

The nurse is caring for a patient who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment? A) Assessing the patient's activity level B) Facilitating transthoracic echocardiography C) Vigilant monitoring of the patient's ECG D) Close monitoring of the patient's peripheral perfusion

Ans: C Vigilant monitoring of the patient's ECG Feedback: After a permanent electronic device (pacemaker or ICD) is inserted, the patient's heart rate and rhythm are monitored by ECG. This is a priority over peripheral circulation and activity. Echocardiography is not indicated.

A patient has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this patient's care, what nursing diagnosis is most appropriate? A) Acute pain B) Risk for unilateral neglect C) Risk for activity intolerance D) Risk for fluid volume excess

Ans: C Risk for activity intolerance Feedback: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature.

The nurse is caring for a patient admitted with angina who is scheduled for cardiac catheterization. The patient is anxious and asks the reason for this test. What is the best response? A) "Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are." B) "Cardiac catheterization is most commonly done to detect how efficiently a patient's heart muscle contracts." C) "Cardiac catheterization is usually done to evaluate cardiovascular response to stress." D) "Cardiac catheterization is most commonly done to evaluate cardiac electrical activity."

Ans: Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are. Feedback: Cardiac catheterization is usually used to assess coronary artery patency to determine if revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after stress. An ECG shows the electrical activity of the heart.

The nurse is caring for an acutely ill patient who has central venous pressure monitoring in place. What intervention should be included in the care plan of a patient with CVP in place? A) Apply antibiotic ointment to the insertion site twice daily. B) Change the site dressing whenever it becomes visibly soiled. C) Perform passive range-of-motion exercises to prevent venous stasis. D) Aspirate blood from the device once daily to test pH.

Ans: Change the site dressing whenever it becomes visibly soiled. Feedback: Gauze dressings should be changed every 2 days or transparent dressings at least every 7 days and whenever dressings become damp, loosened, or visibly soiled. Passive ROM exercise is not indicated and it is unnecessary and inappropriate to aspirate blood to test it for pH. Antibiotic ointments are contraindicated.

The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A) Increased urine output B) Decreased heart rate C) Hyperactive bowel sounds D) Cool, clammy skin

Ans: D Feedback: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patient's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring? A) Urinary output increases B) Skin becomes warm and dry C) Adventitious lung sounds occur in the upper airway D) Heart and respiratory rates are elevated

Ans: D Feedback: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the patient begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., renal failure, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock? A) Apply an antibiotic ointment to the patient's mucous membranes, as ordered. B) Perform passive range-of-motion exercises unless contraindicated C) Initiate total parenteral nutrition (TPN) D) Remove invasive devices as soon as they are no longer needed

Ans: D Feedback: Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.

The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient? A) It promotes coping and slows catecholamine release. B) It stimulates the patient so he or she is more alert. C) It decreases gastric secretions. D) It dilates the blood vessels.

Ans: D Feedback: For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patient's anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.

In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the body's needs? A) It slows the proliferation of bacteria and viruses during shock. B) It decreases the energy expended through the functioning of the GI system. C) It assists in expanding the intravascular volume of the body. D) It promotes GI function through direct exposure to nutrients.

Ans: D Feedback: Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition is preferred, promoting GI function through direct exposure to nutrients and limiting infectious complications associated with parenteral feeding. Enteral feeding does not decrease the proliferation of microorganisms or the amount of energy expended through the functioning of the GI system and it does not assist in expanding the intravascular volume of the body.

When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the pooling of blood in the periphery leads to what pathophysiological effect? A) Increased stroke volume B) Increased cardiac output C) Decreased heart rate D) Decreased venous return

Ans: D Feedback: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.

When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? A) Provide a detailed diagnosis and plan of care in order to promote the patient's and family's coping. B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

Ans: D Feedback: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the patient the best chance for survival. Monitoring for significant changes is critical, and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? A) To prevent the formation of infarcts of emboli B) To limit stroke volume and cardiac output C) To prevent pulmonary and peripheral edema D) To maintain adequate mean arterial pressure

Ans: D Feedback: Vasoactive medications can be administered in all forms of shock to improve the patient's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.

The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient states that she is nervous about "things going wrong" during the procedure. What is the nurse's best response? A) "This is basically a risk-free procedure." B) "Thousands of patients undergo EP every year." C) "Remember that this is a step that will bring you closer to enjoying good health." D) "The whole team will be monitoring you very closely for the entire procedure."

Ans: D "The whole team will be monitoring you very closely for the entire procedure." Feedback: Patients who are to undergo an EP study may be anxious about the procedure and its outcome. A detailed discussion involving the patient, the family, and the electrophysiologist usually occurs to ensure that the patient can give informed consent and to reduce the patient's anxiety about the procedure. It is inaccurate to state that EP is "risk-free" and stating that it is common does not necessarily relieve the patient's anxiety. Characterizing EP as a step toward good health does not directly address the patient's anxiety.

When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? A) A diastolic blood pressure that is lower during exhalation B) A diastolic blood pressure that is higher during inhalation C) A systolic blood pressure that is higher during exhalation D) A systolic blood pressure that is lower during inhalation

Ans: D A systolic blood pressure that is lower during inhalation Feedback: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.

The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? A) Pulseless electrical activity (PEA) B) Ventricular fibrillation C) Ventricular tachycardia D) Asystole

Ans: D Asystole Feedback: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.

The nurse is reviewing a newly admitted patient's electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated? A) Teach the patient deep breathing and coughing exercises. B) Administer supplemental oxygen at all times. C) Limit the patient's activity level. D) Avoid positioning the patient supine.

Ans: D Avoid positioning the patient supine. Feedback: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and, consequently, the nurse should avoid positioning the patient supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.

Following cardiac resuscitation, a patient has been placed in a state of mild hypothermia before being transferred to the cardiac intensive care unit. The nurse's assessment reveals that the patient is experiencing neuromuscular paralysis. How should the nurse best respond? A) Administer hypertonic IV solution. B) Administer a bolus of warned normal saline. C) Reassess the patient in 15 minutes. D) Document this as an expected assessment finding

Ans: D Document this as an expected assessment finding. Feedback: The nurse caring for a patient with hypothermia (passive or induced) needs to monitor for appropriate level of cooling, sedation, and neuromuscular paralysis to prevent seizures; myoclonus; and shivering. Neuromuscular paralysis is an expected finding and does not necessitate further interventions.

An ECG has been ordered for a newly admitted patient. What should the nurse do prior to electrode placement? A) Clean the skin with providone-iodine solution. B) Ensure that the area for electrode placement is dry. C) Apply tincture of benzoin to the electrode sites and wait for it to become "tacky." D) Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

Ans: D Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth. Feedback: An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. The abrading of skin will enhance signal transmission. Disinfecting the skin is unnecessary and conduction gel is used.

The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first? A) Check for a carotid pulse. B) Apply supplemental oxygen. C) Give two full breaths. D) Gently shake and shout, "Are you OK?"

Ans: D Gently shake and shout, "Are you OK?" Feedback: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.

A cardiac care nurse is aware of factors that result in positive chronotropy. These factors would affect a patient's cardiac function in what way? A) Exacerbating an existing dysrhythmia B) Initiating a new dysrhythmia C) Resolving ventricular tachycardia D) Increasing the heart rate

Ans: D Increasing the heart rate Feedback: Stimulation of the sympathetic system increases heart rate. This phenomenon is known as positive chronotropy. It does not influence dysrhythmias.

The nurse is assessing a patient who had a pacemaker implanted 4 weeks ago. During the patient's most recent follow-up appointment, the nurse identifies data that suggest the patient may be socially isolated and depressed. What nursing diagnosis is suggested by these data? A) Decisional conflict related to pacemaker implantation B) Deficient knowledge related to pacemaker implantation C) Spiritual distress related to pacemaker implantation D) Ineffective coping related to pacemaker implantation

Ans: D Ineffective coping related to pacemaker implantation Feedback: Depression and isolation may be symptoms of ineffective coping with the implantation. These psychosocial symptoms are not necessarily indicative of issues related to knowledge or decisions. Further data would be needed to determine a spiritual component to the patient's challenges.

A patient calls his cardiologist's office and talks to the nurse. He is concerned because he feels he is being defibrillated too often. The nurse tells the patient to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what? A) Infection B) Failure to capture C) Premature battery depletion D) Oversensing of dysrhythmias

Ans: D Oversensing of dysrhythmias Feedback: Inappropriate delivery of ICD therapy, usually due to oversensing of atrial and sinus tachycardias with a rapid ventricular rate response, is the most frequent complication of ICD. Infections, failure to capture, and premature battery failure are less common.

An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patient's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient's subsequent care, what nursing diagnosis should be identified? A) Risk for ineffective tissue perfusion related to dysrhythmia B) Risk for fluid volume excess related to medication regimen C) Risk for ineffective breathing pattern related to hypoxia D) Risk for falls related to hypotension

Ans: D Risk for falls related to hypotension Feedback: The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patient's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.

The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patient's risk for heart failure (HF)? A) The patient takes Lasix (furosemide) 20 mg/day. B) The patient's potassium level is 4.7 mEq/L. C) The patient is an African American man. D) The patient's age is greater than 65.

Ans: D The patient's age is greater than 65. Feedback: HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physician's office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for HF. The fact that the patient takes Lasix 20 mg/day does not indicate an increased risk for HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate an increased risk for HF.

A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments? A) They are the part of an ECG that reflects systole. B) They are the part of an ECG used to calculate ventricular rate and rhythm. C) They are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D) They are the part of an ECG that represents early ventricular repolarization.

Ans: D They are the part of an ECG that represents early ventricular repolarization. Feedback: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval.

A nurse is providing health education to a patient scheduled for cryoablation therapy. The nurse should describe what aspect of this treatment? A) Peeling away the area of endocardium responsible for the dysrhythmia B) Using electrical shocks directly to the endocarduim to eliminate the source of dysrhythmia C) Using high-frequency sound waves to eliminate the source of dysrhythmia D) Using a cooled probe to eliminate the source of dysrhythmia

Ans: D Using a cooled probe to eliminate the source of dysrhythmia Feedback: Cryoablation therapy involves using a cooled probe to create a small scar on the endocardium to eliminate the source of the dysrhythmias. Endocardium resection involves peeling away a specified area of the endocardium. Electrical ablation involves using shocks to eliminate the area causing the dysrhythmias. Radio frequency ablation uses high-frequency sound waves to destroy the area causing the dysrhythmias.

The nurse is caring for a patient on telemetry. The patient's ECG shows a shortened PR interval, slurring of the initial QRS deflection, and prolonged QRS duration. What does this ECG show? A) Sinus bradycardia B) Myocardial infarction C) Lupus-like syndrome D) Wolf-Parkinson-White (WPW) syndrome

Ans: D Wolf-Parkinson-White (WPW) syndrome Feedback: In WPW syndrome there is a shortened PR interval, slurring (called a delta wave) of the initial QRS deflection, and prolonged QRS duration. These characteristics are not typical of the other listed cardiac anomalies.

The nurse is relating the deficits in a patient's synchronization of the atrial and ventricular events to his diagnosis. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization? Select all that apply. A) Loop connectivity B) Excitability C) Automaticity D) Conductivity E) Independence

Ans: Excitability, Automaticity, Conductivity Feedback: Three physiologic characteristics of two types of specialized electrical cells, the nodal cells and the Purkinje cells, provide this synchronization: automaticity, or the ability to initiate an electrical impulse; excitability, or the ability to respond to an electrical impulse; and conductivity, the ability to transmit an electrical impulse from one cell to another. Loop connectivity is a distracter for this question. Independence of the cells has nothing to do with the synchronization described in the scenario.

A patient is brought into the ED by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain. The care team recognizes the need to monitor the patient's cardiac function closely while interventions are performed. What form of monitoring should the nurse anticipate? A) Left-sided heart catheterization B) Cardiac telemetry C) Transesophageal echocardiography D) Hardwire continuous ECG monitoring

Ans: Hardwire continuous ECG monitoring Feedback: Two types of continuous ECG monitoring techniques are used in health care settings: hardwire cardiac monitoring, found in EDs, critical care units, and progressive care units; and telemetry, found in general nursing care units or outpatient cardiac rehabilitation programs. Cardiac catheterization and transesophageal echocardiography would not be used in emergent situations to monitor cardiac function.

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult patient who has been experienced vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis? A) Pleurisy B) Heart failure C) Valve dysfunction D) Cardiomyopathy

Ans: Heart failure Feedback: The level of BNP in the blood increases as the ventricular walls expand from increased pressure, making it a helpful diagnostic, monitoring, and prognostic tool in the setting of HF. It is not specific to cardiomyopathy, pleurisy, or valve dysfunction.

The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patient's CVP is increasing. Of what may this indicate? A) Psychosocial stress B) Hypervolemia C) Dislodgment of the catheter D) Hypomagnesemia

Ans: Hypervolemia Feedback: CVP is a useful hemodynamic parameter to observe when managing an unstable patient's fluid volume status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility. Stress, dislodgement of the catheter, and low magnesium levels would not typically result in increased CVP.

The nurse is conducting patient teaching about cholesterol levels. When discussing the patient's elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what? A) "Increased LDL and decreased HDL increase my risk of coronary artery disease." B) "Increased LDL has the potential to decrease my risk of heart disease." C) "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls." D) "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."

Ans: Increased LDL and decreased HDL increase my risk of coronary artery disease. Feedback: Elevated LDL levels and decreased HDL levels are associated with a greater incidence of coronary artery disease.

The physician has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a patient. The results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis? A) Immunosuppression B) Inflammation C) Infection D) Hemostasis

Ans: Inflammation Feedback: High-sensitivity CRP is a protein produced by the liver in response to systemic inflammation. Inflammation is thought to play a role in the development and progression of atherosclerosis.

A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the nurse perform? A) Instruct the patient to drink 1 liter of water before the test. B) Administer IV benzodiazepines and opioids. C) Inform the patient that she will remain on bed rest following the procedure. D) Inform the patient that an access line will be initiated in her femoral artery.

Ans: Inform the patient that she will remain on bed rest following the procedure. Feedback: During the recovery period, the patient must maintain bed rest with the head of the bed elevated to 45 degrees. The patient must be NPO 6 hours preprocedure. The patient is sedated to make him or her comfortable, but will not be heavily sedated, and opioids are not necessary. Also, the patient will have a peripheral IV line initiated preprocedure.

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A) Left midclavicular line of the chest at the level of the nipple B) Left midclavicular line of the chest at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum

Ans: Left midclavicular line of the chest at the fifth intercostal space Feedback: The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.

A critical care nurse is caring for a patient with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill patients? A) Pulmonary artery systolic pressure B) Right ventricular afterload C) Pulmonary artery pressure D) Left ventricular preload

Ans: Left ventricular preload Feedback: Monitoring of the pulmonary artery diastolic and pulmonary artery wedge pressures is particularly important in critically ill patients because it is used to evaluate left ventricular filling pressures (i.e., left ventricular preload). This device does not directly measure the other listed aspects of cardiac function.

The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? A) Development of an atrial-septal defect B) Myocardial ischemia C) Formation of a pulmonary embolism D) Release of potassium ions from cardiac cells

Ans: Myocardial ischemia Feedback: Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Patients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital.

The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.) A) Need for careful monitoring for cardiac symptoms B) Need for carefully regulated exercise C) Need for dietary modifications D) Need for early resumption of prediagnosis activity E) Need for increased fluid intake

Ans: Need for careful monitoring for cardiac symptoms, Need for carefully regulated exercise, Need for dietary modifications Feedback: Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased.

A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care? A) Fluctuations in core body temperature B) Signs and symptoms of esophageal varices C) Signs and symptoms of compartment syndrome D) Perfusion distal to the insertion site

Ans: Perfusion distal to the insertion site Feedback: The radial artery is the usual site selected. However, placement of a catheter into the radial artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in temperature and the development of esophageal varices or compartment syndrome are not high risks.

The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate? A) Possible hypovolemia B) Possible myocardial infarction (MI) C) Left-sided heart failure D) Aortic valve regurgitation

Ans: Possible hypovolemia Feedback: Hypovolemia may cause a decreased CVP. MI, valve regurgitation and heart failure are less likely causes of decreased CVP.

The critical care nurse is caring for a patient who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the patient's left ventricular function? A) Central venous pressure (CVP) monitoring B) Pulmonary artery pressure monitoring (PAPM) C) Systemic arterial pressure monitoring (SAPM) D) Arterial blood gases (ABG)

Ans: Pulmonary artery pressure monitoring (PAPM) Feedback: PAPM is used to assess left ventricular function. CVP is used to assess right ventricular function; SAPM is used for continual assessment of BP. ABG are used to assess for acidic and alkalotic levels in the blood.

The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patient's plan of care? A) Risk for ineffective breathing pattern related to hypotension B) Risk for falls related to orthostatic hypotension C) Risk for ineffective role performance related to hypotension D) Risk for imbalanced fluid balance related to hemodynamic variability

Ans: Risk for falls related to orthostatic hypotension Feedback: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompanies it. It does not normally affect breathing or fluid balance. The patient's ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety.

The critical care nurse is caring for a patient who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located? A) SA node B) AV node C) Bundle of His D) Purkinje cells

Ans: SA node Feedback: The heart rate is determined by the myocardial cells with the fastest inherent firing rate. Under normal circumstances, the SA node has the highest inherent rate (60 to 100 impulses per minute).

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? A) SA node to bundle of His to AV node to Purkinje fibers B) SA node to AV node to Purkinje fibers to bundle of His C) SA node to bundle of His to Purkinje fibers to AV node D) SA node to AV node to bundle of His to Purkinje fibers

Ans: SA node to AV node to bundle of His to Purkinje fibers Feedback: The normal electrophysiological conduction route is SA node to AV node to bundle of HIS to Purkinje fibers.

The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurse's most appropriate response? A) Administer sublingual nitroglycerin to allow the patient to finish the test. B) Initiate cardiopulmonary resuscitation. C) Administer analgesia and slow the test. D) Stop the test and monitor the patient closely.

Ans: Stop the test and monitor the patient closely. Feedback: Signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs of cardiac or respiratory arrest were evident.

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? A) Systole B) Diastole C) Repolarization D) Ejection fraction

Ans: Systole Feedback: Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of the heart is not diastole (relaxations), ejection fraction (the amount of blood expelled), or repolarization (electrical charging).

A patient's declining cardiac status has been attributed to decreased cardiac action potential. Interventions will be aimed at restoring what aspect of cardiac physiology? A) The cycle of depolarization and repolarization B) The time it takes from the firing of the SA node to the contraction of the ventricles C) The time between the contraction of the atria and the contraction of the ventricles D) The cycle of the firing of the AV node and the contraction of the myocardium

Ans: The cycle of depolarization and repolarization Feedback: This exchange of ions creates a positively charged intracellular space and a negatively charged extracellular space that characterizes the period known as depolarization. Once depolarization is complete, the exchange of ions reverts to its resting state; this period is known as repolarization. The repeated cycle of depolarization and repolarization is called the cardiac action potential.

A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause? A) The pain is worse when the resident inhales deeply. B) The pain occurs immediately following physical exertion. C) The pain is worse when the resident coughs. D) The pain is most severe when the resident moves his upper body.

Ans: The pain occurs immediately following physical exertion. Feedback: Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of chest pain are more closely associated with noncardiac etiologies.

A patient with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the patient in anticipation of this diagnostic procedure? A) The test is noninvasive, and nothing will be inserted into the patient's body. B) The patient's pain will be managed aggressively during the procedure. C) The test will provide a detailed profile of the heart's electrical activity. D) The patient will remain on bed rest for 1 to 2 hours after the test.

Ans: The test is noninvasive, and nothing will be inserted into the patient's body. Feedback: Before transthoracic echocardiography, the nurse informs the patient about the test, explaining that it is painless. The test does not evaluate electrophysiology and bed rest is unnecessary after the procedure.

The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? A) This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B) Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury. C) This is an accurate indicator of myocardial injury. D) This result indicates muscle injury, but does not specify the source.

Ans: This is an accurate indicator of myocardial injury. Feedback: Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.

The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function. What is an additional function of pulmonary artery pressure monitoring systems? A) To assess the patient's response to fluid and drug administration B) To obtain specimens for arterial blood gas measurements C) To dislodge pulmonary emboli D) To diagnose the etiology of chronic obstructive pulmonary disease

Ans: To assess the patient's response to fluid and drug administration Feedback: Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left ventricular function (cardiac output), diagnosing the etiology of shock, and evaluating the patient's response to medical interventions, such as fluid administration and vasoactive medications. Pulmonary artery monitoring is preferred for the patient with heart failure over central venous pressure monitoring. Arterial catheters are useful when arterial blood gas measurements and blood samples need to be obtained frequently. Neither intervention is used to clear pulmonary emboli.

The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment? A) Whether the patient and involved family members understand the role of genetics in the etiology of the disease B) Whether the patient and involved family members understand dietary changes and the role of nutrition C) Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately D) Whether the patient and involved family members understand the importance of social support and community agencies

Ans: Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately Feedback: During the health history, the nurse needs to determine if the patient and involved family members are able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome (ACS) or HF, and seek timely treatment for these symptoms. Each of the other listed topics is valid, but the timely and appropriate response to a cardiac emergency is paramount.

The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult? A) Decreased left ventricular ejection time B) Decreased connective tissue in the SA and AV nodes and bundle branches C) Thinning and flaccidity of the cardiac values D) Widening of the aorta

Ans: Widening of the aorta Feedback: Changes in cardiac structure and function are clearly observable in the aging heart. Aging results in decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, increased connective tissue in the SA and AV nodes and bundle branches, and an increased left ventricular ejection time (prolonged systole).

The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise? A) "Do not exercise unsupervised." B) "Eventually aim to work up to 30 minutes of exercise each day." C) "Slow down if you get dizzy or short of breath." D) "Start your exercise program with high-impact activities."

Ans:B "Eventually aim to work up to 30 minutes of exercise each day." Feedback: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms should prompt the patient to stop exercising, not simply to slow the pace. Low-impact activities should be prioritized.

33. A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patient's medication regimen, what nursing diagnosis should be prioritized? A) Risk for injury B) Risk for infection C) Risk for peripheral neurovascular dysfunction D) Risk for unstable blood glucose

B Feedback: Immunosuppressants decrease the body's ability to resist infections, and a satisfactory balance must be achieved between suppressing rejection and avoiding infection. These drugs do not create a heightened risk of injury, neurovascular dysfunction, or unstable blood glucose levels.

7. A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension. What valvular disorder should the nurse anticipate being diagnosed in this patient? A) Aortic regurgitation B) Mitral stenosis C) Mitral valve prolapse D) Aortic stenosis

B Feedback: The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its usual size. Patients are likely to show progressive fatigue as a result of low cardiac output. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Patients may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections. Pulmonary venous hypertension is not typically caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis.

6. A patient with pericarditis has just been admitted to the CCU. The nurse planning the patient's care should prioritize what nursing diagnosis? A) Anxiety related to pericarditis B) Acute pain related to pericarditis C) Ineffective tissue perfusion related to pericarditis D) Ineffective breathing pattern related to pericarditis

B Feedback: The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment.

3. A patient with hypertrophic cardiomyopathy (HCM) has been admitted to the medical unit. During the nurse's admission interview, the patient states that she takes over-the-counter "water pills" on a regular basis. How should the nurse best respond to the fact that the patient has been taking diuretics? A) Encourage the patient to drink at least 2 liters of fluid daily. B) Increase the patient's oral sodium intake. C) Inform the care provider because diuretics are contraindicated. D) Ensure that the patient's fluid balance is monitored vigilantly.

C Feedback: Diuretics are contraindicated in patients with HCM, so the primary care provider should be made aware. Adjusting the patient's sodium or fluid intake or fluid monitoring does not address this important contraindication.

2. A patient who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following? A) Exposure to immunocompromised individuals B) Future hospital admissions C) Dental procedures D) Live vaccinations

C Feedback: Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to vaccination, future hospital admissions, or exposure to people who are immunosuppressed.

1. A patient with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the patient to exhibit what heart rhythm? A) Ventricular fibrillation (VF) B) Ventricular tachycardia (VT) C) Atrial fibrillation D) Sinus bradycardia

C Feedback: In patients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation. Bradycardia, VF, and VT are not characteristic of this valvular disorder.

24. A patient has been admitted with an aortic valve stenosis and has been scheduled for a balloon valvuloplasty in the cardiac catheterization lab later today. During the admission assessment, the patient tells the nurse he has thoracolumbar scoliosis and is concerned about lying down for any extended period of time. What is a priority action for the nurse? A) Arrange for an alternative bed. B) Measure the degree of the curvature. C) Notify the surgeon immediately. D) Note the scoliosis on the intake assessment.

C Feedback: Most often used for mitral and aortic valve stenosis, balloon valvuloplasty is contraindicated for patients with left atrial or ventricular thrombus, severe aortic root dilation, significant mitral valve regurgitation, thoracolumbar scoliosis, rotation of the great vessels, and other cardiac conditions that require open heart surgery. Therefore notifying the physician would be the priority over further physical assessment. An alternative bed would be unnecessary and documentation is not a sufficient response.

13. The nurse is admitting a patient with complaints of dyspnea on exertion and fatigue. The patient's ECG shows dysrhythmias that are sometimes associated with left ventricular hypertrophy. What diagnostic tool would be most helpful in diagnosing cardiomyopathy? A) Cardiac catheterization B) Arterial blood gases C) Echocardiogram D) Exercise stress test

C Feedback: The echocardiogram is one of the most helpful diagnostic tools because the structure and function of the ventricles can be observed easily. The ECG is also important, and can demonstrate dysrhythmias and changes consistent with left ventricular hypertrophy. Cardiac catheterization specifically addresses coronary artery function and arterial blood gases evaluate gas exchange and acid balance. Stress testing is not normally used to differentiate cardiomyopathy from other cardiac pathologies.

15. A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse's interview is most suggestive of this valvular disorder? A) "I get chest pain from time to time, but it usually resolves when I rest." B) "Sometimes when I'm resting, I can feel my heart skip a beat." C) "Whenever I do any form of exercise I get terribly short of breath." D) "My feet and ankles have gotten terribly puffy the last few weeks."

C Feedback: The first symptom of mitral stenosis is often breathing difficulty (dyspnea) on exertion as a result of pulmonary venous hypertension. Patients with mitral stenosis are likely to show progressive fatigue as a result of low cardiac output. Palpitations occur in some patients, but dyspnea is a characteristic early symptom. Peripheral edema and chest pain are atypical.

37. The nurse is caring for a recent immigrant who has been diagnosed with mitral valve regurgitation. The nurse should know that in developing countries the most common cause of mitral valve regurgitation is what? A) A decrease in gamma globulins B) An insect bite C) Rheumatic heart disease and its sequelae D) Sepsis and its sequelae

C Feedback: The most common cause of mitral valve regurgitation in developing countries is rheumatic heart disease and its sequelae.

18. The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient? A) Absence of complications B) Adherence to the self-care program C) Improved cardiac output D) Increased activity tolerance

C Feedback: The priority nursing diagnosis of a patient with cardiomyopathy would include improved or maintained cardiac output. Regardless of the category and cause, cardiomyopathy may lead to severe heart failure, lethal dysrhythmias, and death. The pathophysiology of all cardiomyopathies is a series of progressive events that culminate in impaired cardiac output. Absence of complications, adherence to the self-care program, and increased activity tolerance should be included in the care plan, but they do not have the priority of improved cardiac output.

34. The nurse is caring for a patient with acute pericarditis. What nursing management should be instituted to minimize complications? A) The nurse keeps the patient isolated to prevent nosocomial infections. B) The nurse encourages coughing and deep breathing. C) The nurse helps the patient with activities until the pain and fever subside. D) The nurse encourages increased fluid intake until the infection resolves.

C Feedback: To minimize complications, the nurse helps the patient with activity restrictions until the pain and fever subside. As the patient's condition improves, the nurse encourages gradual increases of activity. Actions to minimize complications of acute pericarditis do not include keeping the patient isolated. Due to pain, coughing and deep breathing are not normally encouraged. An increase in fluid intake is not always necessary.

25. A patient is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this procedure will affect her busy work schedule. What guidance should the nurse provide to the patient? A) "Patients generally stay in the hospital for 6 to 8 days." B) "Patients are kept in the hospital until they are independent with all aspects of their care." C) "Patients need to stay in the hospital until they regain normal heart function for their age." D) "Patients usually remain at the hospital for 24 to 48 hours."

D Feedback: After undergoing percutaneous balloon valvuloplasty, the patient usually remains in the hospital for 24 to 48 hours. Prediagnosis levels of heart function are not always attainable and the patient does not need to be wholly independent prior to discharge.

31. The nurse is teaching a patient diagnosed with aortic stenosis appropriate strategies for attempting to relieve the symptom of angina without drugs. What should the nurse teach the patient? A) To eat a small meal before taking nitroglycerin B) To drink a glass of milk before taking nitroglycerin C) To engage in 15 minutes of light exercise before taking nitroglycerin D) To rest and relax before taking nitroglycerin

D Feedback: The venous dilation that results from nitroglycerin decreases blood return to the heart, thus decreasing cardiac output and increasing the risk of syncope and decreased coronary artery blood flow. The nurse teaches the patient about the importance of attempting to relieve the symptoms of angina with rest and relaxation before taking nitroglycerin and to anticipate the potential adverse effects. Exercising, eating, and drinking are not recommended prior to using nitroglycerin.

14. The nurse is preparing a patient for cardiac surgery. During the procedure, the patient's heart will be removed and a donor heart implanted at the vena cava and pulmonary veins. What procedure will this patient undergo? A) Orthotopic transplant B) Xenograft C) Heterotropic transplant D) Homograft

A Feedback: Orthotopic transplantation is the most common surgical procedure for cardiac transplantation. The recipient's heart is removed, and the donor heart is implanted at the vena cava and pulmonary veins. Some surgeons still prefer to remove the recipient's heart, leaving a portion of the recipient's atria (with the vena cava and pulmonary veins) in place. Homografts, or allografts (i.e., human valves), are obtained from cadaver tissue donations and are used for aortic and pulmonic valve replacement. Xenografts and heterotropic transplantation are not terms used to describe heart transplantation.

20. A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following? A) The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) B) The need to learn to sleep in a semi-Fowler's position for the first 6 to 8 weeks to prevent emboli C) The need to avoid foods that contain vitamin K D) The need to take enteric-coated ASA on a daily basis

A Feedback: Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.

23. A patient is admitted to the critical care unit (CCU) with a diagnosis of cardiomyopathy. When reviewing the patient's most recent laboratory results, the nurse should prioritize assessment of which of the following? A) Sodium B) AST, ALT, and bilirubin C) White blood cell differential D) BUN

A Feedback: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels. Consequently, sodium levels are followed more closely than other important laboratory values, including BUN, leukocytes, and liver function tests.

27. The patient has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should know that complications following this procedure include what? Select all that apply. A) Emboli B) Mitral valve damage C) Ventricular dysrhythmia D) Atrial-septal defect E) Plaque formation

A, B, C Feedback: Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty.

38. Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient have with mitral valve prolapse? Select all that apply. A) Anxiety B) Fatigue C) Shoulder pain D) Tachypnea E) Palpitations

A, B, E Feedback: Most people who have mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not characteristic symptoms of mitral valve prolapse.

A nurse is caring for a client who weighs 220 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) _____ mg

ANS: 90 mg The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 220 pounds (110 kg), and so will get the maximal dose.

A child who weighs 37 pounds needs a dose of lidocaine prior to cardioversion for ventricular tachycardia. What dose does the nurse prepare to administer? Write your answer using a whole number. _____ mg

ANS: 17 First determine the child's weight in kg: 37/2.2 = 16.6666. Lidocaine is dosed at 1 mg/kg 16.6666 1 = 16.6666. Round up to the nearest whole number = 17 mg.

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

ANS: D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs

ANS: D, E The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding, or provision of breast milk by bottle, for the first 4 to 6 months of life, preferably until the child reaches 1 year of age or beyond. This does not include infants with congenital heart disease who have difficulty maintaining breastfeeding due to poor oxygenation and fatigue. Is this statement true or false?

ANS: F The AAP states that breastfeeding should not be precluded for most high-risk neonates and infants, including those with congenital heart disease. The benefits of breastfeeding these infants includes; higher and more stable oxygen saturation measurements, improved weight gain, and shorter hospital stays.

The nurse is calculating a cardiac patient's pulse pressure. If the patient's blood pressure is 122/76 mm Hg, what is the patient's pulse pressure? A) 46 mm Hg B) 99 mm Hg C) 198 mm Hg D) 76 mm Hg

Ans: 46 mm Hg Feedback: Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46 mm Hg.

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the patient's heart? A) P wave B) T wave C) U wave D) QRS complex

Ans: B Feedback: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex.

The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A) P wave B) T wave C) QRS complex D) U wave

Ans: C QRS complex Feedback: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle.

The nurse has entered a patient's room and found the patient unresponsive and not breathing. What is the nurse's next appropriate action? A) Palpate the patient's carotid pulse. B) Illuminate the patient's call light. C) Begin performing chest compressions. D) Activate the Emergency Response System (ERS).

Ans: D Activate the Emergency Response System (ERS). Feedback: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.

A patient has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. You are aware that the damage occurred where? A) Endocardium B) Pericardium C) Myocardium D) Visceral pericardium

Ans: Myocardium Feedback: The myocardium is the layer of the heart responsible for the pumping action.

A critical care nurse is caring for a patient with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. A) Pneumothorax B) Infection C) Atelectasis D) Bronchospasm E) Air embolism

Ans: Pneumothorax, Infection, Air embolism Feedback: Complications from use of hemodynamic monitoring systems are uncommon, but can include pneumothorax, infection, and air embolism. Complications of hemodynamic monitoring systems do not include atelectasis or bronchospasm.

40. The nurse is auscultating the breath sounds of a patient with pericarditis. What finding is most consistent with this diagnosis? A) Wheezes B) Friction rub C) Fine crackles D) Coarse crackles

B Feedback: A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with pericarditis.

17. The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic regurgitation causes what? A) Cardiac tamponade B) Left ventricular hypertrophy C) Right-sided heart failure D) Ventricular insufficiency

B Feedback: Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood from the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. Aortic regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular insufficiency.

9. The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM? A) Dilated ventricles with atrophy of the ventricles B) Dilated ventricles without hypertrophy of the ventricles C) Dilation and hypertrophy of all four heart chambers D) Dilation of the atria and hypertrophy of the ventricles

B Feedback: DCM is characterized by significant dilation of the ventricles without significant concomitant hypertrophy and systolic dysfunction. The ventricles do not atrophy in patients with DCM.

8. The nurse is caring for a patient with mitral stenosis who is scheduled for a balloon valvuloplasty. The patient tells the nurse that he is unsure why the surgeon did not opt to replace his damaged valve rather than repairing it. What is an advantage of valvuloplasty that the nurse should cite? A) The procedure can be performed on an outpatient basis in a physician's office. B) Repaired valves tend to function longer than replaced valves. C) The procedure is not associated with a risk for infection. D) Lower doses of antirejection drugs are required than with valve replacement.

B Feedback: In general, valves that undergo valvuloplasty function longer than prosthetic valve replacements and patients do not require continuous anticoagulation. Valvuloplasty carries a risk of infection, like all surgical procedures, and it is not performed in a physician's office. Antirejection drugs are unnecessary because foreign tissue is not introduced.

16. The nurse is caring for a patient who is scheduled to undergo mechanical valve replacement. Patient education should include which of the following? A) Use of patient-controlled analgesia B) Long-term anticoagulant therapy C) Steroid therapy D) Use of IV diuretics

B Feedback: Mechanical valves necessitate long-term use of required anticoagulants. Diuretics and steroids are not indicated and patient-controlled analgesia may or may be not be used in the immediate postoperative period.

22. A patient with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the patient's symptoms, the nurse should teach the patient to do which of the following? A) Eat a high-protein, low-carbohydrate diet. B) Avoid activities that cause an increased heart rate. C) Avoid large crowds and public events. D) Perform deep breathing and coughing exercises.

B Feedback: Patients with mitral stenosis are advised to avoid strenuous activities, competitive sports, and pregnancy, all of which increase heart rate. Infection prevention is important, but avoiding crowds is not usually necessary. Deep breathing and coughing are not likely to prevent exacerbations of symptoms and increased protein intake is not necessary.

30. A 17-year-old boy is being treated in the ICU after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. What type of cardiomyopathy is particularly common among young people who appear otherwise healthy? A) Dilated cardiomyopathy (DCM). B) Arrhythmogenic right ventricular cardiomyopathy (ARVC) C) Hypertrophic cardiomyopathy (HCM) D) Restrictive or constrictive cardiomyopathy (RCM)

C Feedback: With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people, including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy.

4. The critical care nurse is caring for a patient who is receiving cyclosporine postoperative heart transplant. The patient asks the nurse to remind him what this medication is for. How should the nurse best respond? A) Azathioprine decreases the risk of thrombus formation. B) Azathioprine ensures adequate cardiac output. C) Azathioprine increases the number of white blood cells. D) Azathioprine minimizes rejection of the transplant.

D Feedback: After heart transplant, patients are constantly balancing the risk of rejection with the risk of infection. Most commonly, patients receive cyclosporine or tacrolimus (FK506, Prograf), azathioprine (Imuran), or mycophenolate mofetil (CellCept), and corticosteroids (prednisone) to minimize rejection. Cyclosporine does not prevent thrombus formation, enhance cardiac output, or increase white cell counts.

5. A patient with a history rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the patient knows the importance of taking which of the following drugs? A) Enoxaparin (Lovenox) B) Metoprolol (Lopressor) C) Azathioprine (Imuran) D) Amoxicillin (Amoxil)

D Feedback: Although rare, bacterial endocarditis may be life-threatening. A key strategy is primary prevention in high-risk patients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic.

28. The nurse is caring for a patient with right ventricular hypertrophy and consequently decreased right ventricular function. What valvular disorder may have contributed to this patient's diagnosis? A) Mitral valve regurgitation B) Aortic stenosis C) Aortic regurgitation D) Mitral valve stenosis

D Feedback: Because no valve protects the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. As a result, the right ventricle must contract against an abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right ventricle fails. None of the other listed valvular disorders has this pathophysiological effect.

21. A nurse is planning discharge health education for a patient who will soon undergo placement of a mechanical valve prosthesis. What aspect of health education should the nurse prioritize in anticipation of discharge? A) The need for long-term antibiotics B) The need for 7 to 10 days of bed rest C) Strategies for preventing atherosclerosis D) Strategies for infection prevention

D Feedback: Patients with a mechanical valve prosthesis (including annuloplasty rings and other prosthetic materials used in valvuloplasty) require education to prevent infective endocarditis. Despite these infections risks, antibiotics are not used long term. Activity management is important, but extended bed rest is unnecessary. Valve replacement does not create a heightened risk for atherosclerosis.

35. A patient who has recently recovered from a systemic viral infection is undergoing diagnostic testing for myocarditis. Which of the nurse's assessment findings is most consistent with myocarditis? A) Sudden changes in level of consciousness (LOC) B) Peripheral edema and pulmonary edema C) Pleuritic chest pain D) Flulike symptoms

D Feedback: The most common symptoms of myocarditis are flulike. Chest pain, edema, and changes in LOC are not characteristic of myocarditis.

Elevated blood pressure in the blood vessels of the lungs is a condition known as PAH or _____________________ __________________ .

Pulmonary hypertension Pulmonary hypertension is diagnosed when the mean arterial pressure exceeds 20 mm Hg (normal is 15 mm Hg). The most common cause of pulmonary hypertension in children is congenital heart disease.