Adult Health - Archer Review (1/8) - Cardiovascular

- Reports of epigastric pain - Reports of shortness of breath - Progressive worsening of symptoms - Reports of dizziness Pale skin and diaphoresis

- Reports of epigastric pain - Reports of shortness of breath - Progressive worsening of symptoms - Reports of dizziness - Pale skin and diaphoresis

Choice D is correct. Coffee contains the stimulant caffeine. It causes vasoconstriction and increased blood pressure. Caffeine is classified as a drug (i.e., a systemic factor) that can cause or contribute to a rhythm disturbance in cardiac or arrhythmia clients. Repeated studies have demonstrated that decaffeinated beverages, including various brands of coffees studies, contain varying amounts of caffeine. In addition to placing the client at risk for adverse cardiac events, the consumption of caffeine also puts the client at risk for inaccurate test results. Therefore, caffeine consumption should be avoided by clients with dysrhythmias (or possible dysrhythmias).

A 45-year-old client is admitted to the medical telemetry unit to observe for possible dysrhythmias. After waking in the morning, the client asks the nurse for coffee. Which of the following would be the best response by the nurse? A. "Hot beverages are not allowed because of the condition of your heart." B. "Coffee is not included in your diet ordered by your health care provider (HCP)." C. "We don't have coffee on the unit. I can bring you some tea if you would like." D. "Currently, you cannot have coffee as it contains caffeine, which can adversely affect your heart."

Choice B is correct. Monitoring the daily weight of the client and noting any changes provides the nurse with a picture of the client's fluid volume status, which is influenced by the client's cardiac output. Weight is the most reliable indicator of fluid gain and loss.

A cardiac intensive care unit nurse is caring for a client who underwent a coronary artery bypass graft (CABG) 24 hours ago. The nursing care plan indicates a nursing diagnosis of "decreased cardiac output related to alterations in cardiac contractility." Based on the formulated nursing diagnosis, which nursing intervention should be implemented in the nursing care plan? A. Monitor the client's arterial blood gas (ABG) continuously. B. Monitor the client's weight daily and calculate the change. C. Administer prescribed opioids. D. Monitor mediastinal chest tubes for hourly output.

Choice C is correct. Turkey breast contains 2.2 grams of saturated fats, 2.1 grams of polyunsaturated fats, and 2.6 grams of monounsaturated fats per 100 grams. It is also a high protein source `with 29 grams per 100 grams.

A client admitted due to emergent hypertension is about to be discharged. The nurse is giving instructions about dietary modifications. Which food choice by the client would indicate an accurate understanding of a low fat, low cholesterol diet? A. Macaroni and cheese B. Fish and chips C. Turkey breast salad D. Pepperoni pizza

Choice A is correct. People with heart failure may improve their symptoms by reducing the amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt. Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup. Patients should be encouraged to follow a low-sodium diet to help manage symptoms of hypertension and to reduce edema. One of the most natural things a patient can do at home is to reduce the amount of sodium intake. They can also eat fresh vegetables rather than canned. If canned vegetables are the only option, the patient should rinse the plants with clean water and cook them with unsalted water.

A client has been placed on a sodium-restricted diet following a myocardial infarction. Which of the following would be the most appropriate meals to suggest? A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. B. Broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk. C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple. D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.

Choice D is correct. For a client with a pacemaker, it is recommended that they talk on their cellular phone opposite of the pulse generator to prevent electromagnetic interference.

A client is being discharged following the insertion of a permanent pacemaker. Which of the following should be included in the client's discharge instructions? A. Air travel will not be possible due to airport screening equipment. B. You will need to discard any radios at home that have antennas. C. Computed tomography (CT) scans are not permitted with this device. D. You should use your cellular phone on the opposite side of the generator.

Choice D is correct. The normal heart rate in an average adult is between 60 to 100 beats per minute. A heart rate less than 60 beats per minute is referred to as bradycardia. Bradycardia can be symptomatic or asymptomatic. Some healthy adults and athletes may have a heart rate between 40 and 60 beats per minute and do not experience any symptoms. When symptomatic, bradycardia can lead to shortness of breath, dizziness, and low blood pressure (hypotension, shock). A patient experiencing symptomatic bradycardia will likely need transcutaneous pacing. In addition, an EKG must be performed to confirm the rhythm. The etiology of bradycardia may vary and include reversible (medications) and irreversible causes (heart blocks). Therefore, one should explore causes, but the priority intervention in a patient experiencing symptoms from bradycardia is to restore the heart rate quickly with transcutaneous pacing and maintain circulation.

A client is currently experiencing bradycardia, low blood pressure, and dizziness. Which of the following does the nurse expect to be ordered? A. Defibrillation B. Digoxin C. Monitor the client closely D. Prepare patient for transcutaneous pacing

Choice A is correct. Congestive heart failure (CHF) is characterized by the heart's inability to pump sufficient blood to meet the body's demands. It can result in fluid overload and increased pressure in the blood vessels. A potential complication in a client with CHF is decreased cardiac output, which can lead to decreased blood pressure. Initially, the blood pressure may increase. However, a complication is decompensation which may cause the compensatory mechanisms to fail.

A client with a history of congestive heart failure is admitted to the intensive care unit with acute exacerbation. Upon assessment of the client's vital signs which finding would indicate a potential complication of heart failure? A. Decrease in blood pressure B. Increase in temperature C. Decrease in respiratory rate D. Increase in blood pressure

Choice B is correct. Herbal supplements are not regulated in the same manner as traditional pharmacy-dispensed medications. Although the use of some herbal supplements may provide some beneficial effects, not all herbal supplements are safe for use. Clients on conventional pharmaceutical therapy (i.e., hypertensive medications) should be discouraged from using herbal supplements, especially those with similar pharmacological effects, as the combination may produce an excessive reaction of unknown interaction effects. The nurse should advise the client to discuss all herbal supplements (regardless of whether they address hypertension or not) with her attending HCP.

A hypertensive client was prescribed antihypertensive medication. The client tells a clinic nurse that she prefers to take an herbal supplement to help lower her blood pressure. Which is the most appropriate response from the nurse? A. Tell the client that herbal supplements are unsafe and should be avoided B. Encourage the client to discuss the use of herbal supplements with her attending health care provider (HCP) C. Teach the client how to take her blood pressure and ask her to monitor it every fifteen minutes D. Tell the client that if she takes the herbal supplement, it will require the nurses to monitor her blood pressure closely

Choice A is correct. Most Chinese Americans maintain a formal distance from others as a form of respect. Often, Chinese Americans are uncomfortable with face-to-face communication, especially when eye contact is direct. Direct and prolonged eye contact is avoided in Chinese culture, as doing so is meant to convey anger and challenge the other person.

A nurse is providing discharge instructions to a Chinese-American client regarding dietary modifications. As the nurse reviews the discharge instructions, the client continuously turns away from the nurse. Which of the following is the most appropriate response by the nurse? A. Continue with the instructions, verify client understanding, and let the client ask questions B. Walk around the client so that the nurse constantly faces the client while maintaining eye-to-eye contact C. Give the client a dietary booklet and let him know you will return later to continue with the instructions D. Emphasize to the client that it is imperative he provides his full attention during the provision of the discharge instructions

Choice A is correct. Based on the assessment information, the nurse can determine the patient is experiencing cardiogenic shock secondary to myocardial infarction. Since cardiogenic trauma occurs as a result of the heart not pumping effectively, the highest priority is to increase cardiac output to ensure adequate tissue perfusion. Cardiac Output = Stroke volume x Heart rate. Medications that improve stroke volume will improve cardiac output in cardiogenic shock. The following agents may be used in the pharmacological management of cardiogenic shock. Inotropes: Positive inotropes strengthen the heart contractility (increase stroke volume). Dobutamine has more beta-adrenergic action than alpha activity. It causes peripheral vasodilation while increasing contractility. But in higher doses, it may increase heart rate and exacerbate myocardial ischemia. Vasopressors: In severe shock, vasopressors (Dopamine, Norepinephrine) maintain blood pressure but decrease blood flow to organs. They increase afterload and reduce cardiac output. However, they may be needed initially to provide hemodynamic support.Dopamine increases myocardial contractility and maintains blood pressure. If dopamine fails to

A patient recovering from myocardial infarction is presenting with heart rate 110 beats per minute, blood pressure 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority? A. Administer medications to increase stroke volume. B. Provide analgesics. C. Obtain a STAT electrocardiogram and troponins. D. Administer fluid replacement to increase blood pressure.

Choice B is correct. Combining condoms and spermicidal contraceptive foam is highly effective in preventing pregnancy. In addition to being easily accessible, this method is also relatively inexpensive (often free if received from a local public health department). This combination is the most appropriate contraceptive method for this client.

A postpartum client is preparing to be discharged home with her full-term newborn. Prior to discharge, the client verbalizes, "I really should not get pregnant again in the next three years so I can finish college." History reveals that she smokes a pack of cigarettes a day. Which method of contraception would be the most appropriate for this client? A. Medroxyprogesterone acetate injectable suspension B. Condoms and spermicidal contraceptive foam C. Natural family planning D. Oral contraceptives

Choice B is correct. The nurse should prioritize assessing the client's vital signs and level of consciousness. This tracing reflects sinus bradycardia. While sinus bradycardia may be benign, if the client should experience unstable blood pressure or dizziness, the nurse will need to act by establishing vascular access and administering atropine. However, this is predicated on the client's overall stability, which can only be discerned by assessment.

An emergency department (ED) nurse establishes continuous cardiac monitoring for a client. The following tracing is observed on the monitor. The nurse should take which initial action? See the image below. A. Establish vascular access and request a prescription for atropine B. Assess the client's blood pressure and level of consciousness C. Obtain and review the client's current medications D. Document the findings and reassess the client in one hour

Acute Coronary Syndrome

Based on the clinical data, which problem is the client most likely experiencing? Pancreatitis Acute Coronary Syndrome Peptic Ulcer Disease Esophagitis

Activated Partial Thromboplastin Time (aPTT) 110 seconds 30-40 seconds

Hemoglobin 12.4 g/dL 12-16 g/dL Platelets 155,000 150,000 - 400,000 International Normalized Ratio (INR) 2.7 0.9-1.2; Rx: 2-3 Activated Partial Thromboplastin Time (aPTT) 110 seconds 30-40 seconds Blood Urea Nitrogen 17 mg/dL 10-20 mg/dL Creatinine 1.0 mg/dL 0.6-1.2 mg/dL

aPTT; weight; platelet count

Prior to administering heparin, the nurse should obtain the client's _____ and _____ While the client is receiving the prescribed heparin, the nurse will also need to monitor the client's _____

Saw Palmetto; vitamin K rich foods; 2-3

Prior to discharge, the nurse should review the client's current medication list for ____ as it could interact with the prescribed warfarin. The dietary education that should be reinforced is that the client should have a consistent intake of _____ The nurse should remind the client that they will need a follow-up appointment to monitor their international normalized ratio (INR) as the treatment goal is for it to be between ____

Blood pressure Dizziness Generalized headache Lower extremity edema

Select four (4) findings from the nurses' notes and vital signs that require follow-up? Blood pressure Heart tones Lung sounds Dizziness Generalized headache Lower extremity edema

venous thromboembolism; venous duplex ultrasonography

The client is at greatest risk for _____ The primary healthcare provider (PHCP) will likely order a _____ to confirm this diagnosis.

atrial fibrillation; irregular pulse

The client is at highest risk of developing ____ as evidenced by ___

cardiac tamponade

The client is at most likely experiencing ___

7 days; low potassium; pulse

The client should be instructed to change the clonidine patch every ____ and apply it to a clean and dry area. Additionally, the client should have a _____ diet while taking the spironolactone and take it in the morning. Finally, the client should be instructed to monitor their ____ while taking the prescribed labetalol.

Choice D is correct. The client's history of congestive heart failure significantly increases the risk for pulmonary edema. The vital signs show respiratory distress (tachypnea, hypoxia, and tachycardia), which supports the complication of pulmonary edema.

The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below. A. Pulmonary embolism B. Hypovolemic shock C. Disseminated intravascular coagulation (DIC) D. Pulmonary edema

Choice C is correct. Based on the information provided, this rhythm is sinus tachycardia. The PR and QRS intervals, as well as the rhythm, are normal. The rate of 105 is high, suggesting tachycardia.

The nurse assessed a client's cardiac rhythm strip. The nurse should plan to document this rhythm as which of the following? See the image below. A. Ventricular fibrillation B. Complete (3rd degree) heart block C. Sinus tachycardia D. Sinus bradycardia

Choice D is correct. Based on the acute symptoms (unilateral leg swelling and tenderness) following a risk factor (a long flight trip), the client has a high clinical probability of deep vein thrombosis (DVT). The gold standard for diagnosing a DVT is venous duplex ultrasonography. This noninvasive test is an ultrasound that assesses the flow of blood through the veins of the arms and legs.

The nurse assesses a client with acute left leg swelling and calf tenderness following a long car ride. The nurse anticipates that the primary healthcare provider (PHCP) will order which diagnostic test? A. D-dimer test B. Ankle-Brachial Index C. Radiograph (X-Ray) D. Venous Duplex Ultrasonography

Shock; heart rate and restlessness

The nurse assesses the client two hours after undergoing percutaneous coronary intervention (PCI) via the femoral artery. The nurse updates the nursing note with the following entry: 2200 - Client was restless and feeling 'not good'. The femoral catheter site remained clean and dry. Extensive bruising noted over the flank area with some induration. Reported no pain. Vital signs obtained and the primary healthcare provider was notified. Vital Signs: Oral temperature 97.0° F (36° C); Pulse 110 bpm; Respirations 19; BP 100/67 mm Hg; Oxygen saturation 95% on room air. Based on the 2200 nurses' notes, complete the sentences below to fill in the blanks The client is showing early signs of _____ based on the _____ and _____

Choice C is correct. Ventricular tachycardia is depicted in this rhythm strip, and the nurse must prioritize this client because of the emergent nature of this dysrhythmia.

The nurse assesses the following electrocardiogram (ECG) strips for assigned clients. The nurse should immediately follow up with the client with which ECG strip?

Choice C is correct. Percutaneous coronary intervention (PCI) is cardiac catheterization that involves the insertion of a large catheter into the femoral or radial artery to access the coronary arteries. A stent may be placed to keep the lumen of the artery open. This test can diagnose narrowing in the coronary arteries and intervene with angioplasty and stenting, if necessary. If this is not available, the physician may order an intravenous thrombolytic to bust the clot in the coronary artery.

The nurse cares for a client with acute myocardial infarction (AMI). The nurse anticipates the physician will order an emergent A. exercise electrocardiography. B. computed tomography (CT) of the chest with contrast. C. percutaneous coronary intervention (PCI). D. echocardiogram.

- Notify the rapid response team (RRT) - Shout for the code cart/defibrillator - Assess the client's carotid pulse and assess if the client is breathing - Start chest compressions at 100 to 120/minute - Provide rescue breaths

The nurse enters a client's room and finds the client lying on the ground. After determining that the client is unresponsive, the nurse should perform which actions? Place the actions the nurse should take in the appropriate order. - Assess the client's carotid pulse and assess if the client is breathing - Start chest compressions at 100 to 120/minute - Notify the rapid response team (RRT) - Shout for the code cart/defibrillator - Provide rescue breaths

Choice B is correct. A transesophageal echocardiogram (TEE) is advantageous because it views the left atrial appendage, which is the major reservoir for thromboembolism. This test may be done before cardioversion to determine if anticoagulation is necessary.

The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching? A. "I will need to take antibiotics for one week following this test." B. "This test will determine if I have any blood clots in my heart." C. "I will receive general anesthesia for this procedure." D. "I may feel a flushing sensation when the contrast dye is given."

Choices A, C, E, and F are correct. Regular physical exercise is important for maintaining cardiovascular health. It helps to strengthen the heart, improve circulation, and control weight. Exercise can also help lower blood pressure and cholesterol levels, reducing the risk of cardiovascular disease. Smoking is a major risk factor for cardiovascular disease. The nurse should educate clients about the harmful effects of smoking on the heart and blood vessels. Encouraging smoking cessation is crucial for reducing the risk of cardiovascular disease. Cholesterol screenings help identify individuals with high cholesterol levels, including elevated levels of low-density lipoprotein (LDL) cholesterol, commonly referred to as "bad" cholesterol. High levels of LDL cholesterol are a significant risk factor for the development of atherosclerosis, the buildup of plaque in the arteries. Identifying high cholesterol levels early allows for early intervention and management.

The nurse in a community-based setting is teaching clients strategies for preventing cardiovascular disease. Which of the following interventions should the nurse include? Select all that apply. - Encouraging regular physical exercise - Promoting a diet high in saturated fats - Advising smoking cessation - Recommend no more than 5 alcoholic drinks a day - Educating about the importance of regular blood pressure monitoring - Instructing on the importance of regular cholesterol screenings.

Choices D and E are correct. Classic manifestations of cardiac tamponade include tachycardia, tachypnea, pericardial rub, jugular venous distention, and hypotension with a narrowed pulse pressure.

The nurse is assessing a client who has developed cardiac tamponade. Which of the following findings would the nurse expect to observe? Select all that apply. bibasilar crackles systolic murmur bradycardia jugular venous distention hypotension

Choice B is correct. An S3 gallop is an expected finding in heart failure. This is often an early manifestation of heart failure; it and this sound are best auscultated at the apex of the heart.

The nurse is assessing a client with congestive heart failure. Which physical assessment finding should the nurse expect? A. Intermittent claudication B. S3 gallop C. Venous stasis ulcers D. Widened pulse pressure

Choices A, B, C, D, and F are correct. Infective endocarditis (IE) is a serious condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other physical manifestations that may be assessed with IE include a cardiac murmur, Janeway lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of feet).

The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply. Fever Night sweats Osler nodes Cardiac murmur Syncope Weight loss

Choice D is correct. Atrial fibrillation is an irregular rhythm because multiple rapid impulses from many areas of the atria result in a fibrillatory line. Atrial fibrillation classically has no p-waves and is irregular.

The nurse is assessing a client's cardiac rhythm strip and notices that it is irregular without any P waves before the QRS complexes. The nurse should interpret this as A. sinus tachycardia. B. sinus bradycardia. C. normal sinus rhythm with premature ventricular contractions (PVC). D. atrial fibrillation

Choice D is correct. With very few exceptions (i.e., an unresponsive client without anyone legally authorized to give it on their behalf, etc.), cardioversion requires informed consent. Prior to any performing procedure requiring informed consent, it is the nurses' responsibility to ensure that the PHCP has obtained the informed consent, the consent form was appropriately witnessed (if the nurse did not serve as the witness themselves), and the informed consent form is located within the client's medical record.

The nurse is assisting the primary health care provider (PHCP) with an elective electrical cardioversion for a chronic atrial fibrillation client. Prior to this procedure, the nurse should perform which action? A. Remove the client's peripheral vascular access device. B. Review the client's risk factors for post-procedure bleeding. C. Ensure that a water-seal chest tube drainage device is readily available. D. Verify that the informed consent has been obtained by the health care provider (HCP).

Choice A is correct. This action is inappropriate. Deep breathing and coughing must be encouraged. However, client may experience severe pain with coughing following CABG. Analgesics should be administered. However, NSAIDs may be unsafe in post-CABG setting due to risk of cardiovascular events and bleeding. In 2005, the Food and Drug Administration (FDA) issued a boxed warning against NSAID administration after coronary artery bypass graft (CABG) surgery. In accordance with this warning, NSAIDS should be avoided. For pain relief, a post-coronary artery bypass graft (CABG) client should receive opioids, not NSAIDs. The only NSAID that's recommended in post-CABG setting is aspirin. Though aspirin is an NSAID, the American Heart Association guidelines recommend giving aspirin within 6 hours after CABG because aspirin reduces thromboses, improves graft patency, and increases long term survival.

The nurse is caring for a client post-coronary artery bypass graft (CABG) and is implementing measures to promote airway clearance related to retained secretions. Which nursing intervention is inappropriate? A. Administering NSAIDs before deep breathing and coughing exercises. B. Splinting the incision site with "heart pillows" or pillows before and during coughing. C. Assisting the client to ambulate as tolerated. D. Teaching the client the correct use of an incentive spirometer.

Choice C is correct. This tracing reflects atrial fibrillation and diltiazem may be used as a treatment. Diltiazem is a calcium channel blocker and may cause the client to develop heart failure because of its negative inotropic and chronotropic effects. An S3 heart sound is one of the earliest manifestations of heart failure. This, combined with pedal edema, supports the nurses' decision to stop this infusion to prevent further clinical deterioration.

The nurse is caring for a client receiving a continuous infusion of diltiazem who has the below tracing on the electrocardiogram (ECG). On assessment, the client has irregular peripheral pulses, an S3 heart sound, and 2+ pedal edema. The nurse should plan to take which priority action? See the image below. A. Assess the client for chest pain B. Perform a 12-lead electrocardiogram C. Stop the infusion D. Obtain an immediate troponin level

Choice B is correct. B-type natriuretic peptide (BNP) is a commonly ordered test for clients who may have heart failure. Elevations indicate worsening of heart failure as it is indicative of fluid retention.

The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis? A. Basic metabolic panel (BMP) B. B-type natriuretic peptide (BNP) C. Lipid profile D. Troponin

Choices A, C, and E are correct. A client presenting with chest pain radiating to the arm warrants immediate intervention as it could be an acute myocardial infarction. The nurse is correct to obtain an electrocardiogram, establish intravenous access, and administer the prescribed nitroglycerin. The physician will likely order a troponin to determine if the myocardium has been insulted by the lack of perfusion. If a client has a confirmed MI, medications such as nitroglycerin, aspirin, and clopidogrel will likely be prescribed.

The nurse is caring for a client who arrives at the emergency department (ED) reporting chest pain radiating to the arm. The nurse should do which of the following? Select all that apply. Obtain an electrocardiogram (ECG) Prepare the client for cardioversion Establish intravenous (IV) access Insert an indwelling urinary catheter Administer prescribed nitroglycerin

Choice A is correct. Variant angina, also known as Prinzmetal's angina, occurs at about the same time every day, usually at rest. Variant angina is treated with calcium channel blockers.

The nurse is caring for a client who was recently admitted to the cardiac floor for angina. This client states that their chest pain occurs at the same time every day at rest. The client does not believe there are any precipitating factors. Which of the following types of angina is this client most likely experiencing? A. Variant angina B. Stable angina C. Unstable angina D. Nonanginal pain

Choices A, B, and C are correct. S1 and S2 are normal heart sounds. These normal heart sounds would still be auscultated in a client with heart failure. S1 is a benign heart sound caused by the closure of the mitral and tricuspid valves. S2 is a benign heart sound produced by the closure of the aortic and pulmonic valves. S3 ("ventricular gallop") and S4 ("atrial gallop") are abnormal heart sounds that can be auscultated in heart failure. Both heart sounds are low-pitched and best heard at the apex, with the patient in the left lateral decubitus position. While S3 may sometimes be heard in healthy hearts (normal in children, pregnant women, and trained athletes), S4 is almost always abnormal. While S3 is a sign of systolic heart failure, S4 is heard in diastolic heart failure. Understanding these two types of congestive heart failure (CHF) is essential before discussing how S3 and S4 are produced. The nurse would expect to hear an S3 heart sound (Choice C) in systolic heart failure. S3 occurs after S2 with the opening of the mitral valve, and a passive flow makes the sound of a large amount of blood hitting a compliant left ventricle. This large amount of blood hitting the left ventricle

The nurse is caring for a client with systolic heart failure. Which of the following heart sounds would the nurse expect to auscultate? Select all that apply. S1 S2 S3 S4 pleural friction rub

Choice D is correct. This tracing reflects sinus bradycardia. Atropine would be clinically indicated if the client was experiencing symptomatic bradycardia. If the client has bradycardia and concurrent dizziness, hypotension, or dyspnea, this calls for treatment with atropine. Atropine must be administered while an emergency (code) cart is nearby.

The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The client reports dyspnea and dizziness. The nurse should obtain a prescription for which medication? See the image below. A. Diltiazem B. Amiodarone C. Labetalol D. Atropine

Choice D is correct. The tracing in the exhibit shows irregularly irregular rhythm with no identifiable p-waves. This rhythm can be identified as "atrial fibrillation." Diltiazem is a calcium channel blocker (CCB) that controls the atrial fibrillation rate. Atrial fibrillation leads to increased ventricular rate and reduced ventricular diastolic filling. If the ventricular rate is uncontrolled, cardiac output is reduced, resulting in hypotension and congestive heart failure. Initial treatment in atrial fibrillation is aimed at ventricular rate control with calcium channel blockers (diltiazem, verapamil), a beta-blocker (atenolol, metoprolol), or digoxin. If the atrial fibrillation remains persistent, cardioversion is considered.

The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The nurse should anticipate which prescription from the primary healthcare provider (PHCP)? See the exhibit. View Exhibit A. captopril B. atropine C. adenosine D. diltiazem

Choice C is correct. This tracing shows atrial fibrillation. Atrial fibrillation is an irregularly irregular arrhythmia that produces an irregular pulse. This pulse irregularity is often a clinical indicator that a client requires a cardiac evaluation.

The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should expect the client to demonstrate which clinical manifestation in conjunction with this electrocardiogram tracing? See the exhibit. View Exhibit A. Jugular venous distention (JVD) B. Systolic murmur C. Irregular pulse D. Widened pulse pressure

Choice D is correct. The tracing indicated that the client is experiencing ventricular fibrillation (Vfib). This is a fatal rhythm. However, the nurse's priority action is to immediately establish the validity of this fatal arrhythmia tracing by assessing the client's airway, breathing, and circulation. The nurse should always consider the client first - not the monitor. Please note that the same question may be presented differently with assessment findings disclosed within the question (e.g., information such as the patient is unresponsive and pulse is absent within the question stem); the answer would then be choice A (proceed with CPR and defibrillation because the assessment has already been completed).

The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should perform which priority action? See the image below. View Exhibit A. initiate a code blue. B. establish a peripheral vascular access device C. notify the primary healthcare physician (PHCP) D. assess the client's airway, breathing, and circulation

Choices D and E are correct. Pulmonary edema secondary to acute decompensated heart failure (ADHF) is a medical emergency and requires rapid treatment. Vasodilators such as nitroglycerin help decrease preload and afterload, reducing the heart's workload. This medication is often combined with a loop diuretic such as furosemide or bumetanide to decrease volume. If vasodilators or loop diuretics are prescribed, close blood pressure monitoring is essential.

The nurse is caring for a client with the following clinical data. Based on the clinical data, which prescription would the nurse request from the primary healthcare provider (PHCP)? Select all that apply. See the image below.

Choice B is correct. Labetalol is an alpha- and beta-adrenergic blocking agent used to treat a hypertensive emergency. Considering that this client is both hypertensive and tachycardic, labetalol would be a good choice.

The nurse is caring for a client with the following clinical data. The nurse should expect the primary healthcare provider (PHCP) to prescribe what medication? See the exhibit. View Exhibit A. Enalapril B. Labetalol C. Amiodarone D. Nitroglycerin

Choice D is correct. This tracing reflects atrial fibrillation. Atrial fibrillation characteristically has no definitive P-waves because fibrillatory waves replace them before each QRS.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). It would be correct for the nurse to document this tracing as See the tracing in the exhibit. View Exhibit A. sinus bradycardia. B. normal sinus rhythm with first degree block. C. atrial flutter. D. atrial fibrillation.

Nonadherence to medications

The nurse is concerned about the client's symptomatic hypertension The nurse identifies which factor that most likely causing this condition? Knowledge deficit Impaired physical mobility Ineffective health maintenance Nonadherence to medications

Choice D is correct. Adenosine is the initial medication utilized to manage supraventricular tachycardia (SVT). This medication slows the conduction time through the AV node and restores normal sinus rhythm.

The nurse is discussing cardiac dysrhythmias with a student. Which of the following statements, if made by the student, would indicate effective understanding? A. "Atrial fibrillation may cause venous thromboembolism." B. "Immediate defibrillation is needed for asystole." C. "Cardioversion may be used for ventricular fibrillation." D. "Adenosine is used to treat supraventricular tachycardia."

Choice B is correct. Janeway lesions are common with infective endocarditis (IE). The cause of these findings are the cause of the lesions are septic microemboli from the valvular lesion. These macules are not painful and are typically located on the toes' palms, soles, and plantar surfaces.

The nurse is performing a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are A. Heberden's nodes B. Janeway lesions C. Tophi D. Bouchard's nodes

Choice A is correct. When educating a hypertensive client on the dietary modifications to implement, one of the modifications included is to decrease the amount of saturated fats consumed. Following the client's statement, "I'm glad I can still eat beef and pork daily," the nurse should recognize the need to reinforce the correct teaching, as the client has made an inaccurate statement, indicating the need for additional education. Meats and eggs contain a significant amount of saturated fats and are high in cholesterol and should only be eaten sparingly by clients with hypertension.

The nurse is performing client education with a hypertensive client due to be discharged. While discussing dietary modifications, the nurse recognizes the need to reinforce the correct teaching when the client states which of the following: A. "I'm glad I can still eat beef and pork daily." B. "I will need to get used to eating fruits and vegetables." C. "I should avoid eating canned foods." D. "I already told my spouse to buy me some yogurt when I get home."

Choices A, C, D, and E are correct. A client with decreased cardiac output is at risk for hemodynamic instability. Having the client wear compression stockings is helpful because it promotes venous return to the heart. Increasing venous return will increase blood volume (preload). Either compression hose or intermittent sequential pneumatic compression devices may be helpful. Elevating the legs of a supine client redistributes blood to central organs and promotes the venous return to the heart, thereby increasing cardiac output. The client with decreased cardiac output is at greater risk for falls because of orthostatic hypotension. Implementing fall precautions and educating clients to change positions slowly will be beneficial. If a client strains during defecation, the preload will decrease due to a baroreflex. Therefore, the client should be educated not to strain during defecation, and the nurse may need to obtain a prescription for stool softeners (or a laxative).

The nurse is planning care for a client with decreased cardiac output. Which interventions would be appropriate? Select all that apply. Apply compression stockings Obtain a prescription for nitroglycerin via transdermal patch Elevate the client's legs Implement fall precautions Educate the client about not straining when defecating

Choices A and D are correct. Congestive heart failure (CHF) is a chronic condition that causes a decrease in cardiac output. The client must maintain a low-sodium diet, so processed foods such as luncheon meat should be avoided. Annual immunizations are recommended because of the increased risk of complications from influenza. Complications from influenza are higher in those with co-morbidities such as CHF.

The nurse is teaching a client about congestive heart failure (CHF). Which of the following information should the nurse include? Select all that apply. "Foods such as canned vegetables and luncheon meat should be avoided." "Weigh yourself daily and notify the physician if the weight gain is more than ten pounds in a week." "You may continue to take ibuprofen for your aches and pains." "Annual immunizations such as the influenza vaccine are recommended." "If you feel sick, you will need to check your urine for ketones."

Choice B is correct. Compression stockings/hose are effective because the external pressure promotes venous return. Compression hose combined with frequent position changes, daily walks, frequent position changes, and keeping the legs elevated to facilitate venous return is recommended.

The nurse is teaching a group of clients about varicose veins and home care management. Which of the following should the nurse include in the teaching session? A. When you are sitting, keep your legs lower than your heart B. Wear compression stockings during the day C. Participate in activities that have you stand for long periods D. Take a low-dose aspirin to prevent the development of new varicose veins

Choice B is correct. Before calling a code or contacting the physician, the nurse should ensure that the leads are correctly placed on the client and have not been removed. Physically looking and assessing the client as well as the associated equipment should be the first action when an abnormal rhythm is noticed on the cardiac monitor.

The nurse is watching the monitor of a client wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first? A. Press record on the electrocardiogram B. Check the client's lead placement C. Call the code team D. Contact the health care provider

Choice A is correct. This tracing depicts ventricular fibrillation. This rhythm is highly concerning because it can be fatal. Because the nurse has just seen this tracing on the telemetry monitor, the first action the nurse should take is to assess the client. Artifact may be confused for ventricular fibrillation, therefore the nurse should always assess the client first and not the monitor.

The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below. A. Assess the client's level of consciousness B. Prepare the client for immediate defibrillation C. Administer a dose of intravenous epinephrine D. Evaluate the client's cardiac lead placement

Choice A is correct. This procedure involves intravenous (IV) contrast, and a small chance of acute kidney injury may occur when IV contrast is given within 48 hours of metformin. Thus, the PHCP needs to be notified. Prior to this procedure, exposure to metformin is not a contraindication but requires IV fluids to decrease the negative effects on the kidneys. If this goes unrecognized or untreated, an acute kidney injury may occur.

The nurse prepares a client for a scheduled percutaneous coronary intervention (PCI). Which client statement should be reported to the primary healthcare provider (PHCP)? A. "I took my metformin this morning." B. "I get anxious when I am in closed spaces." C. "I am allergic to shellfish." D. "I may feel a warm sensation during the procedure."

defibrillator; cardiac rhythm

The nurse prepares the client for an emergent pericardiocentesis and it is essential to have ____ at the bedside. During the procedure, it is priority for the nurse to monitor the client's ____

Choice B is correct. This statement is incorrect and requires follow-up. When chest pain occurs, the client should take one tablet of nitroglycerin sublingually every five minutes for three doses. Taking the medication too frequently may result in severe hypotension.

The nurse reviews a client's understanding of newly prescribed nitroglycerin sublingual tablets. Which of the statements, if made by the client, would require follow-up? A. "I will get a refill of my prescription every six months." B. "I will take one tablet every 2 minutes if chest pain occurs." C. "I will place my medication in a dark amber bottle." D. "I must not chew on the tablet when taking it."

Choice D is correct. This tracing reflects sinus bradycardia. Verapamil is a calcium channel blocker, and a property unique to verapamil is that it decreases both blood pressure and heart rate. Verapamil may be indicated to prevent migraine headaches, hypertension, or vascular spasms.

The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely causing this tracing? See the image below. A. Losartan B. Nitroglycerin transdermal patch C. Enalapril D. Verapamil

- "I should wear long sleeves and a large-brimmed hat when outdoors." - "Cosmetics must be selected carefully and should include moisturizers and sun protectors."

The nurse reviews the physician's progress note following the procedure Two days later, the client received discharge orders home, and the nurse provided discharge teaching The nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding? "I should limit my exposure to direct sunlight to 45 continuous minutes each day." "I should wear long sleeves and a large-brimmed hat when outdoors." "I should wash my skin with an antibacterial soap." "Cosmetics must be selected carefully and should include moisturizers and sun protectors." "I should refrain from receiving any vaccine."

Choices A, C, and D are correct. The purpose of CPR is to move blood through the heart and to the body's cells to prevent cell death. According to the American Heart Association (AHA), high-quality CPR includes a compression rate of 100-120 per minute to 2-2.4 inches in depth. The provider must allow full chest recoil between each compressor. Full chest recoil allows the heart chambers to fill with blood between compressions. When the ventricles fill, more oxygenated blood will be available to the cells. Fatigue will result in less effective compressions, so the AHA recommends that the compressors rotate every 2 minutes or five cycles of compressions to prevent fatigue.

The nurse teaches a community health course on adult cardiopulmonary resuscitation (CPR). Which of the following statements should the nurse include? Select all that apply. "The compression rate of 100 to 120 per minute." "The compression depth should be 1.5 inches." "Allow full chest recoil between compressions." "Rotate compressor at least every 2 minutes." "Stop to check pulse every 30 seconds."

Hypertensive crisis

The nurse understands that this client is most likely experiencing Hypertensive crisis Pulmonary embolism Myocardial infarction Left-sided heart failure

Choice A is correct. Patients who have undergone cardiac surgery should have their exercise tolerance evaluated by a physician before resuming sexual activity. Many physicians agree that a patient may return to sexual activity if they can climb two flights of stairs without symptoms.

The patient recovering from cardiac surgery is wondering when he can resume sexual activity. The nurse would be most correct in stating that sexual intercourse may be returned at which point in time? A. After exercise tolerance is assessed B. One week after surgery C. When the patient can comfortably jog two miles D. Three months after surgery

Choice C is correct. Reports of swelling require evaluation for pitting edema. This can be done by pressing fingers in the edematous area to evaluate for a remaining indentation after removing one's fingers.

What should the nurse do during assessment when a patient reports swelling in his ankles? A. Measure his ankles at their widest point. B. Ask the patient to elevate his feet to better visualize his ankles. C. Press fingers in the edematous area to evaluate for a remaining indentation after the nurse removes his/her fingers. D. Evaluate further for brown hyperpigmentation that is associated with venous insufficiency.

Choice D is correct. Assessing for a pulse deficit provides an indirect evaluation of the heart's ability to eject enough blood to produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse.

When the nurse notes an irregular radial pulse in a client, further evaluation should include assessing for which of the following? A. The carotid pulse B. Diminished peripheral circulation C. The brachial pulse D. A pulse deficit

- Left lower leg edema - Pain with movement - Left lower leg temperature

Which assessment findings is the nurse most concerned with? Select all that apply. Healing abrasions Left lower leg edema Pain with movement Vital signs Peripheral pulse Left lower leg temperature

cardiac sounds blood pressure pulse

Which of the following assessment findings require immediate follow-up? Select all that apply. lung sounds cardiac sounds temperature blood pressure butterfly-shaped rash on face pulse oximetry pulse

cardiac tamponade cardiogenic shock

Which of the following issues is the client at risk of developing? Select all that apply. cardiac tamponade cardiogenic shock stroke pneumothorax acute coronary syndrome

Choice A is correct. This is the proper blood flow through a healthy heart with normal anatomy. The superior and inferior vena cavas are the large veins that bring back deoxygenated blood from the body to the heart's right atrium. The blood enters the right atrium, passes through the tricuspid valve into the right ventricle, and is pumped into the lungs through the pulmonary artery. In pulmonary circulation, the deoxygenated blood drops off its carbon dioxide and waste products and picks up fresh oxygen to deliver to the body. It is now oxygenated. The blood returns to the left atrium through the pulmonary veins, passes through the mitral valve to enter the left ventricle, and is pumped out to the body through the aorta. Oxygenated blood is now in the systemic circulation, where it can deliver oxygen to all body tissues.

Which of the following statements correctly outlines the proper flow of blood through the heart? A. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation B. Superior and Inferior vena cavas → Right atrium → Mitral valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Tricuspid valve → Left ventricle → Aortic valve → Aorta → Systemic circulation C. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary veins→ Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation D. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Aortic valve → Pulmonary veins→ Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Pulmonary valve → Aorta → Systemic circulation

Atrial fibrillation Cerebrovascular accident (CVA)

Which potential problems is the client at risk for developing? Select all that apply. Atrial fibrillation Bacteremia Cerebrovascular accident (CVA) Infective endocarditis Congestive heart failure Pneumothorax

"Does the epigastric pain radiate anywhere?"

Which statement, if made by the nurse, would help interpret the client's findings? "Why did you wait to come to the emergency department?" "What was your last hemoglobin A1C result?" "Does the epigastric pain radiate anywhere?" "When was the last time you were seen by your physician?"

Irregular pulse Reports of palpitations

Which two (2) client findings require follow-up? Blood pressure Irregular pulse S1/S2 heart tones Palpable peripheral pulses Reports of palpitations Dry and flaky skin

Choice B is correct. Upon auscultation, the nurse should suspect this client is presenting with an abdominal aortic aneurysm (AAA) due to the bruit or swooshing sound. The nurse should immediately notify the client's healthcare provider of this urgent situation. An AAA rupture can occur spontaneously or with trauma. If the aneurysm bursts, it may cause life-threatening bleeding. The aneurysm should be assessed immediately to determine the need for surgical intervention.

While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action? A. Percuss over the area to assess for dullness B. Notify the primary healthcare provider (PHCP) C. Gently palpate the abdomen to assess for tenderness D. Ask the client about recent bowel movements

Choice D is correct. Blurred vision is an unexpected manifestation of atrial fibrillation and may signify that the client has had a stroke. Ischemic stroke is a significant complication of atrial fibrillation which explains why most clients with atrial fibrillation will be prescribed anticoagulants to prevent this life-threatening complication.

The nurse is caring for a client with atrial fibrillation. Which of the following client findings requires immediate follow-up by the nurse? A. Irregular QRS complexes on telemetry reading B. Irregular peripheral pulse C. Reports of intermittent palpitations D. Blurred vision

Choice C is correct. Generally, a lack of decision-making capacity with inadequate time to find an appropriate proxy without harming the client, such as a life-threatening emergency where the client is not conscious, is a situation that allows informed consent to be waived. Here, the delay in providing an emergency craniotomy to an unconscious client would likely result in the client's death, making this case a situation where informed consent would be waived.

A client arrives at the emergency department (ED) via emergency medical services (EMS) after being hit by a car. The name of the client is unknown. The client is unconscious, having sustained a severe head injury and multiple fractures. An emergency craniotomy is indicated. Regarding informed consent for the surgical procedure, which of the following is the best action? A. Obtain a court order for the surgical procedure in place of an informed consent B. Ask the head of the EMS team to sign the informed consent C. Transport the client to the operating room for surgery immediately D. Call the police to report the incident, identify the client, and locate the family

Choices A, B, and D are correct. Several interventions may be necessary to manage fluid volume overload in a client with heart failure. Administering diuretics helps promote the excretion of excess fluid and decrease fluid volume. Monitoring daily weights is crucial to assess changes in fluid status. Assessing lung sounds for crackles is important to detect pulmonary congestion, a sign of fluid overload.

A nurse is caring for a client with heart failure. Which of the following interventions should the nurse implement to manage fluid volume overload? Select all that apply. - Administer diuretics as prescribed - Monitor daily weights - Restrict fluid intake to 500 mL per day - Assess lung sounds for crackles - Encourage high-sodium diet - Assess lung sounds for rhonchi

Choice C is correct. To yield valuable, quality results from an angiogram, the use of contrast media is essential. Like all medications and substances, risks are present even when utilizing the minimum amount required. Two documented risks of contrast media are contrast-associated acute kidney injury (CA-AKI) and contrast-induced nephropathy (CIN), as contrast media is metabolized in the kidneys. To assess for kidney damage, kidney function tests are performed one day after the client receives contrast media to evaluate renal function and compare the result to the pre-procedure testing result.

A nurse is caring for a post-angiography client. The physician utilized a femoral approach during the procedure, and the client received contrast media. Based on this information, which intervention should the nurse include in the client's plan of care? A. Keep the hips in a bent position for 6-8 hours after the procedure B. Discontinue IV fluids immediately after the procedure C. Assess kidney function via lab testing on the day following the procedure D. Maintain NPO status for 4 hours following the procedure

Choice C is correct. Heart failure (HF) is a syndrome of ventricular dysfunction. When occurring on the left side, left ventricular (LV) failure (also known as left-sided heart failure) causes shortness of breath and fatigue. In these clients, cardiac output decreases and pulmonary venous pressure increases as the heart failure worsens. As the amount of blood ejected from the left ventricle diminishes, hydrostatic pressure builds in the pulmonary venous system and results in fluid-filled alveoli and pulmonary congestion, which results in a cough. Dyspnea also results from increasing pulmonary venous pressure and pulmonary congestion. The client's tripod positioning (also known as the orthopneic position) is one in which the client is in a forward-bending posture with their arms held forward in an attempt to facilitate breathing.

An emergency department nurse is caring for a client who presented with fatigue, muscular weakness, and dyspnea. Upon assessment, the client was noted to be coughing frequently and sitting in a tripod position. A subsequent diagnosis of left ventricular failure was made. The nurse understands that manifestations of left-sided heart failure present as respiratory issues because: A. There is venous congestion in the liver. B. There is hypoperfusion of tissue cells. C. There is pulmonary congestion. D. Despite normal cardiac output, the heart cannot meet the accelerated demands of the body.

Choice C is correct. The EKG strip shows normal sinus rhythm with occasional premature ventricular contractions (PVCs). A PVC produces wide, bizarre complexes, with the P wave hidden within the QRS complex (not visible). After assessing the client, the nurse should review the client's most recent laboratory data because low levels of magnesium and potassium may cause PVCs.

The nurse assesses the following telemetry strip for a client on a medical-surgical unit. Based on the rhythm, what is the priority action for the nurse to take? See the exhibit. View Exhibit A. Prepare for synchronized cardioversion B. Obtain a prescription for intravenous (IV) atropine C. Review the most recent labs D. Ask the patient about palpitations

Choice A is correct. A third-degree heart block (complete heart block) is a medical emergency because electrical communication is lost between the atria and the ventricles. On an electrocardiogram, this appears as a complete dissociation of atrial activity from ventricular activity (P waves are independent of QRS complexes). A common finding with this heart block is that the heart rate is usually less than 60 beats per minute. If the escape rhythm is junctional, the heart rate is between 40 and 60 beats per minute. However, if ventricular escape rhythm occurs, the heart rate can fall below 40 beats per minute and result in hemodynamic instability (hypotension). A hemodynamically unstable complete heart block is highly concerning because of the significant reduction in cardiac output. Immediate management includes providing supplemental oxygen if the client has decreased pulse oximetry, pharmacological therapy with atropine, preparing the client for temporary transcutaneous pacing, and admission to the critical care unit for close monitoring. The cure for an irreversible complete heart block would be the placement of a permanent pacemaker.

The nurse cares for a client with a complete (3rd-degree) heart block and hypotension. The nurse should take which appropriate action? A. prepare the client for temporary transcutaneous pacing B. obtain a prescription for an esmolol infusion C. begin chest compressions D. instruct the client to perform the Valsalva maneuver

Choices B and D are correct. These two statements indicate that the patient needs further follow-up education to correct the misconceptions. The client does not need to weigh themselves daily (Choice B) as that would be applicable for CHF and not for atrial fibrillation. Considering daily weight checks in CHF is useful to detect excess fluid retention, which may precede symptoms such as shortness of breath. Wearing a mask in public is unnecessary as an infection is not the concern here (Choice D).

The nurse has provided education to a client with atrial fibrillation. Which of the following statements by the client would require a follow-up? Select all that apply. "I have an increased risk for a stroke." "I should weigh myself daily at the same time." "I may be prescribed medications such as amiodarone." "I should wear a mask when I am in public." "I should follow-up with my primary healthcare provider (PHCP) if I develop shortness of breath."

- administer prescribed morphine sulfate - administer prescribed furosemide - administer supplemental oxygen - administer prescribed 3% saline - seizure precautions

The nurse has received orders from the physician and inserts a peripheral vascular access device. Which five (5) orders should the nurse prioritize? - give report to the nurse in the intensive care unit (ICU) - administer prescribed morphine sulfate - administer prescribed furosemide - administer supplemental oxygen - insert indwelling urinary catheter - administer prescribed 3% saline - call the lab and arrange for serum sodium collections every two hours - transport the client to the radiology department for a head computed tomography (CT) scan - seizure precautions

Choice D is correct. Perfusion refers to the continuous supply of blood through the blood vessels to vital organs. The client with hypotension is at the highest risk for impaired vascular perfusion. Hypotension can result from various causes such as adrenal insufficiency, dehydration, hemorrhage, septic shock, obstructive shock, and cardiogenic shock. A Mean Arterial Pressure (MAP) greater than 65 mmHg is essential to maintain perfusion to vital organs. Prolonged hypoperfusion may lead to end-organ damage, such as renal failure and ischemic hepatitis. Therefore, the cause of hypotension must be identified and treated right away.

The nurse has recently finished education about vascular perfusion. The nurse knows which of the following clients is at greatest risk for experiencing impaired vascular perfusion? A. A 76-year-old female client with a history of alcohol abuse. B. A 76-year-old female client with a history of radon gas exposure. C. A 64-year-old male client with a history of cigarette smoking. D. A 64-year-old male client with hypotension.

Choice A is correct. Right-sided heart failure manifests with peripheral edema, hepatosplenomegaly, jugular venous distention, and oliguria. The client states that his swollen feet would be consistent with right-sided heart failure. This is because of the fluid backing up into the client's body.

The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis? A. "I notice that my feet are always swollen." B. "I can't seem to get rid of this wet cough." C. "I develop shortness of breath after I walk a few feet." D. "My legs start to burn if I walk long distances."

Choices A and B are correct. Peripheral arterial disease (PAD) is characterized by atherosclerosis in the lumen of the peripheral arteries. PAD symptoms include pain in the extremities that may be exacerbated by walking and are relieved by rest(claudication). Decreased peripheral pulses are a consistent manifestation of PAD.

The nurse is assessing a client with peripheral arterial disease (PAD). Which of the following findings would the nurse expect to observe? Select all that apply. - Decreased peripheral pulses - Pain with ambulation - Reddish-brown ankle discoloration - Bilateral dependent edema - Protruding veins in the leg

Choice A is correct. Ascites is a symptom of right-sided heart failure, not left-sided. Right-sided heart failure involves congestion in the systemic circulation. Clients with right-sided heart failure may also experience jugular vein distention, oliguria, weight gain, and peripheral edema.

The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure? A. ascites B. tachypnea C. cough D. orthopnea

Choices A and B are correct. Pain and swelling of the affected extremity are classic manifestations of venous thromboembolism. Other manifestations include warmth to the affected extremity and erythema.

The nurse is assessing a client with venous thromboembolism in the lower extremity. Which of the following assessment findings would be expected? Select all that apply Pain Swelling Paralysis Pulse deficit Dependent rubor

Choice D is correct. Upon seeing a sudden, noticeable drop in the client's heart rate, the nurse would notate a vasovagal response. Here, during the bronchoscopy, the involvement of a foreign object (i.e., the scope used in the bronchoscopy) in the client's pharynx likely caused vagus nerve stimulation. This stimulation resulted in a vasovagal response by the client, manifested by a sudden decrease in the client's heart rate.

The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidence by the client's A. hypertension. B. bronchodilation. C. increase in heart rate (HR). D. decrease in heart rate (HR).

Choices A, C, D, E, and F are correct. This client is experiencing a myocardial infarction (MI), a medical emergency. Starting a vascular access device and obtaining laboratory work such as troponin is especially crucial for the future administration of drugs and assessing the chemical damage done to the heart. The nurse should obtain prescriptions for chewable aspirin, sublingual nitroglycerin, and antiplatelet medications such as clopidogrel. Aspirin is used to exert its antiplatelet effects, and nitroglycerin promotes vasodilation of the coronary arteries. A client experiencing an MI would also get a chest radiograph (x-ray). This is useful in determining if the client is experiencing pulmonary edema due to the MI. Additionally, the radiograph will identify any other pathologies, such as cardiomegaly. Performing continuous cardiac monitoring is appropriate because the nurse needs to watch for the development of dysrhythmias closely.

The nurse is caring for a client experiencing a myocardial infarction. The nurse should prepare to take which action? Select all that apply. - Start a peripheral vascular access device (VAD) - Obtain a prescription for albuterol via nebulizer - Obtain a prescription for chewable aspirin - Obtain a prescription for nitroglycerin - Obtain an order for a chest radiograph (x-ray) - Establish continuous cardiac monitoring

Choice B is correct. The initial treatment for acute pericarditis includes NSAIDs or colchicine. Pericarditis is an inflammatory condition of the pericardium that causes a client to experience chest pain, pericardial friction rub heard on auscultation and leukocytosis. Colchicine reduces the inflammation in the pericardium and may be prescribed for several weeks to achieve efficacy. Corticosteroids may be used as an adjunctive treatment.

The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Isoniazid B. Colchicine C. Allopurinol D. Warfarin

Choice B is correct. Troponin is the most specific iso-enzyme when evaluating a client's myocardial infarction (MI). Troponin levels will elevate within 3-4 hours of myocardial infarction and remain elevated for three weeks. This means that troponin is the most specific cardiac biomarker for an MI and is the most reliable test to run if the client does not seek care for some time after their symptoms begin.

The nurse is caring for a client who has sustained a myocardial infarction. Which cardiac enzyme should the nurse expect to be elevated in response to myocardial injury? A. CPK-MB B. Troponin C. Creatinine kinase D. Myoglobin

Choice C is correct. Arterial and venous blood flow impediments characterize Buerger's disease. This impediment is caused by inflammation and is significantly worsened by smoking. The nicotine causes vasoconstriction and worsens blood flow. A critical intervention for a client with this condition is discussing smoking cessation with this client.

The nurse is caring for a client with Buerger's disease. The nurse plans on suggesting that the client receive a referral for A. occupational therapy. B. speech therapy. C. smoking cessation. D. group psychotherapy.

Choice B is correct. A massive anterior acute myocardial infarction may result in left ventricular failure and flash pulmonary edema. In pulmonary edema, fluid (transudate) fills up the alveoli. Pulmonary edema presents with shortness of breath, tachypnea, and cough with pink frothy sputum. Physical exam may reveal crackles, elevated jugular venous pressure, and peripheral edema. Crackles indicate alveoli that are collapsed by fluid (transudate or exudate). Crackles are adventitious sounds produced when these small alveoli filled with fluid snap open on inspiration. Other causes of crackles include atelectasis, COPD, pneumonia, acute respiratory distress syndrome (ARDS), bronchitis, and bronchiectasis.

The nurse is caring for a client with a myocardial infarction experiencing tachycardia and coughing up frothy, pink-tinged sputum. Which finding would the nurse expect upon lung auscultation? A. Wheezing B. Crackles C. Rhonchi D. Diminished sounds

Choice A is correct. Classic manifestations of cardiac tamponade include tachycardia, tachypnea, jugular venous distention, and hypotension with a narrowed pulse pressure.

The nurse is caring for a client with cardiac tamponade. Which vital signs are expected? A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg

Choice A is correct. Congestive heart failure is a chronic illness that can be debilitating if not appropriately managed. Approximately 50% of individuals diagnosed with heart failure die within five years of the diagnosis. A local support group would be an appropriate recommendation for this client as the support group is a tertiary level of prevention. Support groups are effective because they enable an individual to be expressive and potentially develop social ties with others. All factors that may mitigate depression.

The nurse is caring for a client with congestive heart failure exhibiting signs of ineffective coping. The nurse should take which action based on the findings? A. Recommend a support group B. Review dietary items low in sodium C. Review the client's vaccination status D. Recommend the client take St. John's Wort

Choice D is correct. Even with small doses of nitroglycerin, clients are at risk of severe hypotension, particularly with position changes and when adjusting from a sitting to a standing position. Although all clients are at risk for this complication, elderly clients are more susceptible to nitroglycerin-induced hypotension, placing them at greater risk of falling when taking therapeutic doses of nitroglycerin. Therefore, the client should be educated to make position changes slowly to avoid a sudden drop in blood pressure.

The nurse is caring for a client with heart failure who has an order for a nitroglycerin patch. Which nursing action regarding the administration of a nitroglycerin patch is most relevant? A. Use a bare hand when placing the patch on the client. B. Place the patch in the same spot every day. C. Place the client supine with their feet elevated on a pillow. D. Instruct the client to rise slowly.

Choices A, B, C, and E are correct. Isometric exercise, which increases muscle tension or muscle work but does not shorten or actively move muscle, is ideal for clients who do not tolerate increased activity, such as a client who is immobilized in bed. The benefits include an increase in muscle mass, tone, and strength, thus decreasing the potential for muscle wasting; increased circulation to the involved body part; and increased osteoblastic activity. Reducing sodium intake is crucial in managing hypertension. High sodium consumption can lead to fluid retention and increased blood pressure. Smoking and exposure to secondhand smoke can significantly increase the risk of developing hypertension and cardiovascular diseases. Smoking cessation is strongly recommended to manage hypertension. Maintaining a healthy weight or achieving weight loss if overweight or obese is beneficial in managing hypertension. Losing excess weight can help lower blood pressure and reduce the strain on the cardiovascular system.

The nurse is caring for a client with hypertension. Which of the following lifestyle modifications are recommended for managing hypertension? Select all that apply. Isometric exercises Decreasing sodium intake Smoking cessation Use of herbal supplements Weight loss

Choice D is correct. The client's laboratory data shows a remarkably increased creatinine. This high creatinine level requires the nurse to review the client's current medications that could worsen the creatinine. Captopril is an ACE inhibitor used to manage heart failure and hypertension. While this medication may be nephroprotective, it can become nephrotoxic. While a client takes an ACE inhibitor, the creatinine and GFR must be watched closely. Elevations of the creatinine, especially of this level, requires reporting to the PHCP for further direction.

The nurse is caring for a client with the following clinical data. Based on the laboratory tests, which medication would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the images below. A. bupropion 150 mg XL PO Daily B. clonidine 0.1 mg PO Daily C. albuterol 2.5 mg via nebulizer Daily D. captopril 12.5 mg PO Daily

Choices A and E are correct. This reflects sinus tachycardia (ST). ST can be caused by various conditions, such as a febrile illness likely to induce dehydration. The appropriate action for the nurse is to obtain prescriptions for fluids to rehydrate the client and acetaminophen to mitigate the fever.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The client has an oral temperature of 101 o F (38.3o C). The nurse should be prepared to obtain which prescription from the primary healthcare provider (PHCP)? Select all that apply. See the image below. 0.9% saline bolus Enalapril Levothyroxine Metoclopramide Acetaminophen

Choice A is correct. The tracing reflects supraventricular tachycardia (SVT). The preferred medication for individuals experiencing SVT includes the rapid administration of adenosine followed by a rapid flush of 0.9% saline. Adenosine slows the electrical conduction time through the AV node.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse should anticipate a prescription for which medication? See the image below. A. Adenosine B. Atropine C. Labetalol D. Amiodarone

Choices A, B, C, and D are correct. A is correct. Stroke volume refers to the amount of blood ejected by the left ventricle during each contraction. An increase in stroke volume would directly increase cardiac output, as it is one of the two factors determining cardiac output (Workman, 2021). B is correct. An increase in blood volume can lead to an increase in cardiac output. More blood volume can stretch the heart muscle fibers, leading to a more muscular contraction and stroke volume, thereby increasing cardiac output (Frank-Starling law) (Workman, 2021). C is correct. Sympathetic stimulation increases both heart rate and the force of myocardial contraction, which can increase cardiac output. This is part of the body's 'fight or flight' response (Workman, 2021). D is correct. Positive inotropic drugs, such as digoxin, increase the force of myocardial contraction. This can lead to increased stroke volume and cardiac output (Workman, 2021).

The nurse is educating nursing students about factors that can influence cardiac output. Which of the following would cause an increase in cardiac output? Select all that apply. Increased stroke volume Increased blood volume Increased sympathetic stimulation Administration of positive inotropic drugs Increased systemic vascular resistance (SVR).

Choices A, B, C, E, and F are correct. Choice A is correct. Knowledge of the indications for pacemaker placement is essential for nurses caring for clients with pacemakers. By understanding the medical conditions or heart conditions that may necessitate a pacemaker, nurses can better assess and anticipate the needs of the client. Choice B is correct. Recognizing signs and symptoms of a malfunctioning pacemaker, such as dizziness, palpitations, or shortness of breath, enables nurses to respond promptly and seek appropriate medical intervention. Identifying potential issues with the pacemaker's functioning can prevent serious complications and improve client outcomes.

The nurse is educating the staff about caring for a client with a pacemaker. Which of the following teaching topics should the nurse prioritize? Select all that apply. - Understanding the indications for pacemaker placement. - Recognizing signs of pacemaker malfunction. - Explaining different types of pacemakers and how they function. - Advising clients with pacemakers to avoid all sources of electromagnetic fields (EMFs). - Discussing the importance of regular pacemaker check-ups and follow-up care. - Providing guidelines on safe physical activities and exercise after pacemaker placement

Choices A, C, and D are correct. Dietary recommendations for reducing CAD risk include increasing dietary complex carbohydrates and vegetable proteins; complex carbohydrates are dense in fiber and help reduce cholesterol. Reducing sodium intake is key as it assists with lowering blood pressure. Exercising at least 150 minutes a week is recommended. Exercising has many benefits, including weight loss, mood improvement, and vascular perfusion.

The nurse is teaching a group of individuals at a health fair regarding the prevention of heart disease. It would be correct for the nurse to recommend Select all that apply. increasing complex carbohydrates in the diet. a body mass index greater than 25. reducing dietary sodium. exercising at least 150 minutes per week. chewing tobacco instead of cigarettes.

Choice B is correct. Furosemide is a loop diuretic that should be dosed early in the day. This prevents the client from experiencing nocturia. This also reduces the risk of falls by the client as they will not have to wake up at night when there is reduced lighting.

The nurse is visiting a client who was recently prescribed antihypertensive medications. Which statement, if made by the client, requires follow-up? A. "My pulse decreases after taking my metoprolol." B. "I started taking my furosemide right before I went to sleep." C. "I am seasoning my foods with salt substitutes while taking my hydrochlorothiazide." D. "I wear my clonidine patch for seven days."

Choice A is correct. Tight postoperative glucose control is essential for optimal outcomes. Amongst the priorities of airway patency, ensuring appropriate hemodynamics, vital signs, and thermoregulation, the nurse will obtain frequent capillary blood glucose levels to ensure it is less than 180 mg/dL. Immediately postoperative, a continuous infusion of regular insulin is prescribed and is titrated based on the client's glucose level. The stress of this major surgery raises serum glucose levels and requires appropriate control via regular insulin. Choice D is correct. Grounding (connecting) the epicardial pacing wires to the pacemaker generator is appropriate. Epicardial pacing wires are placed on the heart to control postoperative cardiac dysrhythmias. Also, they are used to increase cardiac output by increasing the client's heart rate, if necessary. Choice E is correct. After a CABG, clients usually have two mediastinal chest tubes to drain fluid or blood around the heart. Clearing of this excess fluid and blood prevents hemodynamic compromise. These tubes are connected to a chest tube drainage system. The drainage should not exceed no more than 150 mL/hr.

The nurse plans care for a client immediately postoperative following a coronary artery bypass graft surgery (CABG). Which interventions are appropriate during this time? Select all that apply. - obtain the client's capillary blood glucose - provide tracheostomy care, as needed - teach the client about the driving restrictions after this procedure - ground the epicardial pacing wires to the pacemaker generator - ensure patency of the mediastinal chest tubes

Choice A is correct. To answer this question correctly, you must know the right formula for Cardiac Output (CO). CO = Heart Rate (HR) x Stroke Volume (SV). Heart rate is measured in beats per minute, and stroke volume is measured in milliliters (mL). The HR is the number of times per minute the heart beats, whereas the SV is the mL of blood that the heart pumps out with each contraction. By multiplying the two together, you get how many mL of blood the heart is pumping out each minute. This is the cardiac output. Cardiac output is usually reported in liters/min; the average is about 5 L/min but varies greatly depending on the patient's size. A decreased cardiac output (low-output failure) is seen in congestive heart failure. A high cardiac output state refers to resting cardiac output more significant than 8 L/min. An increased cardiac output (high-output failure) may be seen in hyperthyroidism, thiamine deficiency, and severe uncorrected anemia. For this problem: Cardiac Output (CO) = 102 beats per minute (HR) x 72 mL (SV) = 7,344 mL/min or 7.344 L/min.

You are attending to a male client on a postoperative day one following mitral valve replacement. He is getting ready to ambulate for the first time. His heart rate is 102 beats/minute, and the stroke volume based on the echocardiogram is 72 mL. Which of the following represents his cardiac output (CO)? A. 7.344 L/min B. 30 L/min C. 55% D. 73.444 mL/min

Choice A is correct. This rhythm represents a 3rd-degree heart block because there is no QRS complex after every other p wave. This is because the AV node has no conduction during a 3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with each other.

What EKG rhythm represents a third-degree heart block?

pulmonary edema; serum sodium level

The nurse's greatest concern is that the client is at risk for_____ based on the client's _____

Choice A is correct. This client displays signs and symptoms of an ST-segment elevation myocardial infarction (STEMI). In a STEMI, myocardial necrosis occurs, with the client exhibiting ECG changes showing ST-segment elevation not quickly reversible by nitroglycerin administration. The primary focus should be on improving myocardial oxygenation and reducing cardiac workload, as these measures will reduce the further expansion of myocardial necrosis.

A client arrives at the emergency department (ED) complaining of substernal chest pain. A 12-lead electrocardiogram (ECG) showed ST-segment elevation and laboratory findings showed an elevated troponin level. Based on these findings, the priority treatment goal for the client is A. reducing cardiac workload and improving myocardial oxygenation. B. reducing modifiable risk factors to prevent re-occurrence. C. planning outpatient cardiac rehabilitation. D. providing a quiet environment and reducing anxiety.

Choice D is correct. Red meats are rich in saturated fat and should therefore be consumed less often by this client based on the recent diagnosis of hyperlipidemia. Red meats contribute to high cholesterol levels and would contribute to increasing, not decreasing the client's already elevated hyperlipidemia levels. Therefore, this choice is incorrect.

A client has just been diagnosed with hyperlipidemia. Aside from the prescribed atorvastatin, the client has been advised to lose weight and implement dietary changes. During the discussion with the client, the nurse discusses all the following dietary modifications except: A. Replace hydrogenated vegetable oils with canola oil when cooking. B. Eat fish like tuna and salmon more often. C. Eat more fruits and vegetables. D. Consume red meat more often.

Choice B is correct. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference regularly. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if the patient experiences any chest pain or dyspnea. The patient should be instructed not to massage the legs.

How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg? A. By palpating the skin over the tibia and fibula B. By documenting daily calf circumference measurements C. By recording vital signs obtained four times a day D. By noting difficulty with ambulation

- stop the diltiazem infusion - notify the primary healthcare provider

The ICU nurse reviewed the client's medical record Based on the 2000 vital signs, select two (2) immediate actions the nurse should take - stop the diltiazem infusion - apply supplemental oxygen via nonrebreather face mask - stop the 0.9% saline infusion - notify the primary healthcare provider - assess the client for back pain - request a prescription to change the intravenous fluids to hypertonic saline

Choice D is correct. CK-MB, or creatine kinase myocardial muscle, levels measure muscle cell death and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels first begin elevating about 3 to 6 hours after a cellular injury or myocardial infarction and stay elevated for about 48 to 72 hours.

The cardiac nurse is evaluating cardiac markers to determine whether or not their client's heart has suffered from muscle damage. The nurse is aware if damage has occurred, CK-MB levels will be their highest after how many hours? A. 3 to 6 B. 1 to 2 C. 48 to 72 D. 18

supine; sitting; standing, keep the blood pressure cuff in the same position; 20mmHg; 10mmHg

The nurse prepares to obtain the client's orthostatic blood pressure (BP) by first positioning the client ___ then positioning the client ____ and finally repositioning the client _____ When obtaining the blood pressure, the nurse should _____ The nurse should be concerned for orthostatic hypotension if the systolic blood pressure decreases by _____ or the diastolic blood pressure decreases by ____

Choice B is correct. This client is being treated for hyperlipidemia and still has suboptimal values. The triglycerides are high, along with the LDL-C. The first step is to assess whether the client is taking the medication as prescribed. Side effects and adverse reactions commonly deter a client from adhering to prescribed medication, and this should be assessed before going further in the process, such as notifying the prescriber of a potential dosage adjustment.

The nurse reviews a client's lipid panel who is being treated for hyperlipidemia with simvastatin. Which of the following actions should the nurse take based on the results? Total cholesterol 235 mg/dl (6.07 mmol/l) [less than 200 mg/dl (<5.18 mmol/l)] High-density lipoprotein (HDL) 35 mg/dl (0.91 mmol/l) [more than 45 mm/dL (>0.75 mmol/L) for men; more than 55 mg/dL (>0.91 mmol/L) for women] Low-density lipoprotein (LDL) 135 mg/dl (3.49 mmol/l) [less than 130 mg/dL (< 3.36 mmo/l)] Triglycerides 169 mg/dL [Females: 35-135 mg/dL or 0.40-1.52 mmol/L; Males: 40-160 mg/dL or 0.45-1.81 mmol/L] A. Review the client's most recent creatinine B. Assess the client's adherence to the prescribed medication C. Determine if the client is adhering to a low salt diet D. Document the results as within normal limits

- lung sounds - diminished deep tendon reflexes - pulse oximetry - confusion

Which of the following assessment findings require immediate follow-up? Select all that apply. lung sounds diminished deep tendon reflexes pulse oximetry temperature cardiac sounds confusion

Choice B is correct. The heart is a double pump with four chambers, four valves, and a conduction system with a pacemaker originating in the atrium.

Which of the following statements best describes the cardiovascular system? A. It has a heart with six chambers, strong vessels, and valves. B. It is a double-pump circulating blood out to the lungs and the body. C. It includes concepts of precontractility, postcontractility, and load. D. It functions with a conduction system and starts in the ventricles.

Choice C is correct. Bleeding is the priority concern for any patient who is taking a thrombolytic medication.

While monitoring a client with myocardial infarction, who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following? A. Observe for neurological changes B. Monitor for any signs of renal failure C. Observe for signs of bleeding D. Check the client's food diary

Choice B is correct. Epinephrine is necessary as this arrhythmia reflects asystole. Asystole (also known as ventricular standstill) requires an aggressive treatment consisting of high-quality cardiopulmonary resuscitation (CPR) and intravenous (IV) epinephrine. Epinephrine is necessary as this medication assists with restoring vascular tone.

he nurse assists the code team with an unresponsive and pulseless client. Which intervention does the nurse prepare for based on the electrocardiogram (ECG) tracing? See the image below. A. Prepare an infusion of sodium bicarbonate B. Administer epinephrine C. Defibrillation D. Cardioversion

Choice A is correct. This tracing reflects sinus tachycardia (ST). ST can be caused by an array of conditions such as dehydration, hypo- and hyperglycemia, stress, anxiety, and thyroid conditions such as hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism, and this increased metabolic and sympathetic activity would cause tachycardia.

The nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below. A. Graves' disease B. Increased intracranial pressure C. Severe hypothermia D. Myxedema coma

Choice C is correct. This statement requires immediate follow-up by the nurse because this client experienced a myocardial infarction (MI) two weeks ago and is at risk of reinfarction. Antiplatelet medications such as clopidogrel are prescribed after an MI to prevent another infarction, and the sudden abandonment of the treatment could be a precipitating factor for another MI. Clients are usually prescribed a one-year course of therapy after an MI, which may be continued indefinitely depending on their risk factors.

The home health nurse is caring for a client who experienced a myocardial infarction two weeks ago. Which of the following client statement requires immediate follow-up? A. "I am having difficulty coping with the stress at work." B. "I am unsure if I want to continue with cardiac rehabilitation." C. "I have not been taking my prescribed clopidogrel because I cannot afford it." D. "I started using nicotine patches to help me quit smoking."

epinephrine; resuming CPR

The next essential intervention is the administration of ____ followed by _____

Choice B is correct. A pulse deficit is a difference between the apical and peripheral pulses. This finding may signal that the client has a dysrhythmia, and the nurse should consider obtaining a 12-lead electrocardiogram and/or continuous telemetry monitoring.

The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as A. a widened pulse pressure. B. a pulse deficit. C. pulsus paradoxus. D. an expected finding.

Choice C is correct. ST-segment elevation isolated in two leads is consistent with an acute ST-elevation myocardial infarction. A 12-lead electrocardiogram is a high-yield test to determine if the client is actively experiencing an infarction. Myocardial infarction may also present without ST elevations (NSTEMI or non-ST elevation MI) - EKG findings in NSTEMI may include normal EKG, ST segment depressions, and T-wave inversions.

The emergency department nurse suspected a client may have an acute myocardial infarction. Which finding on the electrocardiogram (ECG) abnormality would support this possibility? A. U-waves B. T-wave inversion C. ST-segment elevation D. Prolonged PR-interval

Choice A is correct. Enalapril is an ACE inhibitor and this drug class is indicated in the treatment of heart failure to prevent ventricular remodeling.

The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication? A. Enalapril B. Verapamil C. Lovastatin D. Gemfibrozil

Choice B is correct. This statement by the nurse is incorrect and, therefore, the correct answer to the question. Typically, clients scheduled to undergo an exercise electrocardiography (ECG) (i.e., exercise stress test) are instructed to remain NPO for 4 to 6 hours before the stress test. Additionally, caffeine intake by a client may cause an alteration in the procedure's findings.

A nurse is reviewing instructions with a client for the client's upcoming exercise electrocardiography (ECG). All of the following are appropriate statements by the nurse, except for which? A. "Please wear loose, comfortable clothing with non-slip athletic footwear." B. "You may have a light breakfast and a small cup of coffee before the exam." C. "We will monitor your blood pressure, heart rate, and rhythm before, during, and after the stress test." D. "You should not do any strenuous activity before your stress test."

Choice C is correct. In myocardial ischemia, the ST-segment may appear elevated or depressed. In the presence of acute myocardial ischemia, ST-segment changes result from lack of oxygen to a specific region of the cardiac muscle. If treatment has been successful, the ST-segment will return to baseline.

After presenting with acute myocardial ischemia, a client was given 324 mg PO aspirin, three doses of 0.4 mg SL nitroglycerin tablets (taken five minutes apart), and oxygen via nasal cannula at 2L/minute. Which ECG change would indicate these interventions have been effective? A. Widening of the QRS complex B. Decrease in ectopic heartbeats C. ST-segment has returned to the baseline D. Reduction of the significant Q-wave

Choice C is correct. Pressure-reduction mattresses and beds are available to decrease the pressure on the client's pressure points when the client is in bed. More specifically, these support surfaces are used to prevent (or treat) pressure ulcers by attempting to redistribute pressure beneath the skin of the client's body to increase blood flow to tissues and relieve skin and soft tissue distortion. However, implementing measures to ease the stress on the pressure points is the lowest priority when managing a client experiencing acute pulmonary edema.

An intensive care unit nurse is caring for a client with left-sided heart failure experiencing pulmonary edema as a complication. The nurse identifies a nursing diagnosis of "impaired gas exchange related to ineffective breathing patterns." Which nursing intervention would be the lowest priority based on the nursing diagnosis? A. Administer oxygen and monitor for drying of the nasal mucus membranes. B. Place the client in a semi-Fowler's position. C. Provide a pressure-reducing mattress. D. Encourage the client to turn, deep breathe, cough, and use the incentive spirometer.

Choice B is correct. The client is exhibiting signs and symptoms of cardiac tamponade following surgical trauma. Cardiac tamponade is a medical emergency where an accumulation of blood or fluid in the pericardial sac of sufficient volume and pressure occurs to the point of impairing cardiac filling. As a result, obstructive shock occurs. Clients with cardiac tamponade typically exhibit Beck's triad, consisting of hypotension, muffled heart tones, and neck vein distention. Treatment of cardiac tamponade includes immediate pericardiocentesis (inserting a needle into the pericardial cavity to drain the fluid or blood).

The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate A. thoracentesis. B. pericardiocentesis. C. arthrocentesis. D. paracentesis.

Choice B is correct. Congestive Heart Failure (CHF) may be confirmed by an elevation of the B-type natriuretic peptide (BNP). This peptide is elevated when it is cleaved from the ventricle wall because of increased ventricular filling pressures.

The nurse cares for a client with suspected congestive heart failure (CHF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis? A. Basic metabolic panel (BMP) B. B-type natriuretic peptide (BNP) C. Complete Metabolic Profile (CMP) D. C-Reactive Protein (CRP)

Choice B is correct. This concerning tracing on the electrocardiogram is ventricular fibrillation. Ventricular fibrillation is electrical chaos in the ventricles that produces no cardiac output. The priority is to defibrillate the client immediately, according to ACLS protocol. If a defibrillator is not readily available, high-quality CPR must be initiated and continued until the defibrillator arrives. ➢ External electrical defibrillation remains the most successful treatment for ventricular fibrillation (VF) and is a priority treatment.

The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse. The nurse should take which priority action based on the tracing? A. Start cardiopulmonary resuscitation (CPR) B. Perform immediate defibrillation C. Initiate intravenous (IV) access D. Review the client's most recent electrolyte levels

Choice D is correct. Peripheral arterial disease is caused by conditions such as hypertension, hyperlipidemia, and diabetes mellitus which cause atherosclerosis of the peripheral arteries. This impeded blood flow may cause the client to experience intermittent claudication (pain with ambulation that is relieved with resting). The client should be educated on self-management strategies, including sleeping or resting with the legs dependent (below the heart) to facilitate blood flow and not wearing constrictive clothing that may further impede blood flow. This statement requires follow-up because the client's legs should be below the heart to facilitate blood flow.

The nurse has attended a staff education program about managing clients with peripheral arterial disease. Which of the following statements by the nurse would require follow-up? A. "The client should engage in a daily exercise regimen." B. "Smoking cessation is an essential treatment goal for clients who smoke." C. "Resting in a recliner with the legs dependent should be recommended." D. "Devices that elevate the legs above the heart should be provided at discharge."

Choice B is correct. Ventricular tachycardia (VT) is an ominous dysrhythmia that may portend the client clinically deteriorating. Following a cardiac catheterization, the client is at risk for an array of complications, including hemorrhage, cardiac dysrhythmias, and reinfarction. Although brief, these two runs of VT need to be reported to the PHCP immediately, so prescribed medications such as amiodarone may be given to prevent further ventricular irritability.

The nurse in the medical-surgical unit is observing the telemetry monitor for assigned clients. Which client condition change requires immediate notification to the primary healthcare provider (PHCP)? A client A. with normal sinus rhythm (NSR), who has had three premature ventricular contractions (PVCs) in the past hour. B. recovering from cardiac catheterization and has had two brief runs of ventricular tachycardia (VT). C. with atrial fibrillation, whose heart rate decreased from 113 to 95 beats per minute. D. who has developed sinus tachycardia (ST) following the application of nitroglycerin paste.

Choice A is correct. Positive pressure ventilation (PPV) would be detrimental to a client experiencing cardiac tamponade. This order requires follow-up. PPV increases intrathoracic pressure, which decreases venous return to the heart. This reduction of venous return impairs ventricular filling and decreases cardiac output. This would be detrimental in a cardiac tamponade where the cardiac output is already impaired.

The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)? A. Positive pressure ventilation B. Pericardiocentesis C. Echocardiography D. 0.9% saline bolus

Choice C is correct. The essential action for a client with a femoral artery occlusion is to notify the PHCP or rapid response. This is a medical emergency! If untreated, this extremity may have to be amputated because of the interruption in distal perfusion.

The nurse is caring for a client with a suspected femoral artery occlusion. The nurse should take which action? A. Elevate the affected leg B. Apply a cold compress C. Notify the primary healthcare provider (PHCP) D. Perform passive range of motion to the affected leg

Choice A is correct. The client is presenting with signs of arterial insufficiency and an arterial ulcer. The application of compression (TED hose) to the extremities is contraindicated in cases of severe arterial insufficiency because the compression may further aggravate the ischemia. TED hose should not be applied until cleared by the primary healthcare provider (PHCP). The PHCP may want to ensure that the perfusion is adequate before clearance is given to apply a compression device.

The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated? A. Apply TED hose to bilateral legs B. Assess the need for smoking cessation C. Physical therapy consult D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler

Choices A, C, and D are correct. A is correct. It is not possible to eliminate sodium from the diet, nor would it be recommended. Sodium is a principal cation and it plays a role in driving the sodium-potassium pump as well as regulating water balance, so wholly eliminating sodium is not a good idea. C is correct. Canned vegetables do use a large amount of sodium to preserve flavor, so you should advise your client with hypertension to avoid them. D is correct. The body indeed needs some sodium as it plays a vital role in water balance, so this is an appropriate teaching point for your client.

The nurse is educating a client newly diagnosed with hypertension about sodium and its role in blood pressure. Which of the following statements about sodium are true? Select all that apply. Sodium cannot be completely eliminated from the diet. There is no sodium in fresh fruits and vegetables. Canned vegetables should be avoided. The body needs some sodium as it plays an important role in water balance. Reduce daily sodium intake to 2,000 mg

Choices A, B, C, and D are all correct. All rhythm changes will affect cardiac output. This is especially important to remember when administering antiarrhythmics to your client, as these medications and their effect will also change the cardiac output. There are two reasons that rhythm changes affect cardiac output. 1 - they break your heart rate. 2 - they change your stroke volume. Remember, CO = HR x SV, so any change to either heart rate or stroke volume subsequently affects your cardiac output. A - Supraventricular tachycardia (SVT) - There is an increase in heart rate but a decrease in stroke volume. This is because the heart is beating so fast that there is not enough time for diastole and, therefore, not enough time for the atriums to fill with blood. This decreases preload, which decreases contractility due to Starling's law, which reduces stroke volume. Clients with SVT have decreased cardiac output. B - Sinus bradycardia - The heart rate is lower due to bradycardia, so the cardiac output is lowered. Remember, CO = HR x SV. Decreased HR = decreased CO. C - Ventricular tachycardia - There is an increase in heart rate and a decrease in stroke volume. This is because the heart is

The nurse is reviewing an EKG strip for a client. Which of the following rhythm changes could impact the patient's cardiac output? Select all that apply. Supraventricular tachycardia Sinus bradycardia Ventricular tachycardia Mobitz type II heart block Isolated premature atrial contraction (PAC)

Choice A is correct. The nurse should assess the client first before implementing any intervention. Asking what the client means by his statement explores the client's feelings and provides information regarding his condition.

The nurse is taking care of a client that is 24 hours post-angioplasty. The client says, "I don't feel good today. I don't feel like eating." What is the nurse's best action? A. Ask what the statement means to the client. B. Delegate an LPN to assess the client. C. Notify the physician. D. Encourage the client to eat.

Choice A is correct. This patient is presenting with early signs/symptoms consistent with compartment syndrome. Later signs of compartment syndrome include paralysis and the absence of pulses in the affected extremity. If not caught and treated early, compartment syndrome can result in permanent muscle and nerve damage

The patient with a right distal fibula fracture complains of pain and a tingling sensation in the right foot. Upon assessment, the nurse notes the right foot is cold to the touch with a weak dorsalis pedis pulse. Which potential complication should the nurse be most concerned about? A. Compartment syndrome B. Sepsis C. Peripheral neuropathy D. Pressure Injury

Choice D is correct. When assessing pulses, the strength, volume, and fullness of the peripheral pulses are categorized and documented as follows: 0: Absent pulses 1: Weak pulse 2: Normal pulse 3: Increased volume 4: Abounding pulse

What is the correct documentation of the patient's peripheral pulse when the finding is that the posterior tibial pulse is weak and thready? A. Grade C posterior tibial pulse B. Posterior tibial pulse is Grade B C. The client's posterior tibial is 2 D. Posterior tibial pulse is 1