Adult I: ATI Cardiovascular
A nurse is caring for a client who s being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication? A. Lightheadedness B. Shortness of breath C. Metallic taste D. Dry cough
A. Lightheadedness Explanation: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness. Furosemide is used to manage shortness of breath secondary to heart failure. This is not an adverse reaction to this medication. A metallic taste and dry cough is not an adverse reaction to furosemide.
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? A. Replace the patch at the onset of angina. B. Apply the new patch to the same site as the previous patch C. Place the patch on an area of skin away from skin folds and joints D. Keep the patch on 24 hr per day
A. Replace the patch at the onset of angina. Explanation: The client should apply the patch to an area of intact skin that has enough room for the patch to fit smoothly. The client should have a patch-free interval of 10 to 12 hr per day to prevent tolerance to the medication. Rotating the patch site can prevent skin irritation. The nurse should emphasize that nitroglycerin patches offer ongoing prevention of angina attacks. The patches do not treat angina attacks because they do not take effect immediately.
A nurse is an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week postoperative following an open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? A. Helping the client to the bedside commode B. Assisting with thrombolytic therapy C. Administering oxygen at 2L/min via nasal cannula D. Administering IV morphine sulfate
B. Assisting with thrombolytic therapy Explanation: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy. Using a bedside commode is less stressful than using a bedpan, and most clients are allowed to use a commode following a myocardial infarction. The nurse should administer supplemental oxygen to the client to increase myocardial tissue perfusion. The nurse should administer IV morphine to the client to relieve pain and reduce myocardial oxygen demand
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions? A. Defibrillation B. Vagal stimulation C. Administration of atropine IV D. Delivery of a precordial thump
B. Vagal stimulation Explanation: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole. The nurse should identify that cardioversion, rather than defibrillation, is used to treat supraventricular tachycardia. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia. The nurse should identify that atropine is used to treat bradydysrhythmias. Supraventricular tachycardia does not require atropine. The nurse should identify that a precordial thump is used for witnessed ventricular tachycardia if a defibrillator is unavailable. Supraventricular tachycardia does not require a precordial thump.
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? A. Hemoglobin 14.4 g/dL B. History of peripheral arterial disease C. Previous allergic reaction to shellfish D. Urine output 200 mL/4 hr
C. Previous allergic reaction to shellfish Explanation: The contrast medium used is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine. A hemoglobin level of 14.4 g/dL is within the expected reference range. This procedure involves access through large arteries or veins into the heart and is not affected by peripheral arterial disease. An output of 200 mL in 4 hr is within the expected reference range.
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse A. Aortic B. Pulmonary C. Tricuspid D. Mitral
D. Mitral Explanation: Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Valvular disease B. Ventricular depolarization C. Myelodysplastic syndrome D. Guillain-Barre syndrome
A. Valvular disease Explanation: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium. Ventricular depolarization occurs during a normal cardiac cycle and is not a potential complication of endocarditis. Myelodysplastic syndrome is a disorder of the bone marrow and is not a potential complication of endocarditis. Guillain-Barré syndrome is associated with certain bacterial and viral infections but is not a potential complication of endocarditis.
A nurse is caring for a client who is 8 hr postoperatice following a coronary artery bypass graft (CABG). Which of the following client findings should the nurse report? A. Potassium 4.0 mEq/L B. Temperature 37.1 C (98.8 F) C. Mediastinal drainage 100 mL/hr D. Blood pressure 160/80 mm Hg
D. Blood pressure 160/80 mm Hg Explanation: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites. Mediastinal drainage of up to 150 mL/hr is expected during this time. A potassium level of 4.0 mEq/L is the desired goal in the postoperative period after CABG. A body temperature within the expected reference range is desired following a CABG.
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Ask if the client has had a recent infection B. Explore the client's family history of peripheral vascular disease C. Note the presence or absence of pain at the ulcer site D. Inquire about the presence or absence of claudication
D. Inquire about the presence or absence of claudication Explanation: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not. Both arterial and venous ulcers have the potential to become infected. Family history is important, but it does not help to differentiate between arterial and venous ulcers. Both arterial and venous ulcers cause varying degrees of pain or discomforT.
A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. The nurse should identify that which of the following findings indicates the medication is effective? A. INR 2.0 B. Decreased blood pressure C. Hemoglobin 14 g/dL D. Minimal bruising of extremities
A. INR 2.0 Explanation: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke. The nurse should recognize that decreased blood pressure is a manifestation of bleeding, which is an adverse effect of warfarin. The nurse should recognize that minimal bruising or no bruising is desired and that a hemoglobin level of 14 g/dL is within the expected reference range. However, this is not evidence of effective warfarin therapy.
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find? A. Jugular venous neck distention B. Weak peripheral pulses C. Increased abdominal girth D. Dependent edema
B. Weak peripheral pulses Explanation: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. All other options are a result of right sided HF
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 0.9 kg (2 lb) in 24 hr B. Dyspnea with exertion C. Increase of 10 mm Hg in systolic blood pressure D. Dizziness when rising quickly
A. Weight gain of 0.9 kg (2 lb) in 24 hr Explanation: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately. Dyspnea with exertion is a nonurgent finding that is expected for a client who has heart failure. An increase of 10 mm Hg in systolic blood pressure is a nonurgent finding. Dizziness when rising quickly is a nonurgent finding that is expected for a client who is taking medications to treat heart failure. Although the client should report these, there is another finding the client should report immediately.
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I smoked a cigarette this morning to calm my nerves about having this procedure" B. "I have had chest pain a couple of times since I saw my doctor in the office last week." C. "I'm still hungry after the bowl of cereal I ate at 7 a.m." D. "I didn't take my heart pills this morning because my doctor told me not to"
B. "I have had chest pain a couple of times since I saw my doctor in the office last week." Explanation: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test. Episodes of chest pain are not a contraindication to this test. It is not necessary for the client to be NPO prior to this procedure. The provider might withhold cardiovascular medications prior to this procedure to effectively monitor cardiovascular response to stress.