AH1 MOD 6 CARDIO Shock Iggy NCLEX, Iggy Chp 35 - Care of Patients with Cardiac Problems, CH 33, 35 Cardiac, Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome, Nursing Assessment: Cardiovascular System

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? A) Friction rub auscultated at the left lower sternal border B) Pain aggravated by breathing, coughing, and swallowing C) Splinter hemorrhages D) Thickening of the endocardium (Chp. 35; elsevier)

C) Splinter hemorrhages (Chp. 35; elsevier)

Which medication, when given in heart failure, may improve morbidity and mortality? A) Dobutamine (Dobutrex) B) Carvedilol (Coreg) C) Digoxin (Lanoxin) D) Bumetanide (Bumex) (Chp. 35; elsevier)

B) Carvedilol (Coreg) (Chp. 35; elsevier)

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? A) Auscultation of crackles B) Pedal edema C) Weight loss of 6 pounds since the last visit D) Reports sucking on ice chips all day for dry mouth (Chp. 35; elsevier)

C) Weight loss of 6 pounds since the last visit (Chp. 35; elsevier)

Physiological Integrity 19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness

A The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity. DIF: Cognitive Level: Apply (application) REF: 757 TOP: Nursing Process: Diagnosis MSC:

6. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. administer IV morphine sulfate 2 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase dopamine (Intropin) infusion by 2 mcg/kg/min. d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.

A Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output but will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea. Cognitive Level: Analysis Text Reference: pp. 828-829 Nursing Process: Implementation NCLEX: Physiological Integrity

21. A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will a. dilate arterial and venous blood vessels, decreasing ventricular preload and afterload. b. improve the ability of the ventricular myocardium to contract, strengthening contractility. c. enhance the speed of impulse conduction through the heart, increasing the heart rate. d. increase calcium sensitivity in vascular smooth muscle, boosting systemic vascular resistance.

A Rationale: Nesiritide, a recombinant form of BNP, causes both arterial and venous vasodilation, leading to reductions in preload and afterload. Inotropic medications, such as dopamine and dobutamine, may be used in ADHF to improve ventricular contractility. Nesiritide does not increase impulse conduction or calcium sensitivity in the heart. Cognitive Level: Application Text Reference: p. 829 Nursing Process: Implementation NCLEX: Physiological Integrity

Physiological Integrity 3. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin. DIF: Cognitive Level: Apply (application) REF: 748 TOP: Nursing Process: Assessment MSC:

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging A client with acute coronary syndrome who has just been admitted and needs an admission assessment

B. The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan.

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? Client with abdominal pain and belching Client with pressure in the mid-abdomen and profound diaphoresis Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows Client with claudication and fatigue

B. Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? Dietary consult Sodium restriction Daily weight monitoring Restricted activity

C. A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? This blood pressure is good because it is a normal reading. This blood pressure indicates that the client has hypertension or high blood pressure. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension.

C. Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? Auscultate the client's precordium for murmurs. Teach the client about the reason for the TEE. Reassure the client that the test is painless. Validate that the client has remained NPO.

D. Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur; auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable.

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? C-reactive protein of 1 mg/dL Homocysteine level of 13 mmol/L Creatine kinase (CK) of 125 mg/dL Troponin of 5.2 ng/mL

D. The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A C-reactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.

19. An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient a. has BP of 88/42. b. has an apical pulse rate of 56. c. complains of feeling tired. d. has 2+ pedal edema.

A Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of -Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. -adrenergic blockade will initially worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Assessment NCLEX: Analysis

1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to a. auscultate the lung sounds. b. assess the orientation. c. check the capillary refill. d. palpate the abdomen.

A Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority. Cognitive Level: Application Text Reference: pp. 824-825 Nursing Process: Assessment NCLEX: Physiological Integrity

Physiological Integrity 21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff. DIF: Cognitive Level: Apply (application) REF: 757 TOP: Nursing Process: Implementation MSC:

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? A) "I should avoid eating hamburgers." B) "I must cut out bacon and canned foods." C) "I shouldn't put the salt shaker on the table anymore." D) "I should avoid lunchmeats but may cook my own turkey." (Chp. 35; elsevier)

A) "I should avoid eating hamburgers." (Chp. 35; elsevier)

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? A) "I will call the provider if I have a cough lasting 3 or more days." B) "I will report to the provider weight loss of 2 to 3 pounds in a day." C) "I will try walking for 1 hour each day." D) "I should expect occasional chest pain." (Chp. 35; elsevier)

A) "I will call the provider if I have a cough lasting 3 or more days." (Chp. 35; elsevier)

After receiving change-of-shift report about these four clients, which client should the nurse assess first? A) A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions B) A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C) A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min (Chp. 35; elsevier)

A) A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (Chp. 35; elsevier)

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Select all that apply. A) Chest discomfort or pain B) Tachycardia C) Expectorating thick, yellow sputum D) Sleeping on back without a pillow E) Fatigue (Chp. 35; elsevier)

A) Chest discomfort or pain B) Tachycardia E) Fatigue (Chp. 35; elsevier)

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? A) Ibuprofen (Motrin) B) Hydrochlorothiazide (HydroDIURIL) C) NPH insulin D) Levothyroxine (Synthroid) (Chp. 35; elsevier)

A) Ibuprofen (Motrin) (Chp. 35; elsevier)

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? Fatigue Swelling of one leg Slow heart rate Brown discoloration of lower extremities

A. Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.

Which client has the highest risk for cardiovascular disease? Man who smokes and whose father died at 49 of myocardial infarction (MI) Woman with abdominal obesity who exercises three times per week Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL Man who is sedentary and reports four episodes of strep throat

A. Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.

Which statement reflects correct cardiac physical assessment technique? Auscultate the aortic valve in the second intercostal space at the right sternal border. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. Palpate the apical pulse over the third intercostal space in the midclavicular line. Assess for carotid bruit by auscultating over the anterior neck.

A. The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) Troponin 3.2 ng/mL Myoglobin 234 mcg/L C-reactive protein 13 mg/dL Triglycerides 400 mg/dL Lipoprotein-a 18 mg/dL

A.B. Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. A) Hypokalemia B) Sinus bradycardia C) Fatigue D) Serum digoxin level of 1.5 E) Anorexia (Chp. 35; elsevier)

B) Sinus bradycardia C) Fatigue E) Anorexia (Chp. 35; elsevier)

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? A) The client's ability to understand medication teaching B) The risk for hypotension C) The potential for bradycardia D) Liver function tests (Chp. 35; elsevier)

B) The risk for hypotension (Chp. 35; elsevier)

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? NPO status will cause the client to be thirsty. The dye causes an osmotic diuresis. The dye contains a heavy sodium load. The pedal pulses will be more easily palpable.

B. The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment. Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodine-based. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids.

Psychosocial Integrity 20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events.

B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting. DIF: Cognitive Level: Apply (application) REF: 762 TOP: Nursing Process: Planning MSC:

Physiological Integrity 10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. cardiac monitor shows a heart rate of 61 beats/minute.

B Patients taking -adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. DIF: Cognitive Level: Apply (application) REF: 745 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

B Patients who have been taking -adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking -adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries. DIF: Cognitive Level: Apply (application) REF: 745 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. decrease spasm of the coronary arteries. c. increase the force of the heart contractions. d. help prevent plaque from forming in the coronary arteries.

B Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and -adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand. DIF: Cognitive Level: Apply (application) REF: 742 | 744 TOP: Nursing Process: Implementation MSC:

The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? A) Determines the client's physical limitations B) Encourages alternate rest and activity periods C) Monitors and documents heart rate, rhythm, and pulses D) Positions the client to alleviate dyspnea (Chp. 35; elsevier)

D) Positions the client to alleviate dyspnea (Chp. 35; elsevier)

14. The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about a. an apical pulse rate of 106 beats/min. b. an oxygen saturation of 88% on room air. c. weight gain of 1 kg (2.2 lb) over 24 hours. d. decreased hourly patient urinary output.

B Rationale: A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action. Cognitive Level: Analysis Text Reference: pp. 829-830 Nursing Process: Assessment NCLEX: Physiological Integrity

22. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? a. Teach the patient the reasons for remaining on bed rest. b. Monitor the patient's BP every hour. c. Adjust the drip rate to keep the systolic BP >90 mm Hg. d. Call the health care provider about a decrease in urine output.

B Rationale: An experienced LPN/LVN would be able to monitor BP and would know to report significant changes to the RN. Teaching patients and making adjustments to the drip rate for vasoactive medications are RN-level skills. Because the health care provider may order changes in therapy based on the decrease in urine output, the RN should call the health care provider about the decreased urine output. Cognitive Level: Application Text Reference: pp. 827-829 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

5. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that a. hypertensive crisis may lead to development of acute heart failure in some patients. b. hypertension eventually will lead to heart failure by overworking the heart muscle. c. high BP increases risk for rheumatic heart disease. d. high systemic pressure precipitates papillary muscle rupture.

B Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients. Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A -hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the papillary muscle). Cognitive Level: Application Text Reference: p. 822 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

8. A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as a. pulsus alternans. b. paroxysmal nocturnal dyspnea. c. two-pillow orthopnea. d. acute bilateral pleural effusion.

B Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment NCLEX: Physiological Integrity

11. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as a. administering sedatives to promote rest and decrease myocardial oxygen demand. b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed. c. administering oxygen per mask or nasal cannula. d. encouraging leg exercises to improve venous return.

B Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload. Cognitive Level: Application Text Reference: pp. 827-828 Nursing Process: Planning NCLEX: Physiological Integrity

7. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops a. a drop in heart rate to 54 beats/min. b. a systolic BP <90 mm Hg. c. any symptoms indicating cyanide toxicity. d. an increased amount of ventricular ectopy.

B Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After 48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy. Cognitive Level: Application Text Reference: p. 828 Nursing Process: Evaluation NCLEX: Physiological Integrity

10. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient a. says that the nitroglycerin patch will be used for any chest pain that develops. b. calls when the weight increases from 124 to 130 pounds in a week. c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime. d. makes an appointment to see the doctor at least once yearly.

B Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. Heart failure is a chronic condition that will require frequent follow-up rather than an annual health care provider examination. Cognitive Level: Application Text Reference: pp. 826, 833-834, 838 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? A) The client has diuresis of 400 mL in 24 hours. B) The client's blood pressure is 122/84 mm Hg. C) The client has an apical pulse of 82 beats/min. D) The client's weight decreases by 2.5 kg. (Chp. 35; elsevier)

D) The client's weight decreases by 2.5 kg. (Chp. 35; elsevier)

15. While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include a. transfer to a dementia care service. b. referral to a home health care agency. c. placement in a long-term-care facility. d. arrangements for around-the-clock care.

B Rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient to develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term-care, or around-the-clock home care. Cognitive Level: Application Text Reference: pp. 836-837 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

Physiological Integrity 13. When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. DIF: Cognitive Level: Apply (application) REF: 753 TOP: Nursing Process: Evaluation MSC:

Psychosocial Integrity 22. When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during the surgery." b. "I will have small incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."

B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 752 TOP: Nursing Process: Evaluation MSC:

A client who recently had a heart valve replacement is taking warfarin (Coumadin) as prescribed. What statement by the client indicates that the nurse will need to do additional health teaching? A) "I will take my pulse every day, and call my doctor if it is below 60." B) "I will eat foods that are high in vitamin K, such as kale and spinach." C) "I will weigh myself every day in the morning using the same scale." D) "I will take my blood pressure every day and call if it is too high or low." (Chp. 35; p. 697)

B) "I will eat foods that are high in vitamin K, such as kale and spinach." (Chp. 35; p. 697)

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? A) Assess the client for peripheral edema. B) Auscultate the client's posterior breath sounds. C) Notify the health care provider about the client's weight gain. D) Remind the client about dietary sodium restrictions. (Chp. 35; elsevier)

B) Auscultate the client's posterior breath sounds. (Chp. 35; elsevier)

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? A) Serum potassium level of 3.2 mEq/L B) Ejection fraction of 60% C) B-type natriuretic peptide (BNP) of 760 ng/dL D) Chest x-ray report showing right middle lobe consolidation (Chp. 35; elsevier)

B) C) B-type natriuretic peptide (BNP) of 760 ng/dL (Chp. 35; elsevier)

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? A) Ejection fraction is 25%. B) Client states that she is able to sleep on one pillow. C) Client was hospitalized five times last year with pulmonary edema. D) Client reports that she experiences palpitations. (Chp. 35; elsevier)

B) Client states that she is able to sleep on one pillow. (Chp. 35; elsevier)

Which client is best to assign to an LPN/LVN working on the telemetry unit? A) Client with heart failure who is receiving dobutamine (Dobutrex) B) Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea C) Client with pericarditis who has a paradoxical pulse and distended jugular veins D) Client with rheumatic fever who has a new systolic murmur (Chp. 35; elsevier)

B) Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea (Chp. 35; elsevier)

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? A) Calls the family to lift the client's spirits B) Considers further assessment for depression C) Sedates the client to decrease myocardial oxygen demand D) Tells the client that things will get better (Chp. 35; elsevier)

B) Considers further assessment for depression (Chp. 35; elsevier)

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. A) Peripheral edema B) Crackles in both lungs C) Breathlessness D) Ascites E) Tachypnea (Chp. 35; p. 683)

B) Crackles in both lungs C) Breathlessness E) Tachypnea (Chp. 35; p. 683)

An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action? A) Call the ED physician immediately B) Draw a serum digoxin level C) Assess for signs of hypokalemia D) Establish the client's airway (Chp. 35; p. 687)

B) Draw a serum digoxin level (Chp. 35; p. 687)

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? A) Serum sodium level of 135 mEq/L B) Serum potassium level of 2.8 mEq/L C) Serum creatinine of 1.0 mg/dL D) Serum magnesium level of 1.9 mEq/L (Chp. 35; elsevier)

B) Serum potassium level of 2.8 mEq/L (Chp. 35; elsevier)

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? "I don't know how I am going to change my lifestyle." "I don't need to change. It hasn't killed me yet." "I don't think it is as bad as the doctors say." "I will have to change my diet and exercise more."

B. A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because "it hasn't killed me yet" indicates maladaptive denial. Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicates a willingness to change.

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? No intervention is needed; this is a normal reading. Collaborate with the health care provider to administer a positive inotropic agent. Administer a STAT dose of metoprolol (Lopressor). Ask the client to perform the Valsalva maneuver.

B. A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.

Which statement about diagnostic cardiovascular testing is correct? Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. The left side of the heart is catheterized first and may be the only side examined.

B. Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? Calcium 8.5 mEq/L Potassium 3.0 mEq/L Magnesium 2.1 mEq/L International normalized ratio (INR) of 1.0

B. Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain Client who has many questions about the electrophysiology studies (EPS) scheduled for today

B. The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN. An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable; the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS; the newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently.

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? "Monitor the pulses in your feet when you get home." "Keep your affected leg straight for 2 to 6 hours." "Do not take your blood pressure medications on the day of the procedure." "Take your oral hypoglycemic with a sip of water on the morning of the procedure."

B. The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure; therefore, antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating; they are not taken when the client is NPO for procedures or surgery.

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? The client has had intermittent substernal chest pain for 6 months. The client develops wheezes and dyspnea after eating crab or lobster. The client reports that a previous arteriogram was negative for coronary artery disease. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

B. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.

Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.) Squeezing, vise-like chest pain Chest pain relieved by sitting upright Chest and abdominal pain relieved by antacids Sudden-onset chest pain relieved by anti-inflammatory agents Pain in the chest described as sharp or stabbing

B.D.E. The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing; squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) Consuming a diet rich in fiber Elevated C-reactive protein levels Low blood pressure Elevated high-density lipoprotein (HDL) cholesterol level Smoking

B.E. Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? Right atrial pressure is 4 mm Hg. Mean arterial pressure (MAP) is 58 mm Hg. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. PO2 is reported as 78 mm Hg.

B.To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.

2. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet. b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods. c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring. d. educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.

C Rationale: The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening; it is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate interventions but are not the first nursing actions indicated. There is no evidence that the patient's weight gain is caused by excessive dietary intake of fat or calories, so the answer beginning "instruct the patient in a low-calorie, low-fat diet" describes an inappropriate action. Cognitive Level: Application Text Reference: p. 826 Nursing Process: Assessment NCLEX: Physiological Integrity

Physiological Integrity 15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.

C A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise. DIF: Cognitive Level: Apply (application) REF: 761 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 12. Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation. b. Heparin decreases coronary artery plaque size. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. DIF: Cognitive Level: Understand (comprehension) REF: 746 TOP: Nursing Process: Implementation MSC:

Health Promotion and Maintenance 2. Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

C Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful. DIF: Cognitive Level: Apply (application) REF: 736-737 TOP: Nursing Process: Implementation MSC:

20. An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is a. 12-lead electrocardiogram (ECG). b. arterial blood gases (ABGs). c. B-type natriuretic peptide (BNP). d. serum creatine kinase (CK).

C Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP. Cognitive Level: Application Text Reference: p. 827 Nursing Process: Assessment NCLEX: Physiological Integrity

16. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's a. weight increases from 120 pounds to 122 pounds over 3 days. b. liver is palpable 2 cm below the ribs on the right side. c. serum potassium level is 3.0 mEq/L after 1 week of therapy. d. has 1 to 2+ edema in the feet and ankles in the morning.

C Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level. Cognitive Level: Application Text Reference: pp. 832-833 Nursing Process: Assessment NCLEX: Physiological Integrity

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? A) "How does this make you feel?" B) "This can be caused by taking performance-enhancing drugs." C) "This may be caused by a genetic trait." D) "Just imagine how bad it would be if you weren't in good shape." (Chp. 35; elsevier)

C) "This may be caused by a genetic trait." (Chp. 35; elsevier)

3. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. incompetent jugular vein valves. c. elevated right atrial pressure. d. jugular vein atherosclerosis.

C Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or atherosclerosis. Cognitive Level: Comprehension Text Reference: p. 825 Nursing Process: Assessment NCLEX: Physiological Integrity

9. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to venous congestion. b. disturbed body image related to massive leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure.

C Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate. Cognitive Level: Application Text Reference: p. 836 Nursing Process: Diagnosis NCLEX: Physiological Integrity

Physiological Integrity 16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. DIF: Cognitive Level: Apply (application) REF: 752 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect some nausea as a side effect of nitroglycerin." b. "I should only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."

C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved after 3 sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis. DIF: Cognitive Level: Apply (application) REF: 743 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 18. In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will check my pulse rate before I take any nitroglycerin tablets." b. "I will put the nitroglycerin patch on as soon as I get any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."

C The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates. DIF: Cognitive Level: Apply (application) REF: 743 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 17. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. DIF: Cognitive Level: Apply (application) REF: 749 TOP: Nursing Process: Implementation MSC:

Physiological Integrity 14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy. DIF: Cognitive Level: Apply (application) REF: 743 TOP: Nursing Process: Assessment MSC:

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings: Crackles in all fields S3 present Oliguria Diagnostic Findings: Ejection fraction 30% BNP 560 Sodium 130 mEq/L Provider Prescriptions: Diagnosis: heart failure Enalapril 10 mg orally daily Heparin 5000 units subcutaneously every 12 hours Furosemide 40 mg IV daily Strict I & O Which prescription does the nurse implement first? A) Enalapril B) Heparin C) Furosemide D) Intake and output (I & O) (Chp. 35; elsevier)

C) Furosemide (Chp. 35; elsevier)

Which nursing action may be delegated to a nursing assistant working on the medical unit? A) Determine the usual alcohol intake for a client with cardiomyopathy. B) Monitor the pain level for a client with acute pericarditis. C) Obtain daily weights for several clients with class IV heart failure. D) Check for peripheral edema in a client with endocarditis. (Chp. 35; elsevier)

C) Obtain daily weights for several clients with class IV heart failure. (Chp. 35; elsevier)

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A) Monitor pulse oximetry and cardiac rate and rhythm. B) Reassure the client that his distress can be relieved with proper intervention. C) Place the client in high-Fowler's position with the legs down. D) Ask a family member to remain with the client. (Chp. 35; elsevier)

C) Place the client in high-Fowler's position with the legs down. (Chp. 35; elsevier)

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A) The client ambulates around the nursing unit with a walker. B) The nurse monitors the client's pulse and blood pressure frequently. C) The nurse obtains a bedside commode before administering furosemide. D) The nurse returns the client to bed when he becomes tachycardic. (Chp. 35; elsevier)

C) The nurse obtains a bedside commode before administering furosemide. (Chp. 35; elsevier)

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? Maintains NPO (nothing by mouth) until this resolves Calls in another nurse for a second opinion Performs a complete neurologic assessment and notifies the health care provider Explains to the client and family that this is expected after sedation

C. Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention. Be confident in this decision; this assessment does not warrant a second opinion. Keeping the client NPO and waiting for symptoms to resolve is not appropriate. Slurred speech is not expected after sedation.

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? White blood cell count Low-density lipoproteins Serum troponin I level C-reactive protein

C. Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.

Physiological Integrity 6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet. DIF: Cognitive Level: Apply (application) REF: 738 TOP: Nursing Process: Evaluation MSC:

1. When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. increased risk of cardiovascular disease as people age. d. elevation of the patient's low-density lipoprotein (LDL) level.

D Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD. DIF: Cognitive Level: Apply (application) REF: 736 TOP: Nursing Process: Planning MSC:

Physiological Integrity 11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. the ability to do daily activities without chest pain.

D Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective -adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature. DIF: Cognitive Level: Apply (application) REF: 753 TOP: Nursing Process: Evaluation MSC:

Physiological Integrity 4. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient states that the pain "wakes me up at night." b. The patient rates the pain at a level 3 to 5 (0 to 10 scale). c. The patient states that the pain has increased in frequency over the last week. d. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.

D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina. DIF: Cognitive Level: Understand (comprehension) REF: 742 TOP: Nursing Process: Assessment MSC:

17. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. -adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

D Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Implementation NCLEX: Physiological Integrity

4. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. improvement in hourly urinary output. c. reduction in systolic BP. d. decreased dyspnea with the head of the bed at 30 degrees.

D Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles. The other assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful in evaluating this patient's response. Cognitive Level: Application Text Reference: p. 825 Nursing Process: Evaluation NCLEX: Physiological Integrity

23. A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective? a. "I will need to include more high-potassium foods in my diet." b. "I will expect to feel more short of breath for the next few days." c. "I will be sure to take the medication after eating something." d. "I will call for help when I need to get up to the bathroom."

D Rationale: Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparring, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of -blocker therapy for heart failure, not for ACE-inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating. Cognitive Level: Application Text Reference: p. 832 Nursing Process: Evaluation NCLEX: Physiological Integrity

13. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include a. avoid dietary sources of potassium because too much can cause digitalis toxicity. b. take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min. c. take the hydrochlorothiazide before bedtime to maximize activity level during the day. d. notify the health care provider immediately if nausea or difficulty breathing occurs.

D Rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the medications are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. Digoxin toxicity is potentiated by hypokalemia, rather than hyperkalemia. Patients should be taught to check their pulse daily before taking the digoxin and, if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption. Cognitive Level: Application Text Reference: p. 835 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

18. A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that a. heart transplants are experimental surgeries that are not covered by most insurance. b. the patient is too old to be placed on the transplant list. c. the diagnoses and symptoms indicate that the patient is not an appropriate candidate. d. candidacy for heart transplant depends on many factors.

D Rationale: Indications for a heart transplant include inoperable coronary artery disease and refractory end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Heart transplants are not considered experimental; rather, transplantation has become the treatment of choice for patients who meet the criteria. The patient is not too old for a transplant. The patient's diagnoses and symptoms indicate that the patient may be an appropriate candidate for a heart transplant. Cognitive Level: Comprehension Text Reference: p. 837 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

12. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. eggs and other high-cholesterol foods. b. canned and frozen fruits. c. fresh or frozen vegetables. d. milk, yogurt, and other milk products.

D Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction. Cognitive Level: Application Text Reference: p. 833 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

Physiological Integrity 8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Understand (comprehension) REF: 749 TOP: Nursing Process: Assessment MSC:

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEp/L. What is the nurse's best action at this time? A) Assess the client's oxygen saturation level B) Ask the laboratory to retest the potassium level C) Give potassium as an IV infusion. D) Check the client's serum creatinine (Chp. 35; p.686)

D) Check the client's serum creatinine (Chp. 35; p. 686)

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? A) Give the digoxin; reassess the heart rate in 30 minutes. B) Give the digoxin; document assessment findings in the medical record. C) Hold the digoxin, and obtain a prescription for an additional dose of furosemide. D) Hold the digoxin, and obtain a prescription for a potassium supplement. (Chp. 35; elsevier)

D) Hold the digoxin, and obtain a prescription for a potassium supplement. (Chp. 35; elsevier)

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? "This is a noninvasive test performed to assess your heart rhythm." "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." "This is a painless test that is done to assess the structure of your heart using sound waves." "This test evaluates you for potentially fatal cardiac rhythms."

D. EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? Saline infusion Morphine sulfate No treatment, continue monitoring Intravenous furosemide

D. Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure. Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse should collaborate with the provider to decrease the right atrial pressure.

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? Assess preprocedure medications the client took that day. Have the client sign the consent form before the procedure is performed. Educate the client about the need to remain on bedrest after the procedure. Obtain client vital signs and a resting electrocardiogram (ECG).

D. Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? Men do not tend to report chest pain. Men are more likely than women to die after MI. Men more than women tend to deny the importance of symptoms. Women may experience extreme fatigue and dizziness as sole symptoms.

D. Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.