Alterations in Cardiovascular System NCLEX Part 3

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. A. The RR intervals are relatively consistent. B. One P wave precedes each QRS complex. C. Four to eight complexes occur in a 6-second strip. D. The ST segment is higher than the PR interval. E. The QRS complex ranges from 0.12 to 0.2 seconds.

A & B (1) The consistency of the RR interval indicates a regular rhythm. (2) A normal P wave before each complex indicates the impulse originated in the SA node.

Hypertension that can be attributed to an underlying cause is termed A. secondary hypertension. B. primary hypertension. C. isolated systolic hypertension. D.essential hypertension.

A. Secondary hypertension may be caused by a tumor of the adrenal gland (e.g., pheochromocytoma). Primary, or essential, hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg).

A 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn't able to obtain pulses in his left foot using Doppler ultrasound. She immediately notifies the physician, who asks her to prepare the client for surgery. As the nurse enters the client's room to prepare him, he states that he won't have any more surgery. What is the most appropriate initial action of the nurse? A. Explaining the risks of not having the surgery B. Notifying the physician immediately C. Notifying the nursing supervisor D. Recording the client's refusal in the nurses' notes

A. The best initial response is to explain the risks of not having the surgery. If the client understands the risks but still refuses, the nurse should notify the physician and the nursing supervisor and then record the client's refusal in the nurses' notes.

The nurse is caring for a client with a blood pressure of 210/100 mm Hg in the emergency room. What is the most appropriate route of administration for antihypertensive agents? A. continuous IV infusion B. oral C. intramuscular D. sublingual

A. The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the sublingual and IM routes as their absorption and dynamics are unpredictable. The oral route would not have as quick an onset as a continuous IV infusion.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? A. Peripheral pulses every 15 minutes after surgery B. Color of the leg every 4 hours C. Blood pressure every 2 hours D. Ankle-arm indices every 12 hours

A. The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable.

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? A. "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." B. "The older I get the higher my risk for peripheral arterial disease gets." C. "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." D. "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease."

A. The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.

Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to see evidence of the drug's desired effect? A. 5 to 10 minutes B. 30 to 60 minutes C. 2 to 4 hours D. 6 to 8 hours

A. 5 to 10 minutes After IV injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. The terminal half-life of furosemide is approximately 2 hours, and the total time of therapeutic effect is 6 to 8 hours. However, the half-life of furosemide will prolong in patients with chronic renal disease.

Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include a demonstration of the proper use of: A. A manual toothbrush B. An electric toothbrush C. An irrigation device D. Dental floss

A. A manual toothbrush Daily dental care and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. In 2007, the AHA modified their infective endocarditis prophylaxis guidelines, and the indications for prophylaxis were reduced for dental procedures, genitourinary, and gastrointestinal tract procedures.

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: A. Alteration in tissue perfusion related to compromised circulation. B. Dysfunctional use of extremities related to muscle spasms. C. Impaired mobility related to stress associated with pain. D. Impairment in muscle use is associated with pain on exertion.

A. Alteration in tissue perfusion related to compromised circulation. Insufficient arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient.

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply. A. Smoking B. Diabetes mellitus C. Gallbladder disease D. Frequent upper respiratory infections E. Physical inactivity

A. B. E. Risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, and family history.

Cancer can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

A. Blood coagulability Charles Emile Troisier later recognized the further association of other abdominal cancers as well as testicular cancer with the presence of Virchow's node. Virchow sought to explain the causation of pulmonary thromboembolism and theorized that pulmonary arterial embolus arises from peripheral/distant thrombosis.

Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? A. Exertional dyspnea B. Confusion C. Elevated creatine phosphokinase concentration D. Chest pain

A. Exertional dyspnea Weight gain, due to fluid retention and worsening heart failure, causes exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward into pulmonary veins, capillaries, and arterioles and eventually to the right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow.

An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: A. Left ventricular atrophy B. Irregular heartbeats C. Peripheral vascular occlusion D. Pacemaker placement

A. Left ventricular atrophy In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. While aging does not itself cause heart failure (HF), it does lower the threshold for the manifestation of the disease. As the populations of most developed countries continue to become older, on average, the importance of aging as a risk factor for all cardiovascular diseases increases in kind.

Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses the client's past compliance with medical regimens. Lack of compliance with which of the following regimens would pose the greatest health hazard to this client? A. Medication therapy B. Diet modification C. Activity restrictions D. Dental care

A. Medication therapy Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Post-op, all clients with mechanical valves and some with bioprostheses are maintained indefinitely on anticoagulation therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence from rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, GI, or GU surgery.

A client's electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is: A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia D. Sinus dysrhythmia

A. Normal sinus rhythm Normal sinus rhythm (NSR) is another name for the normal heart rhythm. The heartbeat is controlled by regular electric signals (also called electrical impulses) that spontaneously arise in a structure called the sinus node. These signals then spread across the heart starting at the atria and then the ventricles. The heart's rhythm is referred to as "sinus rhythm" because the electrical impulse is generated in the sinus node. A normal sinus rhythm is one in which the rate of firing is not too fast nor too slow.

The physician orders continuous intravenous nitroglycerin infusion for the client with MI. Essential nursing actions include which of the following? A. Obtaining an infusion pump for the medication. B. Monitoring BP q4h. C. Monitoring urine output hourly. D. Obtaining serum potassium levels daily.

A. Obtaining an infusion pump for the medication. IV nitro infusion requires an infusion pump for precise control of the medication. When administered as a drip in the emergency room or ICU, its effects are often very closely monitored via an arterial line for real-time blood pressure monitoring. This vigilance is necessary to maximize the effectiveness of the drip and provide rapid feedback on the patient's condition.

A nurse has the order to begin administering warfarin sodium (Coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin? A. Vitamin K B. Aminocaproic acid C. Potassium chloride D. Protamine sulfate

A. Vitamin K The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for use if excessive bleeding or hemorrhage should occur. When managing warfarin toxicity, the initial step would be to discontinue warfarin and then administer vitamin K (phytonadione). The vitamin K may administration can be either via the oral, intravenous, or subcutaneous route. However, the initial administration of oral vitamin K is often preferable in patients without major bleeding or extremely elevated INR.

The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition? A. Myocardial infarction B. Heart failure C. Pericarditis D. Pulmonary embolism

B. An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating A. paroxysmal nocturnal dyspnea. B. orthopnea. C. hyperpnea. D. dyspnea upon exertion.

B. Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Which medication reverses digitalis toxicity? A. Amlodipine B. Digoxin immune FAB C. Warfarin D. Ibuprofen

B. Digoxin immune FAB binds with digoxin and makes it unavailable for use. The dosage is based on the digoxin concentration and the client's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.

A nurse is assessing a client and notes a blood pressure (BP) of 205/115. The client has had BP's within normal limits up until this time. The client reports a sudden onset severe headache. The nurse recognizes this as probable malignant hypertension. What would be the nurse's first action? A. Administer the ordered antihypertensive. B. Notify the health care provider. C. Call a code. D. Wait 15 minutes and reassess the vital signs.

B. Malignant hypertension is fatal unless BP is quickly reduced. Even with intensive treatment, the kidneys, brain, and heart may be permanently damaged.

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atria pressure D. Decreased pulmonary artery pressure

B. Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure.

Which of the following is the most effective intervention for preventing progression of vascular disease? A. Wear sturdy shoes B. Risk factor modification C. Use neutral soaps D. Avoid trauma

B. Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured? A. cardiac ultrasound B. echocardiogram C. cardiac catheterization D. electrocardiogram

B. The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.

A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have? A. Secondary B. Essential (primary) C. Malignant D. Pathologic

B. Essential or primary hypertension, about 95% of cases, is sustained elevated BP with no known cause. This client does not have secondary, pathologic, or malignant hypertension.

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: A. Inside of the ankle just above the heel. B. Anterior surface of the foot near the ankle joint. C. Exterior surface of the foot near the heel. D. Outside of the foot just below the heel.

B. The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone.

A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for: A. Thrombocytopenia and weight gain B. Anorexia, nausea, and visual disturbances C. Diarrhea and hypotension D. Fatigue and muscle twitching

B. Anorexia, nausea, and visual disturbances The first signs and symptoms of digoxin toxicity in adults include abdominal pain, N/V, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias. Symptoms may be mild and include nausea, vomiting, and anorexia. Visual side effects might include color changes, also known as xanthopsia. But yellow or green-tinted vision is usually associated with digoxin toxicity. Patients may also highlight blurry vision or photopsia. At toxic levels, digoxin is proarrhythmic.

Aspirin is administered to the client experiencing an MI because of its: A. Antipyretic action B. Antithrombotic action C. Antiplatelet action D. Analgesic action

B. Antithrombotic action Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason ASA is administered to the client experiencing an MI is its antithrombotic action. Aspirin is a cyclooxygenase-1 (COX-1) inhibitor. It is a modifier of the enzymatic activity of cyclooxygenase-2 (COX-2). Unlike other NSAIDs (ibuprofen/naproxen), which bind reversibly to this enzyme, aspirin binding is irreversible. It also blocks thromboxane A2 on platelets in an irreversible fashion preventing platelet aggregation.

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of: A. Thrombosis and infection B. Bleeding and infection C. Bleeding and wound dehiscence. D. Wound dehiscence and evisceration.

B. Bleeding and infection After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client. During the vascular access for IVC filter insertion, bleeding and thrombosis are the most common complications. Other complications that can occur during this time include filter tilt (angulation of more than 15 degrees along the longitudinal axis of IVC), filter migration (change in position of the filter by more than 2 cm) or operator error (filter placement in the inaccurate location or incorrect orientation); these can result in a difficult to retrieve as well as an ineffective IVC filter.

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to an aneurysm? A. Pulsatile abdominal mass. B. Hyperactive bowel sounds in that area. C. Systolic bruit over the area of the mass. D. Subjective sensation of "heart beating" in the abdomen.

B. Hyperactive bowel sounds in that area Not all clients with abdominal aortic aneurysms exhibit symptoms. Physical exam should also look for other associated aneurysms. The most common associated aneurysm is an iliac artery aneurysm. Peripheral aneurysms are also associated in approximately 5 % of patients, of which popliteal artery aneurysms are the most common.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? A. Evident scaring B. Ulcers and infection in the edematous area C. Cyanosis D. Loose and wrinkled skin

B. In a client with lymphedema, the tissue nutrition is impaired as a result of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scaring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.

A client who has been receiving heparin therapy also is started on warfarin sodium (coumadin). The client asks the nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin sodium: A. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this to exhibit an anticoagulant effect. B. Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect. C. Stimulates production of the body's own thrombolytic substances, but it takes 2-4 days for it to begin. D. Has the same mechanism action of heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic.

B. Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect. Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. Heparin is generally continued for seven to ten days. During this time warfarin is generally begun, and it is important to continue the patient on warfarin for five to seven days while the patient is receiving intravenous heparin therapy. After stopping heparin, oral anticoagulation with warfarin should be continued for six weeks.

With peripheral arterial insufficiency, leg pain during rest can be reduced by: A. Elevating the limb above heart level. B. Lowering the limb so it is dependent. C. Massaging the limb after application of cold compresses. D. Placing the limb in a plane horizontal to the body.

B. Lowering the limb so it is dependent The cornerstone of treatment of PAD is exercise to improve peripheral circulation, walking economy, cardiopulmonary function, and functional capacity. The data to support the efficacy of supervised exercise in improving claudication are robust with the length of the program influencing the magnitude of increase in maximal walking distance of up to 150% (range 74% to 230%).

A client comes to the outpatient clinic and tells the nurse that he has had leg pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? A. An acute obstruction in the vessels of the legs. B. Peripheral vascular problems in both legs. C. Diabetes D. Calcium deficiency

B. Peripheral vascular problems in both legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. Intermittent claudication (IC) typically refers to lower extremity skeletal muscle pain that occurs during exercise. IC presents when there is insufficient oxygen delivery to meet the metabolic requirements of the skeletal muscles. Pain within these muscle groups is reproducibly induced by walking and relieved with rest.

A nurse is preparing to ambulate a client on the 3rd day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? A. Encourage the client to cough and deep breathe. B. Premedicate the client with an analgesic. C. Provide the client with a walker. D. Remove telemetry equipment because it weighs down the hospital gown.

B. Premedicate the client with an analgesic. The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Before performing the exercises, the patients will be asked to quantify their pain and, if they describe an intensity of more than three on the visual analog scale (VAS), a prescription of analgesics (containing moderate opioids) will be requested from their physician and a break will be taken at that moment until the sensation of pain gets better.

Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of MI? A. Liquids as ordered B. Small, easily digested meals C. Three regular meals per day D. NPO

B. Small, easily digested meals Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well.

A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The complication the nurse will constantly observe for is: A. Presence of heart murmur B. Systemic emboli C. Fever D. Congestive heart failure

B. Systemic emboli Emboli are the major problem; those arising in the right heart chambers will terminate in the lungs and left chamber emboli may travel anywhere in the arteries. Complications include conduction disease (first-degree atrioventricular block, bundle branch block, or complete heart block), ischemia (emboli to the coronary arteries), embolic stroke, intracerebral hemorrhage, brain abscess, septic emboli leading to infarction of the kidneys, spleen, lungs and other organs, hematogenous spread of infection leading to vertebral osteomyelitis, septic arthritis, or psoas abscess and systemic immune reaction such as glomerulonephritis.

Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet? A. Apples B. Tomato juice C. Whole wheat bread D. Beef tenderloin

B. Tomato juice Canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided on a sodium-restricted diet. Canned and processed foods, such as gravies, instant cereal, packaged noodles, and potato mixes, olives, pickles, soups, and vegetables are high in salt. Choose the frozen item instead; or better yet, choose fresh foods when you can. Cheeses, cured meats (such as bacon, bologna, hot dogs, and sausages), fast foods, and frozen foods also may contain a lot of sodium.

Which technique is considered the gold standard for diagnosing DVT? A. Ultrasound imaging B. Venography C. MRI D. Doppler flow study

B. Venography Proximal leg vein ultrasound, which when positive, indicates that the patient should be treated as having a DVT. If a patient scores 2 or above, either a proximal leg vein ultrasound scan should be done within 4 hours, and if the result is negative, a D-dimer test should be done. If imaging is not possible within 4 hours, a D-dimer test should be undertaken, and an interim 24-hour dose of a parenteral anticoagulant should be given. A proximal leg vein ultrasound scan should be carried out within 24 hours of being requested.

The nurse determines that a client recently diagnosed with subacute bacterial endocarditis understands discharge teaching upon which client statement? A. "Can I take the antibiotics as a pill now?" B. "If I quit smoking, it will help the endocarditis." C. "I have to call my doctor so I can get antibiotics before seeing the dentist." D. "I need a referral to a dietician to understand a low-sodium diet."

C. Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after dental procedures.

A client with hypertension visits the health clinic for a routine checkup. The nurse measures the client's blood pressure at 184/92 mm Hg and notes a 5-lb (2.3-kg) weight gain within the past month. Which nursing diagnosis reflects the most serious problem in managing a client with hypertension? A. Imbalanced nutrition: More than body requirements B. Excess fluid volume C. Noncompliance (nonadherence to therapeutic regimen) D. Deficient knowledge (disease process)

C. Noncompliance is the most serious problem in managing a client with hypertension. One authority estimates that 40% to 60% of hypertensive clients fail to comply with ordered treatment. Reasons for noncompliance include lack of symptoms, which makes the problem seem less serious; the difficulty of making required lifestyle changes, such as eating a low-sodium diet, stopping smoking, and losing or managing weight; adverse reactions to antihypertensive drugs; and the inconvenience and high cost of obtaining health care. Deficient knowledge contributes to noncompliance; Excess fluid volume, caused by excess sodium intake, and Imbalanced nutrition: More than body requirements may result from noncompliance.

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? A. Numbness, warm skin temperature, and redness B. Redness, cool skin temperature, and swelling C. Numbness, cool skin temperature, and pallor D. Swelling, warm skin temperature, and drainage

C. Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.

The nurse is caring for a client who has had 25 mg of oral hydrochlorothiazide added to the medication regimen for the treatment of hypertension. Which instruction should the nurse give the client? A. "Take this medication before going to bed." B. "You may drink alcohol while taking this medication." C. "Increase the amount of fruits and vegetables you eat." D. "You may develop nasal congestion or depression while taking this medication."

C. Thiazide diuretics cause loss of sodium, potassium, and magnesium, so the client should be encouraged to eat fruits and vegetables that are high in potassium. Diuretics cause increased urination; the client should not take the medication before going to bed. Thiazide diuretics do not cause dry mouth or nasal congestion; both side effects are associated with alpha2-agonists. Postural hypotension may be potentiated by alcohol.

The nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hrs? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. After an MI, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the hearts electrical system.

A client needs to have a cardiac valve replacement. The nurse offers client education about the procedures involved—including the benefits and risks. Which client statement indicates the need for more education? A. "I might lose some blood, but not likely a large quantity of it." B. "Since the procedure is minimally invasive, there is less postoperative pain than with other techniques." C. "I'm anxious because I'll need to have cardiopulmonary bypass." D. "Since the procedure is minimally invasive, there is less surgical trauma."

C. Cardiopulmonary bypass is not normally required for valve replacement, though it is kept available as an option should the need arise. Minimally invasive techniques generally involve less pain, trauma, and blood loss than alternative techniques.

Varicose veins can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

C. Blood flow Venous stasis is more likely to occur in patients with atrial fibrillation, valvular heart disease: prolonged immobility such as bedridden patients or prolonged travel, surgery, and trauma. Exposure to cell proteins triggers anticoagulant pathways on the surface of endothelial cells. The thinking is that as blood flow slows through vascular beds, flow reduces, and the natural anticoagulant properties from interaction with surface proteins are affected, resulting in thrombi production.

Which of the following arteries primarily feeds the anterior wall of the heart? A. Circumflex artery B. Internal mammary artery C. Left anterior descending artery D. Right coronary artery

C. Left anterior descending artery The left anterior descending artery is the primary source of blood for the anterior wall of the heart. The left anterior descending artery (LAD) supplies the anterior two-thirds of the septum. The LAD is one of two major branches of the LMCA, with the other being the left circumflex (LCx) coronary arteries. Combined, these two supply blood to the left atrium and left ventricle.

A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also will be started on digoxin (Lanoxin), a nurse checks the client's most recent: A. Digoxin level B. Sodium level C. Potassium level D. Creatinine level

C. Potassium level The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias. Toxicity can also occur at lower levels, especially in the setting of other risk factors such as low body weight, advanced age, decreased renal function, and hypokalemia. Risk of hypokalemia increases with the use of a high dose of furosemide, decreased oral intake of potassium, in patients with hyperaldosteronism states (liver abnormalities or licorice ingestion) or concomitant use of corticosteroid, ACTH, and laxatives.

A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have any symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the nice lady, the nurse would most likely learn that the client's childhood health history included: A. Chicken pox B. Poliomyelitis C. Rheumatic fever D. Meningitis

C. Rheumatic fever Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. The most common cause of mitral stenosis is rheumatic fever. Uncommon causes of mitral stenosis are calcification of the mitral valve leaflets and congenital heart disease. Other causes of mitral stenosis include infective endocarditis, mitral annular calcification, endocardial fibroelastosis, malignant carcinoid syndrome, systemic lupus erythematosus, Whipple disease, Fabry disease, and rheumatoid arthritis.

Which of the following characteristics is typical of the pain associated with DVT? A. Dull ache B. No pain C. Sudden onset D. Tingling

C. Sudden onset DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease.

A client with angina complains that the angina pain is prolonged and severe and occurs at the same time each day, most often in the morning, On further assessment a nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as: A. Stable angina B. Unstable angina C. Variant angina D. Non anginal pain

C. Variant angina Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Patients with vasospastic angina present with a chronic pattern of episodes of chest pain at rest that last 5 to 15 minutes, from midnight to early morning. Typically, the chest pain is not triggered by exertion or alleviated with rest as is typical angina. Pain decreases with the use of short-acting nitrates. Often, the patient is younger with few or no classical cardiovascular risk factors.

Captopril may be administered to a client with HF because it acts as a: A. Vasopressor B. Volume expander C. Vasodilator D. Potassium-sparing diuretic

C. Vasodilator ACE inhibitors have become the vasodilators of choice in the client with mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure. ACEi improves heart failure by decreasing afterload. Apart from decreasing the afterload, it also reduces cardiac myocyte hypertrophy. The Heart Outcomes Prevention Evaluation (HOPE) Study demonstrated better outcomes for those prescribed ACE inhibitors.

When teaching a client with a cardiac problem, who is on a high-unsaturated fatty-acid diet, the nurse should stress the importance of increasing the intake of: A. Enriched whole milk B. Red meats, such as beef C. Vegetables and whole grains D. Liver and other glandular organ meats

Correct Answer: C. Vegetables and whole grains Vegetables and whole grains are low in fat and may reduce the risk for heart disease. A largely vegetarian "dietary portfolio of cholesterol-lowering foods" substantially lowers LDL, triglycerides, and blood pressure. The key dietary components are plenty of fruits and vegetables, whole grains instead of highly refined ones, and protein mostly from plants. Add margarine enriched with plant sterols; oats, barley, psyllium, okra, and eggplant, all rich in soluble fiber; soy protein; and whole almonds.

A blood pressure (BP) of 140/90 mm Hg is considered to be A. prehypertension. B. a hypertensive emergency. C. normal. D. hypertension.

D. A BP of 140/90 mm Hg or higher is hypertension. A blood pressure less than 120/80 mm Hg is considered normal. A BP of 120 to 139/80 to 89 mm Hg is prehypertension. Hypertensive emergency is a situation in which BP is severely elevated and there is evidence of actual or probable target organ damage.

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? a) Midsternal chest pain b) Thrill c) Pitting edema in lower extremities d) Lower back discomfort

D. Abdominal aortic aneurysm involves a widening, stretching or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? A. Urine output of 150 ml/hour and heart rate of 45 beats/minute B. Urine output of 15 ml/hour and 2+ hematuria C. Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute D. Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

D. Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

The nurse is caring for a client diagnosed with coronary artery disease (CAD). What condition most commonly results in CAD? A. diabetes mellitus B. myocardial infarction C. renal failure D. atherosclerosis

D. Atherosclerosis (plaque formation) is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related.

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? A. "My best time of the day is the morning." B. "I eat six small meals a day when I am hungry." C. "I've stopped eating foods with salt, though I miss the taste." D. "I'm having trouble going up the steps during the day."

D. Difficulty with activities like climbing stairs is an indication of a lessened ability to exercise. Eating small meals and not using salt are usually indicated for clients with heart failure. The client's assertion about morning being the best time of day is a vague statement.

A nurse working in the clinic is seeing a client who has just been prescribed a new medication for hypertension. The client asks why hypertension is sometimes called the "silent killer." What is the best response by the nurse? A. "Hypertension often causes no pain." B. "Hypertension is difficult to diagnose." C. "Hypertension often kills early in the disease process." D. "Hypertension often causes no symptoms."

D. Hypertension is sometimes called the "silent killer" because people with it are often symptom free. Physical examination may reveal no abnormalities other than elevated blood pressure. People with hypertension may remain asymptomatic for many years. The usual consequences of prolonged, uncontrolled hypertension are myocardial infarction, heart failure, renal failure, strokes, and impaired vision. Pain is not usually an issue, but that is not why hypertension is called the "silent killer." Hypertension is easily diagnosed by taking a series of blood pressure readings.

A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? A. "Reduce your level of exercise." B. "Consider cutting down on your smoking." C. "See the physician if complications occur." D. "Practice meticulous foot care."

D. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? A. Wear antiembolic stockings daily to assist with blood return to the heart. B. Keep your feet elevated above your heart. C. Do not cross your legs for more than 30 minutes at a time. D. Stop smoking.

D. Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true? A. Pressures must be equal in both arms. B. Pressures may vary, with the higher pressure found in the left arm. C. Pressures may vary 10 mm Hg or more between arms. D. Pressures should not differ more than 5 mm Hg between arms.

D. Normally, in the absence of any disease of the vasculature, arm pressures differ by no more than 5 mm Hg. The pressures in each arm do not have to be equal to be considered normal. Pressures that vary more than 10 mm Hg between arms are an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomic variant.

A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is? A. Associated with nausea and vomiting B. Described as crushing and substernal C. Accompanied by diaphoresis and dyspnea D. Relieved by rest and nitroglycerin

D. One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.

The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? A. ascites B. nocturia C. hepatomegaly D. inadequate cardiac output

D. Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is A. air plethysmography. B. lymphangiography. C. lymphoscintigraphy. D. contrast phlebography.

D. When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

A client who had cardiac surgery 24 hours ago has a urine output averaging 19 ml/hr for 2 hours. The client received a single bolus of 500 ml of IV fluid. Urine output for the subsequent hour was 25 ml. Daily laboratory results indicate the blood urea nitrogen is 45 mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for: A. Hypovolemia B. UTI C. Glomerulonephritis D. Acute renal failure

D. Acute renal failure The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased BUN and creatinine levels. The client may need medications such as dopamine (Intropin) to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis.

A significant cause of venous thrombosis is: A. Altered blood coagulation B. Stasis of blood C. Vessel wall injury D. All of the above

D. All of the above A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke.

Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? A. Has severe chest pain. B. Can identify risk factors for MI. C. Agrees to participate in a cardiac rehabilitation walking program. D. Can perform personal self-care activities without pain.

D. Can perform personal self-care activities without pain. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Pain is a subjective experience and must be described by the patient. Provides a baseline for comparison to aid in determining the effectiveness of therapy, resolution, and progression of the problem.

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: A. Has a pale colored base. B. Is deep, with even edges. C. Has little granulation tissue. D. Has brown pigmentation around it.

D. Has brown pigmentation around it. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from the accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema.

Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available in the nursing unit? A. Vitamin K B. Aminocaproic acid C. Potassium chloride D. Protamine sulfate

D. Protamine sulfate The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur. Protamine is a medication used to reverse and neutralize the anticoagulant effects of heparin. Protamine is the specific antagonist that neutralizes heparin-induced anticoagulation. When appropriately dosed, this neutralization reduces the risk of postoperative bleeding.

The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: A. Aorta B. Right atrium C. Superior vena cava D. Pulmonary circulation

D. Pulmonary circulation When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select All That Apply )a) Jugular vein distension b) Moist crackles c) Postural hypotension d) Increased heart rate e) Fever

a) Jugular vein distention : The increase in venous pressure due to excessive circulating blood volume results in neck vein distention b) Moist crackles : An indicator of pulmonary edema that can quickly lead to death d) Increased heart rate : fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in increased heart rate and bounding pulses

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The clients vital signs are BP 160/98, HR 102/min, R 22/min, SpO2 95%. Which of the following actions should the nurse take? a) Administer antihypertensive medication for BP b) Monitor that urinary output is 20 ml/hr c) Withhold pain meds to prepare for surgery d) Take vital signs every 2 hours

A. Administer antihypertensive medication for the elevated BP because HTN can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.

The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following? A. Chordae tendineae B. Atrioventricular tendons C. Semilunar tendineae D. Papillary tendons

A. Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Options B, C, and D are distractors for the question.

A client with aortic stenosis is reluctant to have valve replacement surgery. A nurse is present when the health care provider talks to the client about a treatment that is less invasive than surgery which will likely relieve some of the client's symptoms. What treatment option has been discussed? A. Balloon percutaneous valvuloplasty B. Antibiotic therapy C. Placement of a xenograft valve D. Placement of an autograft valve

A. Definitive treatment for aortic stenosis is surgical replacement of the aortic valve. Clients who are symptomatic, but not good surgical candidates may benefit from a one or two balloon percutaneous valvuloplasty. Antibiotic therapy will not open the valve. The client does not want to have a valve replacement of any kind.

Which type of cardiomyopathy is associated with syncope? A. Hypertrophic B. Restrictive C. Arrhythmic D. Dilated

A. Hypertrophic cardiomyopathy is associated with syncope (sudden loss of consciousness) or near-syncopal episodes, which the client may describe as "graying out". Dilated cardiomyopathy, the most common type, is accompanied by dyspnea on exertion and when lying down. Restrictive cardiomyopathy has symptoms of exertional dyspnea, dependent edema in the legs, ascites (fluid in the abdomen), and hepatomegaly (enlarged liver). Arrhythmic cardiomyopathy is inherited.

A client has had an echocardiogram to measure ejection fraction. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects? A. 55% B. 40% C. 45% D. 50%

A. Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.

The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse? A. Quality, volume, and rate B. Rate, quality, and rhythm C. Rate, rhythm, and volume D. Pressure, rate, and rhythm

B. Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse pressure and volume are not assessed in this instance.

A nurse is caring for a client after cardiac surgery. Upon assessment, the client appears restless and reports nausea and weakness. The client's ECG reveals peaked T waves. The nurse reviews the client's serum electrolytes, anticipating which abnormality? A. Hyponatremia B. Hyperkalemia C. Hypercalcemia D. Hypomagnesemia

B. Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without changes in T-wave formation.

The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide? A. Hemoglobin of 12 B. Potassium level of 3.1 C. Sodium level of 135 D. BNP of 100

B. Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP does not demonstrate a severe heart failure. Sodium level of 135 is within normal range, as is the hemoglobin level.

A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 9.8 g/dL D. Calcium 8.0 mg

A. A flattened T wave or the development of U waves is indicative of a low potassium level.

Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. B. Activity intolerance related to increased cardiac output. C. Decreased cardiac output related to structural and functional changes. D. Impaired gas exchange related to decreased sympathetic nervous system activity. E. Acute pain related to inability to meet the oxygen demands.

A, C & E. HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity.

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect? A. Heart failure B. Pulmonary embolism C. Tension pneumothorax D. Cardiac tamponade

A. A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.

The nurse correctly identifies which data as an example of blood pressure and heart rate measurements in a client with postural hypotension? A. supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm B. supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm C. supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm D. supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm

A. Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting position to a standing position. The following is an example of BP and HR measurements in a client with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure.

The nurse is removing a client's femoral sheath after cardiac catheterization. What medication will the nurse have available? A. atropine sulfate B. protamine sulfate C. adenosine D. heparin

A. Removing the sheath after cardiac catheterization may cause a vasovagal response, including bradycardia. The nurse should have atropine sulfate on hand to increase the client's heart rate if this occurs.

A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of the following findings should the nurse expect? a) Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes b) The client is experiencing premature ventricular complexes at 12/min c) Telemetry monitoring shows pacing spikes with no QRS complexes d) The client is experiencing hiccups

A. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min, because the client's intrinsic rate overrides the set rate of the pacemaker.

A client with a recent history of atrial fibrillation has been prescribed warfarin. What action will the nurse take to confirm safe dosing? A. Review the client's international normalized ratio (INR). B. Review the client's most recent warfarin blood levels. C. Assess the client's apical pulse. D. Assess the client's radial pulse.

A. Warfarin doses are adjusted on the basis of the client's INR. Blood levels are not taken for the drug, and the client's heart rate is not the indicator of efficacy or safety.

The nurse is reviewing the laboratory results for a client diagnosed with coronary artery disease (CAD). The client's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as A. high. B. within normal limits. C. low. D. critically high.

A. Treatment of blood cholesterol to reduce cardiovascular risk in adults calls for a fasting lipid profile to demonstrate an LDL value below 100 mg/dL (or less than 70 mg/dL for very high-risk clients). An LDL level of 115 mg/dL is higher than the target for treatment.

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: A. Normal because of the increased blood flow through the leg. B. Slightly deteriorating and should be monitored for another hour. C. Moderately impaired, and the surgeon should be called. D. Adequate from the arterial approach, but venous complications are arising.

A. Normal because of the increased blood flow through the leg. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Aortofemoral bypass surgery is a procedure utilized commonly for the treatment of aortoiliac occlusive disease, sometimes referred to as Leriche syndrome. Aortoiliac occlusive disease can contribute to lower extremity ischemic symptoms necessitating intervention.

The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit? A. Calculate the pauses between pulsations. B. Count the heart rate at the apex. C. Calculate the palpated volume. D. Count the radial pulse for 20 to 25 seconds.

B. The nurse determines the pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. The pulse quality refers to its palpated volume. Pulse rhythm is the pattern of the pulsations and the pauses between them.

A nurse is caring for a client with pericarditis and auscultates a pericardial friction rub. What action does the nurse ask the client to do to distinguish a pericardial friction rub from a pleural friction rub? A. The nurse has the client stand during auscultation. B. The nurse asks the client to hold the breath during auscultation. C. The nurse places the client flat for at least 4 minutes. D. There is really no question to ask the client to tell the difference.

B. A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid as a result of inflammation. The audible rub on auscultation is synchronous with the heartbeat. To distinguish between a pleural rub and a pericardial rub, the client should hold the breath. The pericardial rub will continue. Length of auscultation and standing would not assist in distinguishing one kind of rub from the other.

The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response? A. "Having an orgasm is very strenuous and your husband must be in excellent physical shape before attempting it." B. "The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." C. "The medications will prevent your husband from having an erection." D. "It is usually better to just give up sex after a heart attack."

B. The physiologic demands are greatest during orgasm. The level of activity is equivalent to walking 3 to 4 miles per hour on a treadmill. Sexuality is an important quality of life, so the healthcare provider will be determining when it is safe to have intercourse. Erectile dysfunction may be a side effect of beta-blockers, but other medications may be substituted.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? A. Jugular venous distention B. Pulmonary congestion C. Nausea D. Pedal edema

B. When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.

In preparation for the discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: A. Walking several times each day as an exercise program. B. Keeping the heat up so that the environment is warm. C. Wearing a TED hose during the day. D. Using hydrotherapy for increasing oxygenation.

B. Keeping the heat up so that the environment is warm. The client's instructions should include keeping the environment warm to prevent vasoconstriction. In response to cold temperatures, the body adapts by restricting blood flow to the skin. This is done as a thermoregulatory mechanism to prevent further loss of body heat and to sustain the core body temperature. In Raynaud's phenomenon, blood-flow restriction occurs during cold temperatures and emotional stress.

The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects: A. Left atrial enlargement B. Left ventricular enlargement C. Right atrial enlargement D. Right ventricular enlargement

B. Left ventricular enlargement A normal apical impulse is found under over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

Buerger's disease is characterized by all of the following except: A. Arterial thrombosis formation and occlusion. B. Lipid deposits in the arteries. C. Redness or cyanosis in the limb when it is dependent. D. Venous inflammation and occlusion.

B. Lipid deposits in the arteries Buerger disease, also known as Thromboangiitis obliterans (TAO) is a progressive, nonatherosclerotic, segmental, inflammatory disease that most often affects small and medium arteries of the upper and lower extremities. The typical age range for occurrence is 20 to 50 years, and the disorder is more frequently found in males who smoke.

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: A. Familial tendency toward peripheral vascular disease. B. Smoking history. C. Recent exposures to allergens. D. History of insect bites.

B. Smoking history The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

A 2-gram sodium diet is prescribed for a client with severe hypertension. The client does not like the diet, and the nurse hears the client's request that the spouse "Bring in some good home-cooked food." It would be most effective for the nurse to plan to: A. Call in the dietician for client teaching. B. Wait for the client's family and discuss the diet with the client and family. C. Tell the client that the use of salt is forbidden, because it will raise BP. D. Catch the family members before they go into the client's room and tell them about the diet.

B. Wait for the client's family and discuss the diet with the client and family Clients' families should be included in dietary teaching; families provide the support that promotes adherence. Discuss the necessity for decreased caloric intake and limited intake of fats, salt, and sugar as indicated. Excessive salt intake expands the intravascular fluid volume and may damage kidneys, which can further aggravate hypertension.

A client's blood pressure is being checked at a health clinic. Which statement by the client demonstrates awareness of having a risk factor for hypertension? A. "My doctor told me my body mass index is 23." B. "I usually have a glass of wine or two to unwind when I come home from work." C. "I should get my blood pressure checked more often because I am African American." D. "I have colds during the winter, so I see my doctor to get the flu shot every year."

C. Research studies have shown that clients who are aware of their personal risk factors are more motivated to achieve adequate control of blood pressure. African Americans are at risk for hypertension.

A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of the following actions should the nurse take? a) Check for hypertension b) Auscultate for loud, bounding heart sounds c) Auscultate blood pressure for pulsus paradoxus d) Check for a pulse deficit

C. The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration that on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with S-T segment depression B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D. Chest pain that increases when sitting upright

C. The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postprocedure plan of care? A. Instruct the client on a long-term cardiac conditioning program. B. Administer scheduled doses of acetaminophen. C. Check for peak laboratory markers of myocardial damage. D. Monitor for bleeding.

D. Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client remains on bed rest until hemostasis is assured.

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? a) Pitting edema b) Areas of reddish-brown pigmentation c) Dry, pale skin with minimal body hair d) Sunburned appearance with desquamation

C. A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on lower legs, and weakened pulses.

A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent? A. Diltiazem B. Metoprolol C. Clopidogrel D. Isosorbide mononitrate

C. Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin. Isosorbide mononitrate is a nitrate used for vasodilation. Metoprolol is a beta blocker used for relaxing blood vessels and slowing heart rate. Diltiazem is a calcium channel blocker used to relax heart muscles and blood vessels.

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD? A. To dilate coronary arteries B. To prevent angiotensin II conversion C. To decrease workload of the heart D. To decrease homocysteine level

C. Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

The triage nurse in the Emergency Department (ED) is admitting a client with a history of Class III heart failure. What symptoms would the nurse expect the client to exhibit? A. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea. The client does not experience any limitation of activity. B. Ordinary physical activity results in fatigue, heart palpitation, or dyspnea. C. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. D. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

C. Class III (Moderate): There is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. This makes options A, B, and D incorrect.

A client admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which medication will the nurse administer to relieve the client's anxiety and decrease cardiac workload? A. Atenolol B. IV nitroglycerin C. IV morphine D. Amlodipine

C. IV morphine is the analgesic of choice for the treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart.

A nurse reviewing a client's echocardiogram report reads the following statements: "The heart muscle is asymmetrically thickened and the overall size and mass are increased, especially along the septum. The ventricular walls are thickened, reducing the size of the ventricular cavities. Several areas of the myocardium show evidence of scarring." The nurse knows these manifestations are indicative of which type of cardiomyopathy? A. dilated B. arrhythmogenic right ventricular C. hypertrophic D. restrictive

C. In hypertrophic cardiomyopathy (HCM), the heart muscle asymmetrically increases in size and mass, especially along the septum. It often affects nonadjacent areas of the ventricle. The increased thickness of the heart muscle reduces the size of the ventricular cavities and causes the ventricles to take a longer time to relax after systole. The coronary arteriole walls are also thickened, decreasing the internal diameter of the arterioles. The narrow arterioles restrict the blood supply to the myocardium, causing numerous small areas of ischemia and necrosis. The necrotic areas of the myocardium ultimately fibrose and scar, further impeding ventricular contraction. Because of the structural changes involved, HCM has also been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy (ASH).

A client asks the nurse how long to wait after taking nitroglycerin before experiencing pain relief. What is the best answer by the nurse? A. 15 minutes B. 30 minutes C. 5 minutes D. 60 minutes

C. Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch). The nurse should instruct the client to take a second dose five minutes after the first if pain persists. The nurse should instruct the client to take a third dose five minutes after the second if pain still persists. The nurse should advise the client to call 911 if pressure or pain is not releived in 15 minutes by taking 3 tablets at 5-minute intervals.

The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure? A. Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. B. Ask the client to sit on the edge of the bed and hold breath while the nurse listens. C. Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard. D. Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.

C. During auscultation, the client remains supine and the room should be as quiet as possible while the nurse listens to heart sounds. The client should breathe normally during the examination. Sitting on the edge of the bed is not the preferred client position. The room should be quiet so asking the families to remain quiet is acceptable. The client does not need to take deep breaths during heart auscultation.

A nurse evaluates a client and suspects pericarditis. What indicator is considered the most characteristic symptom of pericarditis? A. Orthopnea B. Fatigue C. Chest pain D. Dyspnea

C. The most characteristic symptom of pericarditis is chest pain. The pain is typically persistent, sharp, pleuritic, and usually felt in the mid chest, although it also may be located beneath the clavicle, in the neck, or in the left trapezius region. The discomfort is usually fairly constant, but is aggravated by deep inspiration, coughing, lying down, or turning. It may be relieved with a forward-leaning or sitting position.

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: A. At least 12 hours B. The first 24 hours C. 2-3 days D. 1 week

C. 2-3 days The onset of action is typically 24 to 72 hours. A peak therapeutic effect is seen 5 to 7 days after initiation. However, the patient's international normalized ratio (INR) may increase within 36 to 72 hours after initiating treatment. Warfarin is a once-daily oral medication. Warfarin administration can be at any time during the day, but recommendations are for administration in the afternoon or evening. By instructing patients to take warfarin later in the day, healthcare providers can have the opportunity to individualize a patient's warfarin dose the same day based on their most current lab values.

Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? A. Risk for infection related to stasis of alveolar secretions. B. Impaired skin integrity related to pressure. C. Activity intolerance related to pump failure. D. Constipation related to immobility.

C. Activity intolerance related to pump failure Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. As heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the body's needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain.

Which finding suggests to the nurse that fluid resuscitation has been effective for a 23-year-old client admitted in hypovolemic shock? A. Urine output of 15 ml/hour B. Urine output of 20 ml/hour C. Urine output of 25 ml/hour D. Urine output of 30 ml/hour

D. In an adult, urine output below 30 ml/hour indicates inadequate blood flow to the kidneys. Therefore, urine output of 30 ml/hour or greater reflects adequate fluid resuscitation.

The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching? A. Restrict your intake of water until the dye is out of the body. B. Eat only soft foods for the next 12 hours. C. Move around whenever the client feels like getting up. D. Report any numbness, tingling, or sharp pain in the extremity.

D. Instructions for the client and family include: Keep the extremity straight for several hours and avoid movement; Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in the extremity; Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. There is no need to eat only soft foods after a cardiac catheterization.

A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? A. Widened QRS complex B. Absent Q wave C. Prolonged PR interval D. Elevated ST segment

D. Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

The nurse coming on duty receives the report from the nurse going off duty. Which client should the on-duty nurse assess first? A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a "do not resuscitate" order C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving I.V. heparin D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving I.V. diltiazem (Cardizem)

D. The client with atrial fibrillation has the greatest potential to become unstable and is on I.V. medication that requires close monitoring. After assessing this client, the nurse should assess the 62-year-old client with thrombophlebitis who is receiving a heparin infusion, and then the 58-year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and don't require immediate attention). The lowest priority is the 89- year-old with end-stage right-sided heart failure, who requires time-consuming supportive measures.

The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following? A. Fluid increase to 2500cc B. Administering antiseptic lozenges C. Warm, salt water gargling D. Obtaining a throat culture

D. When a child has a sore throat and symptoms of a possible infection occur, it is essential that a culture is obtained. A culture can identify group A beta-hemolytic streptococcal infection, which needs to be eliminated with use of an antibiotic. Warm, salt gargles; increasing fluids; and administering antiseptic lozenges are helpful for symptom control. Obtaining a throat culture is a priority.

It is important for a nurse to understand cardiac hemodynamics. For blood to flow from the right ventricle to the pulmonary artery, the following must occur: A. Right ventricular pressure must decrease with systole. B. The pulmonic valve must be closed. C. The atrioventricular valves must open. D. Right ventricular pressure must be higher than pulmonary arterial pressure.

D. For the right ventricle to pump blood in need of oxygenation into the lungs via the pulmonary artery, right ventricular pressure must be higher than pulmonary arterial pressure.

A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

D. Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost volume in the blood stream and is the only solution to use when infusing blood products.

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate? A. complete blood count (CBC) B. partial thromboplastic time (PTT) C.Sodium D. international normalized ratio (INR)

D. The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of warfarin.

Cholesterol, frequently discussed in relation to atherosclerosis, is a substance that: A. May be controlled by eliminating food sources. B. Is found in many foods, both plant and animal sources. C. All persons would be better off without because it causes the disease process. D. Circulates in the blood, the level of which usually decreases when unsaturated fats are substituted for saturated fats.

D. Circulates in the blood, the level of which usually decreases when unsaturated fats are substituted for saturated fats. Cholesterol is a sterol found in tissue; it is attributed in part to diets high in saturated fats. Cholesterol is a lipophilic molecule that is essential for human life. It has many roles that contribute to normally functioning cells. For example, cholesterol is an important component of the cell membrane. It contributes to the structural makeup of the membrane as well as modulates its fluidity.

A nurse caring for a client in one room is told by another nurse that a second client has developed severe pulmonary edema. On entering the 2nd client's room, the nurse would expect the client to be: A. Slightly anxious B. Mildly anxious C. Moderately anxious D. Extremely anxious

D. Extremely anxious Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering. People with severe anxiety typically score higher on scales of distress and lower on functioning. Symptoms of severe anxiety are frequent and persistent and may include increased heart rate, feelings of panic, and social withdrawal.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is most concerned with this dysrhythmia because: A. It is uncomfortable for the client, giving a sense of impending doom. B. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia. C. It is almost impossible to convert to a normal sinus rhythm. D. It can develop into ventricular fibrillation at any time.

D. It can develop into ventricular fibrillation at any time. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. Ventricular tachycardia is characterized as a wide complex (QRS duration greater than 120 milliseconds) tachyarrhythmia at a heart rate greater than 100 beats per minute. The physical examination findings of cannon A waves and variable intensity of the S1 heart sound suggest AV dissociation, a criterion favoring the diagnosis of ventricular tachycardia.

The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is: A. Hormonal secretion B. Independent arterial wall activity. C. The influence of circulating chemicals D. The sympathetic nervous system

D. The sympathetic nervous system The autonomic nervous system exerts influence over the organ systems of the body to upregulate and downregulate various functions. The two aspects of the ANS operate as opposing functions that act to achieve homeostasis. The sympathetic nervous system, also known as the "fight or flight" system, increases energy expenditure and inhibits digestion.