ATI Cardiovascular assessment
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?
"I smoked a cigarette this morning to calm my nerves about having this procedure." Reason: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.
A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals they are 1 week postoperative following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated?
Assisting with thrombolytic therapy Reason: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
A client who has diabetes mellitus Reason: Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.
A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Which of the following areas of the strip should the nurse examine to observe for atrial depolarization? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A is correct. Reason: The nurse should examine this area, the P wave, of the rhythm strip to evaluate for atrial depolarization.
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition?
Absence of adventitious breath sounds Reason: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.
A nurse is caring for a client who is 8 hr postoperative following a coronary artery bypass graft (CABG). Which of the following findings should the nurse report?
Blood pressure 160/80 mm Hg Reason: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.
A nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values?
Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL Reason: These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.
A nurse in an emergency department is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for?
Confusion Reason: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should identify that an increase in which of the following values is diagnostic of a myocardial infarction (MI)?
Creatine kinase-MB Reason: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect?
Dyspnea on exertion Reason: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.
A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?
Elevate the head of the client's bed Reason: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. Which of the following focused assessments should the nurse use to help differentiate between an arterial ulcer and a venous stasis ulcer?
Inquire about the presence or absence of claudication. Reason: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?
Lightheadedness Reason: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.
A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify their provider if they experience which of the following adverse effects of this medication?
Persistent cough Reason: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.
A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin patches. Which of the following instructions should the nurse include in the teaching?
Place the patch on an area of skin away from skin folds and joints. Reason: The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?
Weak peripheral pulses Reason: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.
A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?
Weight gain of 0.9 kg (2 lb) in 24 hr Reason: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
"I can't get rid of these hiccups." Reason: Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?
"I took my warfarin last night according to my usual schedule." Reason: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.
A nurse is providing teaching to a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching?
"You might no longer be able to feel chest pain." Reason: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Area D Reason: Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line.
A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following findings should indicate to the nurse that the medication is effective?
INR 2.0 Reason: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.
A nurse is preparing a client for coronary angiography. Which of the following findings should the nurse report to the provider prior to the procedure?
Previous allergic reaction to iodine Reason: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to iodine might need a steroid or antihistamine prior to the procedure.
A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?
Review serum electrolyte values. Reason: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
Slurred speech Reason: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds?
Stop the heparin infusion. Reason: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.
A nurse is caring for a client who is 1 hr postoperative following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?
Urine output of 20 mL/hr Reason: Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions?
Vagal stimulation Reason: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
Valvular disease Reason: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? (Select all that apply.)
Limited alcohol intake is correct. Clients who have hypertension should limit alcohol intake.Regular exercise program is correct. Clients who have hypertension should develop a regular exercise program to help reduce blood pressure.Decreased magnesium intake is incorrect. Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include.Reduced potassium intake is incorrect. Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include.Tobacco cessation is correct. Clients who have hypertension should have a goal of tobacco cessation because tobacco use exacerbates hypertension.
