Cardio Exam #2
The nurse is caring for a client with heart failure. What are the management goals for the client with heart failure? Select all that apply. Promoting a healthy lifestyle Increasing cardiac output by strengthening muscle contractions Reducing the amount of circulating blood volume Lowering the risk for hospitalization Increasing preload and afterload
Correct Response: Promoting a healthy lifestyle Increasing cardiac output by strengthening muscle contractions Lowering the risk for hospitalization Explanation: The management of a client with heart failure includes promotion of a healthy lifestyle, increasing cardiac output by strengthening muscle contractions, and lowering the risk for hospitalization. There is no need to reduce circulating blood volume for clients with heart failure. The goal in treating heart failure is to decrease preload and afterload, both of which increase stress on the ventricular wall, causing an increase in the workload of the heart.
A client has just received a diagnosis of hypertension after the completion of diagnostics. What can the client do to decrease the consequences of hypertension? Select all that apply. Lose weight. Manage stress effectively. Use smokeless tobacco. Get plenty of rest.
Correct Response: Lose weight. Manage stress effectively. Explanation: Obesity, inactivity, smoking, excessive alcohol intake, and ineffective stress management are risk factors for hypertension.
A older client in the cardiac unit has been admitted for diagnostics to determine the etiology and treatment for a cardiac valvular disorder. Which events could have affected the client's valvular function? Select all that apply. age-related degeneration myocardial infarction intracardiac pressure insufficient exercise
Correct Response: age-related degeneration myocardial infarction Explanation: The structure and function of cardiac valves can be affected by malformations at birth, inflammatory and infectious disorders, structural damage after myocardial infarction (MI), or injury during an intracardiac procedure.
The client is asking the nurse about heart-healthy food choices for lunch. What are foods that are heart healthy? Select all that apply. soy yogurt baked chicken leg white rice with butter broiled trout blueberries
Correct Response: soy yogurt broiled trout blueberries Explanation: Heart-healthy foods include soy products, fish high in omega-3s, and fruit. The chicken leg has more fat than a chicken breast. The white rice does not have enough fiber, so brown rice is a better option.
The nurse is instructing a client with hypertension. What will the nurse teach the client to do before measuring the blood pressure at home? Select all that apply. Drink a glass of water. Sit quietly for 5 minutes. Do not smoke for 30 minutes. Avoid talking during measurement. Place the forearm at heart level on a firm surface.
Correct Response: Sit quietly for 5 minutes. Do not smoke for 30 minutes. Avoid talking during measurement. Explanation: The client with hypertension will be instructed to measure the blood pressure at home. Before measuring the blood pressure, the client should be instructed to sit quietly for 5 minutes, avoid smoking 30 minutes before the measurement, avoid talking during the measurement, and to place the forearm at heart level on a firm surface. These instructions help ensure the client's blood pressure measurement is accurate. There is no reason for the client to drink a glass of water before measuring the blood pressure.
A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply. Low back pain Lower abdominal pain Hypertension An abdominal pulsatile mass A systolic bruit Radiating chest pain
Correct Response: Low back pain Lower abdominal pain An abdominal pulsatile mass A systolic bruit Explanation: Chest pain and hypertension, although they may be present, are not indicators of AAA even if present. All other choices are positive.
Nursing students are reviewing characteristics of a normal sinus rhythm. Which of the following characteristics would they accurately identify as true statements? Heart rate is between 100 and 150 beats/minute. The SA node initiates the impulse. Impulse travels to the AV node in 0.12 to 0.2 second. The ventricles depolarize in 5 seconds or less. Each impulse occurs regularly (evenly spaced).
Correct Response: The SA node initiates the impulse. Impulse travels to the AV node in 0.12 to 0.2 second. Each impulse occurs regularly (evenly spaced) Explanation: In a normal sinus rhythm, heart rate is between 60 and 100 beats/minute. The SA node initiates the impulse (upright P wave before each QRS complex). Impulse travels to the AV node in 0.12 to 0.2 second (the PR interval). The ventricles depolarize in 0.12 second or less (the QRS complex). Each impulse occurs regularly (evenly spaced).
A client is scheduled for transcatheter aortic valve implantation (TAVI). Which statement from the nurse, best explains this procedure to family members? "A small incision in the chest wall will allow for valve repair." "A catheter is used for partial replacement of the valve." "A small window incision is made so a pig valve can replace the diseased valve." "A complete aortic valve replacement is the best surgical treatment."
Correct response: "A catheter is used for partial replacement of the valve." Explanation: TAVI procedure is a minimally invasive procedure (no incision) that uses balloon valvuloplasty, stent, and partial replacement of the diseased valve using a portion of a pig valve. The TAVI is mostly used in older adults who are at high risk for the complete aortic valve replacement and helps to relieve recurring symptoms.
The nurse is caring for an older adult client who previously had a balloon valvuloplasty for treatment of aortic stenosis. In the last 6 months, the client's symptoms have returned and the client has been scheduled for a transcatheter aortic valve implantation. The client is very upset and states, "With all of my other health problems, I'll never survive having my whole chest cut open." What is the nurse's best response to this client? "You will do fine. You have a wonderful surgeon and though it may take a little longer for you to recover, it will eventually happen." "Have you discussed the procedure with your doctor? This type of valve replacement doesn't require an incision in your chest." "You don't have to have the procedure if you don't want to, but your symptoms will just keep getting worse." "Can you tell me more about these other health problems you are concerned about?"
Correct response: "Have you discussed the procedure with your doctor? This type of valve replacement doesn't require an incision in your chest." Explanation: The transcatheter aortic valve replacement (TAVR) is often used in very high risk older adults who would have trouble with traditional open-heart surgery. TAVR is a minimally invasive procedure where the valve in placed in the heart using a catheter that first opens the original valve and then implants the new valve into the heart. The client may not even need general anesthesia, only conscious sedation.
A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? "I can still eat a ham-and-cheese sandwich with potato chips for lunch." "I chose broiled chicken with a baked potato for dinner." "I chose a tossed salad with sardines and oil and vinegar dressing for lunch." "I'm glad I can still have chicken bouillon."
Correct response: "I chose broiled chicken with a baked potato for dinner." Explanation: The client's choice of a baked potato with broiled chicken indicates effective nutrition teaching because potatoes and chicken are relatively low in sodium. Ham, sardines, and bouillon are extremely high in sodium and shouldn't be included in a low-sodium diet.
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I like to soak my feet in the hot tub every day." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I have my wife look at the soles of my feet each day."
Correct response: "I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.
The nurse is providing teaching to a client with an implanted cardiac device. Which client statement indicates that teaching has been effective? "I will stop using the microwave oven." "I will not place my cell phone in my chest pocket." "I can safely have an MRI in the future if I need one." "I will not be able to fly with a pacemaker."
Correct response: "I will not place my cell phone in my chest pocket." Explanation: The implantable cardioverter defibrillator (ICD) is an electronic device that detects and terminates life-threatening episodes of tachycardia or fibrillation, especially those that are ventricular in origin. An ICD has a generator about the size of a pack of chewing gum that is implanted in a subcutaneous pocket, usually in the upper chest wall. Because of this, electronic devices should not be placed near the implanted generator as this could cause electromagnetic interference. There is no reason for the client to stop using the microwave oven. Since the MRI is a large magnetic field, MRIs should not be done in the future. A client is not restriced from flying due to having a pacemaker..
A client has been discharged from the hospital following coronary artery bypass grafting (CABG). The client asks the nurse about the chest pain he experienced prior to coming to the hospital during the heart attack. What instructions should the nurse include in the discharge instructions? "If chest pain occurs, rest. If it doesn't go away, take nitroglycerin and report the event to the physician even if the pain is relieved." "If chest pain occurs, take a nitroglycerin. If unrelieved, take another one 5 minutes later. If relieved, no further action is required". "If chest pain occurs, it may be related to gastritis. Take an antacid and lie down for 30 minutes." "You should not have chest pain because you had the CABG, and it fixed the problem with your heart."
Correct response: "If chest pain occurs, rest. If it doesn't go away, take nitroglycerin and report the event to the physician even if the pain is relieved." Explanation: If chest pain occurs after the client has had a CABG, the client should take a nitroglycerin, and even if relieved, the client needs to report the incidence to the physician. Reocclusion of a vessel may occur, or a new myocardial infarction may occur from another vessel occlusion. If the pain is relieved, the client may have had a coronary vasospasm. The client should notify the physician for any chest pain even if it is relieved. The client should not attribute the pain to a gastrointestinal symptom and notify the physician. Chest pain may still occur as well as a myocardial infarction even after a CABG.
While teaching a CPR class, a student in the class asks what the difference is between cardioversion and defibrillation. What would be the nurse's best response? "Cardioversion is done on a beating heart; defibrillation is not." "The difference is the timing of the delivery of the electric current." "Defibrillation is synchronized with the electrical activity of the heart; cardioversion is not." "Cardioversion is always attempted before defibrillation because it is not as dangerous."
Correct response: "The difference is the timing of the delivery of the electric current." Explanation: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the patient's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized.
The nursing student asks the nurse to describe the difference between sinus rhythm and sinus bradycardia on the electrocardiogram strip. What is the nurse's best reply? "The only difference is the heart rate." "The P waves will be shaped differently." "The QRS complex will be smaller in sinus bradycardia." "The P-R interval will be prolonged in sinus bradycardia."
Correct response: "The only difference is the heart rate." Explanation: All characteristics of sinus bradycardia are the same as those of normal sinus rhythm except for the rate, which will be below 60 in sinus bradycardia. The P waves will be shaped differently in other dysrhythmias. The QRS is the same voltage for sinus rhythms. The P-R interval is prolonged in atrioventricular blocks.
The nurse is providing care to a client who has just undergone an electrophysiologic (EP) study. The client reports being nervous about "things going wrong" during the procedure. What is the nurse's best response? "This is basically a risk-free procedure." "Thousands of clients undergo EP every year." "Remember that this is a step that will bring you closer to enjoying good health." "The whole team will be monitoring you very closely for the entire procedure."
Correct response: "The whole team will be monitoring you very closely for the entire procedure." Explanation: Clients who are to undergo an EP study may be anxious about the procedure and its outcome. A detailed discussion involving the client, the family, and the electrophysiologist usually occurs to ensure that the client can give informed consent and to reduce the client's anxiety about the procedure. It is inaccurate to state that EP is "risk-free" and stating that it is common does not necessarily relieve the client's anxiety. Characterizing EP as a step toward good health does not directly address the client's anxiety.
A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level would alert the nurse to notify the health care provider? 2.6 3.0 3.4 3.8
Correct response: 3.8 Explanation: Warfarin patients usually have individualized target international normalized ratios (INRs) between 2 to 3.5 to maintain adequate anticoagulation. Levels below 2 to 2.5 can result in insufficient anticoagulation and levels greater than 3.5 can result in dangerous and prolonged anticoagulation.
A client in the cardiac unit has been diagnosed with pulmonary congestion secondary to left ventricular dysfunction. The physician orders supplemental oxygen therapy. At what minimum level should the client's SpO2 be maintained? 90 87 85 80
Correct response: 90 Explanation: For a client with pulmonary congestion secondary to left ventricular dysfunction, the nurse should administer supplemental oxygen therapy as prescribed to maintain the SpO2 at or above 90%. If SpO2 is at or above 90%, PaO2 typically is high enough to maintain plasma levels of oxygen within acceptable ranges.
The nurse is assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment? A new myocardial infarction client A client with poor kidney perfusion A client with third-degree heart block A client with atrial arrhythmias
Correct response: A client with atrial arrhythmias Explanation: The nurse is correct to identify a client with atrial arrhythmias as a candidate for cardioversion. The goal of cardioversion is to restore the normal pacemaker of the heart, as well as, normal conduction. A client with a myocardial infarction has tissue damage. The client with poor perfusion has circulation problems. The client with heart block has an impairment in the conduction system and may require a pacemaker.
An older adult client visits the clinic for a blood pressure (BP) check. The client's hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about the blood pressure medicine? Take the medicine on an empty stomach. A possible adverse effect of blood pressure medicine is dizziness when you stand. There are no adverse effects from blood pressure medicine. A severe drop in blood pressure is possible.
Correct response: A possible adverse effect of blood pressure medicine is dizziness when you stand. Explanation: A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. The nurse would not teach the client to take the medicine on an empty stomach.
The nurse has entered a client's room and found the client unresponsive and not breathing. What is the nurse's next appropriate action? Palpate the client's carotid pulse. Illuminate the client's call light. Begin performing chest compressions. Activate the Emergency Response System (ERS).
Correct response: Activate the Emergency Response System (ERS). Explanation: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
A cardiac client's resistance to left ventricular filling has caused blood to back up into the client's circulatory system. Which health problem is likely to result? Acute pulmonary edema Right-sided heart failure Right ventricular hypertrophy Left-sided heart failure
Correct response: Acute pulmonary edema Explanation: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The client quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided heart failure, left-sided heart failure, and right ventricular hypertrophy do not directly occur.
A client with newly diagnosed hypertension asks what to do to decrease the risk for related cardiovascular problems. Which risk factor is not modifiable by the client? Age Obesity Inactivity Dyslipidemia
Correct response: Age Explanation: Age and family history for cardiovascular disease are risk factors that cannot be changed. Obesity, inactivity, and dyslipidemia are risk factors that can be improved by the client through dietary changes, exercise, and other healthy lifestyle choices.
Much information can be gained from comparing blood pressure measurements. What does a blood pressure reading indicate? All of the options are correct. arterial ability to stretch and fill with blood pumping efficacy of the heart circulating blood volume
Correct response: All of the options are correct. Explanation: The measured BP reflects the ability of the arteries to stretch and fill with blood, the efficiency of the heart as a pump, and the volume of circulating blood.
A client will be placed on cardiopulmonary bypass for a mitral valve replacement. What type of medication will be required for this client? An anticoagulant A calcium channel blocker An antipyretic A beta-adrenergic blocker
Correct response: An anticoagulant Explanation: One of the disadvantages of cardiopulmonary bypass is the need for anticoagulation. A calcium channel blocker, antipyretic, and beta-adrenergic blocker are not required for a client on cardiopulmonary bypass.
The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? Begin cardiopulmonary resuscitation (CPR) Administer epinephrine Administer atropine 0.5 mg Defibrillate with 360 joules (monophasic defibrillator)
Correct response: Begin cardiopulmonary resuscitation (CPR) Explanation: Commonly called flatline, ventricular asystole (Fig. 26-19) is characterized by absent QRS complexes confirmed in two different leads, although P waves may be apparent for a short duration. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Ventricular asystole is treated the same as PEA, focusing on high-quality CPR with minimal interruptions and identifying underlying and contributing factors.
The nurse is caring for a client with mild mitral regurgitation who has just been prescribed an angiotensin-converting enzyme as well as a beta-blocker. The nurse, in preparing to teach the client, is aware that the beta-blocker is given for what reason? Beta-blockers are used to reduce preload, which helps preserve the ventricles pumping ability. Beta-blockers are given to reduce fatigue that this disorder causes. Beta-blockers are given to reduce the client's heart rate. Beta-blockers are given to decrease the chest pain the client has been experiencing.
Correct response: Beta-blockers are given to reduce the client's heart rate. Explanation: Beta-blockers are given to a client with mild mitral regurgitation to control the tachycardia that occurs with this disorder. Other meds that may be used to accomplish this same symptom include digitalis and calcium channel blockers. ACE and ARB meds are given to reduce afterload. Beta-blockers actually may cause temporary fatigue and they are not effective at treating chest pain.
The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize? Monitoring liver function studies Blood pressure Vitamin D intake Monitoring potassium levels
Correct response: Blood pressure Explanation: Diuretic therapy increases urine output and decreases blood volume, which places the client at risk of hypotension. Clients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
The nursing instructor is giving a class on assessing cardiac clients after thoracic surgery. What assessment is most important for the nurse to perform when caring for this client? Pulmonary artery pressure Temperature Skin and mentation Blood pressure
Correct response: Blood pressure Explanation: The nurse assesses the blood pressure (BP) and pulse rate in both arms after thoracic surgery. Although it is necessary for the nurse to also assess pulmonary artery pressure, temperature, skin, and mentation after thoracic surgery, blood pressure and pulse rate are the most essential assessments.
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring? Heart rate of 72 beats/minute Respiratory rate of 20 breaths/minute Blood pressure 80/46 mm Hg Oxygen saturation 94%
Correct response: Blood pressure 80/46 mm Hg Explanation: The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the respiratory rate and oxygen saturation.
Which is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Creatinine Brain natriuretic peptide (BNP) Complete blood count (CBC)
Correct response: Brain natriuretic peptide (BNP) Explanation: BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. BUN, creatinine, and a CBC are included in the initial workup.
A client was driving a car without wearing a seat belt and slid off of the road and hit a tree. The client's chest was crushed against a steering wheel. What type of lethal injury does the nurse anticipate the client may have suffered? Cardiac tamponade A pleural effusion Bladder trauma Fractured pelvis
Correct response: Cardiac tamponade Explanation: A nonpenetrating injury of the chest, such as being crushed against a steering wheel, may cause bruising and bleeding of the heart. Because the pericardium encloses the heart, blood accumulates in the pericardial space, resulting in cardiac tamponade. Although a fractured pelvis and bladder trauma may be sustained, they are generally not lethal. A pleural effusion would not result from this traumatic injury.
Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of which complication? Pulmonary edema Pericardiocentesis Cardiac tamponade Pericarditis
Correct response: Cardiac tamponade Explanation: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiologic process.
An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed the client hydrochlorothiazide and enalapril. What will the nurse be sure to include in educating this client? Change positions (lying or sitting to standing) slowly. Check blood pressure every day for signs of rebound hypertension. Do not become dependent on canes, walkers, or handrails. Eat plenty of salty food to prevent hypotension.
Correct response: Change positions (lying or sitting to standing) slowly. Explanation: Antihypertensive medications can cause hypotension, especially postural hypotension that may result in injury. The nurse teaches clients to change positions slowly when moving from a lying or sitting position to a standing position. Rebound hypertension occurs when antihypertensive medications are stopped abruptly. The nurse also counsels elderly clients to use supportive devices such as handrails and walkers to prevent falls that could result from dizziness. Eating salty foods could defeat the purpose of taking the antihypertensive medications.
Which nursing intervention should a nurse perform when a client with cardiomyopathy receives a diuretic? Administer oxygen Check regularly for dependent edema Maintain bed rest Allow unrestricted physical activity
Correct response: Check regularly for dependent edema Explanation: The nurse should regularly monitor for dependent edema if the client with cardiomyopathy receives a diuretic. Oxygen is administered either continuously or when dyspnea or dysrhythmias develop. Bed rest is not necessary. The nurse should ensure that the client's activity level is reduced and should sequence any activity that is slightly exertional between periods of rest.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected? Whistling Rhonchi Crackles Coarseness
Correct response: Crackles Explanation: When the left side of the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Wheezes and gurgles may also be heard.
A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication? Aortitis Deep vein thrombosis Thoracic aortic aneurysm Raynaud disease
Correct response: Deep vein thrombosis Explanation: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. This client has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aortitis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.
Which of the following does the nurse recognize as the therapeutic goal of radiofrequency catheter ablation for a client with cardiac arrhythmias? Reperfusion of ischemic heart tissue Dilation of arterial blood vessels Destruction of errant tissue Stimulation of the impulse center
Correct response: Destruction of errant tissue Explanation: The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue, in hopes of allowing impulse conduction to travel over appropriate pathways. The goal does not include dilation of blood vessels or reperfusion of heart tissue. There is no stimulation of the heart.
The nurse is caring for a client with aortic regurgitation for which the health care provider has prescribed a beta-blocker. The nurse should know that a client with which other disorder will require frequent assessments due to this medication? Peripheral neuropathy Frequent upper respiratory infections Diabetes mellitus Multiple sclerosis
Correct response: Diabetes mellitus Explanation: Beta blockers can cause an increase in blood sugar so clients with diabetes mellitus who have been prescribed beta blockers will need extra blood sugar monitoring. Beta blockers do not affect the symptoms associated with peripheral neuropathy, URIs, or multiple sclerosis.
The nurse is admitting a client with a diagnosis of left ventricular hypertrophy. The client reports dyspnea on exertion, as well as fatigue. Which diagnostic tool would be most helpful in diagnosing this type of myopathy? Cardiac catheterization Arterial blood gases Echocardiogram Exercise stress test
Correct response: Echocardiogram Explanation: The echocardiogram (ECG) is one of the most helpful diagnostic tools because the structure and function of the ventricles can be observed easily. The ECG is also important, and can demonstrate arrhythmias and changes consistent with left ventricular hypertrophy. Cardiac catheterization specifically addresses coronary artery function and arterial blood gases evaluate gas exchange and acid balance. Stress testing is not normally used to differentiate cardiomyopathy from other cardiac pathologies.
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump? Echocardiogram A pulmonary arteriography A chest radiograph Electrocardiogram
Correct response: Echocardiogram Explanation: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart's conduction system.
A patient with long-standing hypertension is admitted to the hospital with hypertensive urgency. The physician orders a chest x-ray, which reveals an enlarged heart. What diagnostic test does the nurse anticipate preparing the patient for to determine left ventricular enlargement? Cardiac catheterization Echocardiography Stress test Tilt-table test
Correct response: Echocardiography Explanation: Left ventricular hypertrophy can be assessed by echocardiography, but not by any of the other measures listed.
The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching? Engage in exercise daily. Restrict dietary potassium. Avoid any alcohol. Drink 3 liters of fluid per day.
Correct response: Engage in exercise daily. Explanation: Lifestyle recommendations after heart failure include restriction of dietary sodium; avoidance of excessive fluid intake, excessive alcohol intake, and smoking; weight reduction when indicated; and regular exercise. The restriction of potassium is not required. Drinking 3 liters of fluid per day would be excessive for a client with heart failure.
Which statement is accurate regarding Raynaud disease? The disease generally affects the client trilaterally. It affects more than two digits on each hand or foot. It is most common in men 16 to 40 years of age. Episodes may be triggered by unusual sensitivity to cold.
Correct response: Episodes may be triggered by unusual sensitivity to cold. Explanation: Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.
The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should identify the priority nursing diagnosis of a risk for which outcome in the client's plan of care? Ineffective breathing pattern related to hypotension Falls related to orthostatic hypotension Ineffective role performance related to hypotension Imbalanced fluid balance related to hemodynamic variability
Correct response: Falls related to orthostatic hypotension Explanation: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompany it. It does not normally affect breathing or fluid balance. The client's ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety.
The nurse visits the home of a client with heart failure. Which assessment finding indicates to the nurse that the client's tolerance to activity is deteriorating? Weight loss of 0.5 kg (1.1 lbs.) Bilateral lower extremity edema +1 Needs to use a scooter for shopping Fatigue after walking to answer the door
Correct response: Fatigue after walking to answer the door Explanation: The client's response to activity needs to be monitored. If the client is at home, the degree of fatigue felt after the activity can be used to assess the response. Weight loss is not used to assess activity tolerance but would be helpful to determine the response to medication therapy. Lower extremity edema is not used to assess activity tolerance but would be helpful to determine the response to medication therapy. Tolerance to exercise would be assessed by monitoring heart rate, which should return to baseline within 3 minutes after the activity. Since the client's heart rate returned to baseline in 2 minutes, the activity is being tolerated. Use of a motorized scooter for shopping would not be the best indicator of exercise and/or activity tolerance.
Which symptom is most important in determining the diagnosis and nursing care for a client experiencing pulmonary hypertension? Increased stroke volume Bradycardia Frothy sputum High systolic pressure
Correct response: Frothy sputum Explanation: Tachycardia, low systolic pressure, and decreased stroke volume are symptoms associated with pulmonary hypertension. A productive cough with pink-tinged frothy sputum can indicate progression of the disorder and need for treatment.
Which medication is categorized as a loop diuretic? Chlorothiazide Chlorthalidone Spironolactone Furosemide
Correct response: Furosemide Explanation: Furosemide is commonly used to treat cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide and chlorthalidone are categorized as thiazide diuretics. Spironolactone is categorized as a potassium-sparing diuretic.
The DASH (Dietary Approaches to Stop Hypertension) diet has been recommended to a 58-year-old woman with a recent diagnosis of primary hypertension. What dietary component will the woman consume most if she adheres to this diet? Grains and grain products Fruits Vegetables Low-fat dairy products
Correct response: Grains and grain products Explanation: The DASH diet recommends 7 to 8 daily servings of grain products, 4 to 5 servings each of fruits and vegetables, and 2 to 3 servings of low-fat dairy products.
A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect? Pulmonary embolism Heart failure Cardiac tamponade Tension pneumothorax
Correct response: Heart failure Explanation: 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.
A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? Hypertension causes the heart's chambers to enlarge and weaken. Hypertension causes the heart's chambers to shrink. Heart failure occurs when blood pressures drops. Hypertension in older males regularly leads to heart failure.
Correct response: Hypertension causes the heart's chambers to enlarge and weaken. Explanation: Hypertension causes the heart's chambers to enlarge and weaken, making it impossible for the ventricles to eject all the blood they receive.
A client with endocarditis is being discharged home. What statement indicates effectiveness of client teaching about preventing recurrence of the infection? "I will start an antibiotic when I am exposed to anyone with infections." "I am going to take an aspirin a day to prevent lesions around my valve." "I will always be on antibiotic therapy." I will ask for antibiotics whenever I have dental work done."
Correct response: I will ask for antibiotics whenever I have dental work done." Explanation: The patient should take antibiotics for dental procedures that involve manipulation of gingival tissue or the periapical area of the teeth or perforation of the oral mucosa. Exceptions include routine anesthetic injections through noninfected tissue, placement of orthodontic brackets, loss of deciduous teeth, bleeding from trauma to the lips or oral mucosa, dental x-rays, adjustment of orthodontic appliances, and placement of removable prosthodontic or orthodontic appliances.
The nurse is caring for a client who has had a heart transplant and is beginning to learn about the antirejection medications that must be taken daily and will be needed for the client's entire lifetime. The nurse teaches the client that which side effects are associated with antirejection medications? Dehydration Diabetes insipidus Increased risk for infection Hypotension
Correct response: Increased risk for infection Explanation: The major side effects associated with antirejection medications include fluid retention, hypertension, diabetes mellitus, and an increased risk for infection.
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Impaired gas exchange related to increased blood flow Excess fluid volume related to peripheral vascular disease Risk for injury related to edema Ineffective peripheral tissue perfusion related to venous congestion
Correct response: Ineffective peripheral tissue perfusion related to venous congestion Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Intermittent claudication Acute limb ischemia Dizziness Vertigo
Correct response: Intermittent claudication Explanation: The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.
The staff educator is teaching a class in arrhythmias. What statement is correct for defibrillation? It is a scheduled procedure 1 to 10 days in advance. The client is sedated before the procedure. It is used to eliminate ventricular arrhythmias. It uses less electrical energy than cardioversion.
Correct response: It is used to eliminate ventricular arrhythmias. Explanation: The only treatment for a life-threatening ventricular arrhythmia is immediate defibrillation, which has the exact same effect as cardioversion, except that defibrillation is used when there is no functional ventricular contraction. It is an emergency procedure performed during resuscitation. The client is not sedated but is unresponsive. Defibrillation uses more electrical energy (200 to 360 joules) than cardioversion.
The nurse identifies which symptom as a characteristic of right-sided heart failure? Jugular vein distention (JVD) Dyspnea Pulmonary crackles Cough
Correct response: Jugular vein distention (JVD) Explanation: JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client? Low-fat diet Low-potassium diet Low-cholesterol diet Low-sodium diet
Correct response: Low-sodium diet Explanation: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be ordered but are not specific to the heart failure.
The nurse is caring for a client with a deep vein thrombosis in the popliteal vein. Which component of a head-to-toe assessment is crucial? Lung sounds Level of consciousness Amount of pain Peripheral edema
Correct response: Lung sounds Explanation: Thrombi that form above the popliteal vein of the leg are at higher risk for migration toward the pulmonary circulation. Assessing lung sounds can identify changes quickly. A pulmonary embolus can be a life-threatening condition. The other options do not reflect on the most crucial assessment for this critical complication of DVT.
The nurse is caring for an older adult client who is deciding whether to have cardiovascular surgery. The client asks the nurse why the risks are greater for them than for a younger person. What would be the nurse's answer? Many older adults have comorbidities in addition to their cardiac problems. Older adults have the same risk factors as younger adults. Older adults have hypersensitive renal systems, and younger adults don't. Older adults have different thought processes than younger adults do.
Correct response: Many older adults have comorbidities in addition to their cardiac problems. Explanation: Many older adults have comorbidities such as diabetes, heart failure, cardiac dysrhythmias, hypertension, and poor renal function, necessitating careful consideration regarding the potential risks and benefits of cardiovascular surgery. These clients require close observation during the postoperative period. The other options are incorrect.
A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea as a result of pulmonary venous hypertension. What valvular disorder would cause pulmonary venous hypertension? Aortic regurgitation Mitral stenosis Mitral valve prolapse Aortic stenosis
Correct response: Mitral stenosis Explanation: The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its usual size. Patients are likely to show progressive fatigue as a result of low cardiac output. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Patients may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections. Pulmonary venous hypertension is not caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis.
Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? Cleanse the site with disinfectants and dress the wound appropriately Refrain from sexual activity for 1 month Monitor the site for bleeding or hematoma. Normal activities of daily living can be resumed the first day after surgery
Correct response: Monitor the site for bleeding or hematoma. Explanation: The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma. A nurse does not advise the client to clean the site with disinfectants or refrain from sexual activity for 1 month.
A client is being evaluated for mitral stenosis versus mitral insufficiency. Which of the following symptoms would the nurse find in either condition? Angina Syncope Murmur High blood pressure
Correct response: Murmur Explanation: Mitral stenosis and mitral insufficiency both create regurgitation of blood back through the mitral valve which can be heard as a murmur. Angina and syncope are not common and would only be exhibited if decrease nourishment of the cardiac muscle and organs occur. Hypertension may be an underlying condition but not necessarily associated with both of these disorders.
The nurse is caring for a client with long-standing hypertension. As a client advocate, what should the nurse suggest is most helpful in preventing further complications? Maintain a healthy diet of fruits and vegetables. Focus on exercise at least twice a week. Obtain a regular appointment with eye doctor. Avoid use of caffeinated beverages.
Correct response: Obtain a regular appointment with eye doctor. Explanation: When a client has long-standing hypertension, the high blood pressure damages the arterial vascular system. As a client advocate, the nurse must instruct on not only prevention but also on early identification of complications. Damages may occur to the tiny arteries in the eyes compromising vision. The most helpful instruction is to maintain a regular appointment with an eye doctor. The other options are good instruction for a healthy lifestyle.
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? Warm, salt water gargling Fluid increase to 2500cc Obtaining a throat culture Administering antiseptic lozenges
Correct response: Obtaining a throat culture Explanation: 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.
Which of the following describes difficulty breathing when lying flat? Paroxysmal nocturnal dyspnea (PND) Orthopnea Tachypnea Bradypnea
Correct response: Orthopnea Explanation: Orthopnea occurs when the patient is having difficulty breathing when laying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.
The nurse has entered the room of a patient and found the patient diaphoretic, panicked, and clutching his chest. What action should the nurse first perform? Provide calm reassurance to the patient. Assist the patient into a semi-Fowler's position. Perform a rapid assessment of the patient. Administer oxygen at 6 LPM by nasal prongs.
Correct response: Perform a rapid assessment of the patient. Explanation: An emergent cardiac event requires a prompt nursing response that should begin with an efficient assessment of the patient's condition (airway, breathing, circulation, and consciousness). The results of this rapid assessment provide the basis for nurse's decision to call a cardiac arrest code. This assessment is a priority over oxygen supplementation, reassurance, and repositioning, even though each of these measures may be appropriate.
The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? Stress Obesity Positive family history Hyperlipidemia
Correct response: Positive family history Explanation: The health history provides an opportunity for the nurse to assess patients' understanding of their personal risk factors for coronary artery, peripheral vascular, and cerebrovascular diseases and any measures that they are taking to modify these risks. Risk factors are classified by the extent to which they can be modified by changing one's lifestyle or modifying personal behaviors. Stress, obesity, and hyperlipidemia are all risk factors that can be modified by personal behaviors. Family history is a nonmodifiable risk factor, because it cannot be changed.
The nurse is collaborating with the dietitian and a client with hypertension to plan dietary modifications. Which modifications should be the priority? Reduced intake of protein and carbohydrates Increased intake of calcium and vitamin D Reduced intake of fat and sodium Increased intake of potassium, vitamin B12 and vitamin D
Correct response: Reduced intake of fat and sodium Explanation: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some clients, but a specific reduction in protein and carbohydrates is not normally indicated.
The nurse is caring for a client newly diagnosed with secondary hypertension. Which condition contributes to the development of secondary hypertension? Hepatic function Renal disease Calcium deficit Acid-based imbalance
Correct response: Renal disease Explanation: Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoetin alfa), and coarctation of the aorta. High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attack, stroke, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension.
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching? Eat only soft foods for the next 12 hours. Report any numbness, tingling, or sharp pain in the extremity. Restrict your intake of water until the dye is out of the body. Move around whenever the client feels like getting up.
Correct response: Report any numbness, tingling, or sharp pain in the extremity. Explanation: 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.
Which factor is the most common cause of mitral valve regurgitation in developing countries? A decrease in gamma globulins An insect bite Rheumatic heart disease and its sequelae Sepsis and its sequelae
Correct response: Rheumatic heart disease and its sequelae Explanation: The most common cause of mitral valve regurgitation in developing countries is rheumatic heart disease and its sequelae, not a decrease in gamma globulins, an insect bite, or sepsis and its sequelae.
Why does a client with left-sided heart failure require careful monitoring? Right-sided heart failure is a risk. Depression is likely. Accelerated weight loss is probable. The client is more likely to develop migraines.
Correct response: Right-sided heart failure is a risk. Explanation: Left-sided heart failure is a major cause of right-sided heart failure.
While auscultating heart sounds, the nurse hears "lub-dub-dee" and recognizes that this would be characterized as which heart sound? S3 S1 S2 S4
Correct response: S3 Explanation: An S3 heart sound is characterized as sounding like "Ken-tuck-y" or "lub-dub-dee." It follows S1 and S2 and is called a ventricular gallop. Although normal in children, it is often an indication of heart failure in an adult. S1 is the first normal heart sound; it sounds like "lub." S2 is the second normal heart sound; it sounds like "dub." An extra sound just before S1 is an S4 heart sound, or atrial gallop. Some say this sound resembles the word "Ten-nes-see" or "lub-lub-dub."
A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion? A loud, blowing murmur Hypertension Shortness of breath Tachycardia
Correct response: Shortness of breath Explanation: Chronic mitral regurgitation is often asymptomatic, but acute mitral regurgitation (e.g., resulting from a myocardial infarction) usually manifests as severe congestive heart failure. Dyspnea, fatigue, and weakness are the most common symptoms. Palpitations, shortness of breath upon exertion, and cough from pulmonary congestion also occur. A loud, blowing murmur often is heard throughout ventricular systole at the apex of the heart. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle. Tachycardia is a compensatory mechanism when stroke volume decreases.
The nurse is caring for a client who developed a ventricular aneurysm as a complication of a myocardial infarction. The nurse will monitor this client closely for what problem associated with this issue? Signs of a stroke Signs of another myocardial infarction Signs of infection Signs of kidney damage
Correct response: Signs of a stroke Explanation: A client who has a ventricular aneurysm will have thrombi that form in the crater of the bulging tissue. These thrombi could be propelled at any time from the heart into the brain which would cause a stroke. A ventricular aneurysm does not put the client at any additional risk for another MI, or infection or kidney damage.
A patient comes to the emergency department with reports of chest pain after using cocaine. The nurse assesses the patient and obtains vital signs with results as follows: blood pressure 140/92, heart rate 128, respiratory rate 26, and an oxygen saturation of 98%. What rhythm on the monitor does the nurse anticipate viewing? Sinus bradycardia Ventricular tachycardia Normal sinus rhythm Sinus tachycardia
Correct response: Sinus tachycardia Explanation: Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate. Causes include medications that stimulate the sympathetic response (e.g., catecholamines, aminophylline, atropine), stimulants (e.g., caffeine, nicotine), and illicit drugs (e.g., amphetamines, cocaine, Ecstasy).
A diastolic blood pressure of 92 mm Hg is classified as Normal blood pressure Elevated blood pressure Stage 1 hypertension Stage 2 hypertension
Correct response: Stage 2 hypertension Explanation: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg.
The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response? Administer sublingual nitroglycerin to allow the client to finish the test. Initiate cardiopulmonary resuscitation. Administer analgesia and slow the test. Stop the test and monitor the client closely.
Correct response: Stop the test and monitor the client closely. Explanation: The client may be experiencing signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs of cardiac or respiratory arrest were evident. The client should not be permitted to continue the test due to risk of MI, therefore the first option, administer nitroglycerin is incorrect. The nurse would not administer pain medication and slow the test as this could mask the symptoms of MI and the client should not be permitted to continue with the test. Further assessment by the nurses must be completed and protocol for MI initiated.
A client with aortic valve regurgitation is asking about the disease process. What would the nurse tell the client is the first sign of aortic valve regurgitation? Tachycardia Left-sided heart failure Pain Dysrhythmias
Correct response: Tachycardia Explanation: Tachycardia is one of the first signs of cardiac compensation. When valve damage affects the left ventricle, the client becomes aware of forceful heart contractions (palpitations). At first, palpitations occur only when lying flat or on the left side. Aortic valve regurgitation does not produce left-sided heart failure, pain, or dysrhythmias as the first symptom of disease.
The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client's risk for heart failure? The client takes furosemide 20 mg/day. The client's potassium level is 4.7 mEq/L. The client is white. The client's age is greater than 65.
Correct response: The client's age is greater than 65. Explanation: Heart failure is the most common reason for hospitalization of people older than 65 years of age and is the second-most common reason for visits to a physician's office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for heart failure. The fact that the client takes furosemide 20 mg/day does not indicate an increased risk for heart failure, although this drug is often used in the treatment of heart failure. The client being white indicates a decreased risk for heart failure compared with Black and Hispanic clients.
A client's recently elevated BP has prompted the primary care provider to prescribe furosemide. The nurse should closely monitor which of the following levels? The client's oxygen saturation level The client's red blood cells, hematocrit, and hemoglobin The client's level of consciousness The client's potassium level
Correct response: The client's potassium level Explanation: Loop diuretics can cause potassium depletion. They do not normally affect level of consciousness, erythrocytes, or oxygen saturation.
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? The nurse asks the client to hold the breath during auscultation. There is really no question to ask the client to tell the difference. The nurse has the client stand during auscultation. The nurse places the client flat for at least 4 minutes.
Correct response: The nurse asks the client to hold the breath during auscultation. Explanation: 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.
A patient tells the nurse, "I was straining to have a bowel movement and felt like I was going to faint. I took my pulse and it was so slow." What does the nurse understand occurred with this patient? The patient may have had a myocardial infarction. The patient had a vagal response. The patient was anxious about being constipated. The patient may have an abdominal aortic aneurysm.
Correct response: The patient had a vagal response. Explanation: When straining during defecation, the patient bears down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow and resulting in syncope in some patients. Straining during urination can produce the same response. Myocardial infarction is damage to the heart and clients will experience pain or shortness of breath. Anxiety causes the heart rate to increase. The client with an abdominal aortic aneurysm will experience back or abdominal pain, not a decrease in heart rate.
The nurse observes a certified nursing assistant (CNA) obtaining a blood pressure reading with a cuff that is too small for the patient. The nurse informs the CNA that using a cuff that is too small can affect the reading results in what way? The results will be falsely decreased. The results will be falsely elevated. It will give an accurate reading. It will be significantly different with each reading.
Correct response: The results will be falsely elevated. Explanation: Select the size of the cuff based on the size of the patient. (The cuff size should have a bladder width of at least 40% of limb circumference and length at least 80% of limb circumference.) The average adult cuff is 12 to 14 cm wide and 30 cm long. Using a cuff that is too small will give a higher BP measurement, and using a cuff that is too large results in a lower BP measurement compared to one taken with a properly sized cuff.
A patient has been admitted to the unit for an electrophysiology (EP) study. For what is an electrophysiology study primarily performed? To facilitate cardioversion To freeze hypersensitive cells To diagnose the dysrhythmia To determine the nursing plan of care
Correct response: To diagnose the dysrhythmia Explanation: A patient may undergo an EP study in which electrodes are placed inside the heart to obtain an intracardiac electrocardiogram (ECG). This is used not only to diagnose the dysrhythmia, but also to determine the most effective treatment plan. However, because an EP study is invasive, it is performed in the hospital and may require that the patient be admitted. The primary purpose of an EP is not freezing hypersensitive cells, facilitating cardioversion, or determining the plan of nursing care.
The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why they have to take an aspirin every day if they don't have any pain. Which rationale for this intervention would be the best? To help restore the normal function of the heart To help prevent blockages that can cause chest pain or heart attacks To help the blood penetrate the heart more freely To help the blood carry more oxygen than it would otherwise
Correct response: To help prevent blockages that can cause chest pain or heart attacks Explanation: An aspirin a day is a common nonprescription medication that improves outcomes in clients with coronary artery disease due to its antiplatelet action, which helps to prevent clots that can lead to chest pain or heart attacks. It does not affect oxygen-carrying capacity or perfusion. Aspirin does not restore cardiac function.
A client has had cardiothoracic surgery, and the nurse is palpating the peripheral pulses. The nurse cannot palpate the left lower extremity pulse. What is the first action by the nurse? Call the physician. Call the charge nurse. Apply a vasodilator such as nitroglycerin cream on the skin surface and then palpate. Use a Doppler ultrasound device.
Correct response: Use a Doppler ultrasound device. Explanation: Palpate the peripheral pulses or use a Doppler ultrasound device if the pulses are not palpable. Prior to calling the physician or notifying the charge nurse, attempt to use the Doppler, and then, if no pulse is heard, the nurse may notify either. Administration of medications without a physician's order is contraindicated.
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first? Sustained asystole Supraventricular tachycardia Atrial fibrillation Ventricular fibrillation
Correct response: Ventricular fibrillation Explanation: Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs attention first because there is no cardiac output, and it is an indication for CPR and immediate defibrillation. Sustained asystole either is from death, or the client is off of the cardiac monitor. Supraventricular tachycardia and atrial fibrillation are monitored and reported to the physician but are not addressed first.
A client with no history of cardiac problems is undergoing diagnostics for a cardiac valvular condition. The cardiologist has indicated that the client has had this particular valvular condition from birth, and the recent onset of symptoms is attributed to age. What disorder is causing the client difficulty? aortic stenosis aortic hypertrophy mitral stenosis mitral regurgitation
Correct response: aortic stenosis Explanation: In older adults without predisposing cardiac conditions, aortic stenosis is an age-related degenerative change from progressive calcium deposits in valve cells. In older adults without predisposing cardiac conditions, narrowing of the aortic valve is an age-related degenerative change from progressive calcium deposits in valve cells. Clients who have had rheumatic carditis are more likely to develop mitral stenosis. Mitral regurgitation is associated with rheumatic carditis and mitral valve prolapse.
The nurse is assessing a client with symptomatic bradycardia. What medication does the nurse anticipate will be ordered by the healthcare provider to treat the bradycardia? atropine lidocaine diltiazem adenosine
Correct response: atropine Explanation: The treatment of symptomatic bradycardia includes transcutaneous pacing and atropine. Lidocaine may be used in the treatment of ventricular fibrillation. Diltiazem and adenosine are medications used to treat clients with atrial fibrillation.
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? hypertrophic dilated restrictive arrhythmogenic right ventricular
Correct response: hypertrophic Explanation: 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). Dilated cardiomyopathy (DCM) is distinguished by significant dilation of the ventricles without simultaneous hypertrophy (increased muscle wall thickness) and systolic dysfunction. The ventricles have elevated systolic and diastolic volumes but a decreased ejection fraction. Restrictive (or constrictive) cardiomyopathy (RCM) is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy (ARVC) occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.
The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia? hypovolemia vagal stimulation hypothyroidism digoxin
Correct response: hypovolemia Explanation: The causes of sinus tachycardia include physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). Vagal stimulation, hypothyroidism, and digoxin will cause a sinus bradycardia.
Obesity is a contributory factor for developing CAD; therefore, decreasing one's store of body fat through exercise and diet modification can reduce the risk factors for heart disease. What is the mechanism through which obesity increases the likelihood of developing CAD? inflammation metabolism oxygenation assimilation
Correct response: inflammation Explanation: Published information in the American Journal of Physiology, Endocrinology, and Metabolism indicates a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins.
When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating orthopnea. dyspnea upon exertion. hyperpnea. paroxysmal nocturnal dyspnea.
Correct response: orthopnea. Explanation: 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.
The physician orders medication to treat a client's cardiac ischemia. What is causing the client's condition? reduced blood supply to the heart pain on exertion high blood pressure indigestion
Correct response: reduced blood supply to the heart Explanation: Ischemia is reduced blood supply to body organs. Cardiac ischemia is caused by reduced blood supply to the heart muscle. It may lead to a myocardial infarction. Chest pain is a symptom of ischemia.
A client is scheduled for bypass surgery with the intent of preventing a MI. For this client, the most important characteristic to assess postoperatively is the client's: tissue perfusion. mental alertness. blood sugar. activity tolerance.
Correct response: tissue perfusion. Explanation: The most important postop assessment of a client in this scenario is for signs and symptoms of inadequate tissue perfusion, such as weak or absent pulse, cold or cyanotic extremities, or mottling of the skin.
The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the emergency room. What is the most important cardiac marker for the client? creatine kinase lactate dehydrogenase myoglobin troponin
Correct response: troponin Explanation: This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin tests can show evidence of muscle injury, but the studies are less specific indicators of myocardial damage than troponin.
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority? insert an oral airway. withhold food and fluids. position the client on his side. introduce a nasogastric (NG) tube.
Correct response: withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.
A client has developed a clot in the femoral artery. The nurse prepares the client for what type of surgery? Embolectomy Commissurotomy Annuloplasty Endarterectomy
Embolectomy Correct response: Embolectomy Explanation: When thrombi or emboli occlude a major vessel, a thrombectomy (removal of a thrombus) or embolectomy (removal of an embolus) is performed. The vessel is opened above the clot, the clot is removed, and the vessel is sutured closed. An endarterectromy is the removal of atherosclerotic plaque from an artery. Commissurotomy and annuloplasty are other cardiovascular surgeries and distracters for this question.
