Cardio Exam
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? 1. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. 2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. 3. SpO2 92 on 2 L nasal cannula, respirations 20, 1+ edema of lower extremities. 4. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
. 2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time? 1. Monitor daily weights and urine output. 2. Permit unrestricted visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand.
. 4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment. CN: Physiological adaptation; CL: Synthesize
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which of the following are expected findings on assessment? Select all that apply. 1. Decreased cardiac output. 2. Increased heart rate. 3. Vasoconstriction in skin, GI tract, and kidneys. 4. Decreased pulmonary perfusion. 5. Fluid overload.
1, 2, 3, 5. Heart failure can be a result of several cardiovascular conditions, which will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure, therefore cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease. CN: Physiologic adaptation; CL: Analyze
When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. 1. Becoming increasingly short of breath at rest. 2. Weight gain of 2 lb (0.9 kg) or more in 1 day. 3. High intake of sodium for breakfast. 4. Having to sleep sitting up in a reclining chair. 5.Weight loss of 2 lb (0.9 kg) in 1 day
1, 2, 4. If the client will call the physician when there is increasing shortness of breath, weight gain over 2 lb (0.9 kg) in 1 day, and need to sleep sitting up, this indicates an understanding of the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future. CN: Reduction of risk potential; CL: Evaluate
The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take Plavix with food. 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot. 5. The client should drink a glass of water after taking Plavix.
1, 3, 4. Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix. CN: Pharmacological and parenteral therapies; CL: Create
A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine? Select all that apply. 1. Reduces myocardial oxygen consumption. 2. Promotes reduction in respiratory rate. 3. Prevents ventricular remodeling. 4. Reduces blood pressure and heart rate. 5. Reduces anxiety and fear.
1, 4, 5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling. CN: Pharmacological and parenteral therapies; CL: Evaluate
A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: 1. Administer the morphine. 2. Obtain a 12-lead ECG. 3. Obtain the blood work. 4. Prescribe the chest radiograph.
1. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action. CN: Physiological adaptation; CL: Synthesize
client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: 1. Heart rate irregular with S3. 2. Heart rate irregular with S4. 3. Heart rate irregular with aortic regurgitation. 4. Heart rate irregular with mitral stenosis.
1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve. CN: Physiological adaptation; CL: Analyze
Which of the following is a risk factor for hypovolemic shock? 1. Hemorrhage. 2. Antigen-antibody reaction. 3. Gram-negative bacteria. 4. Vasodilation.
1. Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock. CN: Physiological adaptation; CL: Analyze
A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. Administer oxygen via nasal cannula. 3. Offer pain medication for the chest heaviness. 4. Inform the physician of the chest heaviness.
1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician. CN: Reduction of risk potential; CL: Synthesize
The physician prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. The nurse should: 1. Obtain an infusion pump for the medication. 2. Take the blood pressure every 4 hours. 3. Monitor urine output hourly. 4. Obtain serum potassium levels daily.
1. IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion. CN: Pharmacological and parenteral therapies; CL: Synthesize
The major goal of nursing care for a client with heart failure and pulmonary edema is to: 1. Increase cardiac output. 2. Improve respiratory status. 3. Decrease peripheral edema. 4. Enhance comfort.
1. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema. CN: Reduction of risk potential; CL: Apply
The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? 1. Assess respiratory status. 2. Draw blood for laboratory studies. 3. Insert a Foley catheter. 4. Weigh the client.
1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate? 1. Urine output greater than 30 mL/h. 2. Systolic blood pressure greater than 110 mm Hg. 3. Diastolic blood pressure greater than 90 mm Hg. 4. Respiratory rate of 20 breaths/min.
1. Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock. CN: Pharmacological and parenteral therapies; CL: Evaluate
When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal space. The nurse should further assess the client for: 1. Left atrial enlargement. 2. Left ventricular enlargement. 3. Right atrial enlargement. 4. Right ventricular enlargement.
2. A normal apical impulse is found 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. CN: Physiological adaptation; CL: Analyze
A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next? 1. Administer prescribed antihistamine and aspirin. 2. Collect blood and urine samples and send to the lab. 3. Administer prescribed diuretics. 4. Administer prescribed vasopressors.
2. ABO- and Rh-incompatible blood causes an antigen-antibody reaction that produces hemolysis or agglutination of red blood cells (RBCs). At the first indication of any sign/symptom of reaction, the blood transfusion is stopped. Blood and urine samples are obtained from the client and sent to the lab along with the remaining untransfused blood. Hemoglobin in the urine and blood samples taken at the time of the reaction provides evidence of a hemolytic blood transfusion reaction. Antihistamine, aspirin, diuretics, and vasopressors may be administered with different types of transfusion reactions. CN: Reduction of risk potential; CL: Synthesize
A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? 1. Dilated coronary arteries. 2. Increased myocardial contractility. 3. Decreased cardiac arrhythmias. 4. Decreased electrical conductivity in the heart.
2. Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema. CN: Pharmacological and parenteral therapies; CL: Evaluate
Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? 1. Increased blood pressure. 2. Increased urine output. 3. Decreased pain. 4. Decreased premature ventricular contractions.
2. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias. CN: Pharmacological and parenteral therapies; CL: Evaluate
When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to: 1. Promote hydration. 2. Dissolve clots. 3. Prevent kidney failure. 4. Treat dysrhythmias.
2. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage. CN: Pharmacological and parenteral therapies; CL: Evaluate
The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? 1. Whole grains. 2. Green leafy vegetables. 3. Meats and dairy products. 4. Broccoli and Brussels sprouts.
3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green, leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).
Which of the following is the most important goal of nursing care for a client who is in shock? 1. Manage fluid overload. 2. Manage increased cardiac output. 3. Manage inadequate tissue perfusion. 4. Manage vasoconstriction of vascular beds.
3. Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock. CN: Physiological adaptation; CL: Synthesize
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last? 1. Notify the attending physician and blood bank. 2. Complete the appropriate Transfusion Reaction Form(s). 3. Stop the transfusion. 4. Keep the IV open with normal saline infusion.
3. Stop the transfusion. 4. Keep the IV open with normal saline infusion. 1. Notify the attending physician and blood bank. 2. Complete the appropriate Transfusion Reaction Form(s).
A client with angina is taking nifedipine. The nurse should teach the client to: 1. Monitor blood pressure monthly. 2. Perform daily weights. 3. Inspect gums daily. 4. Limit intake of green leafy vegetables.
3. The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables.CN: Pharmacological and parenteral therapies; CL: Synthesiz
Which of the following sets of conditions is an indication that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply. 1. Distended jugular veins. 2. Dependent edema. 3. Anorexia. 4. Coarse crackles. 5. Tachycardia.
4, 5. Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.
The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a: 1. Low sodium level. 2. High glucose level. 3. High calcium level. 4. Low potassium level.
4. A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity. CN: Pharmacological and parenteral therapies; CL: Analyze
A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). In which order should the nurse implement the following physician prescriptions? 1. Give 1 unit fresh frozen plasma (FFP). 2. Administer vitamin K 2.5 mg by mouth. 3. Schedule client for sigmoidoscopy. 4. Administer IV dextrose 5% in 0.45% normal saline solution.
4. Administer IV dextrose 5% in 0.45% normal saline solution. 1. Give 1 unit fresh frozen plasma (FFP) 2. Administer vitamin K 2.5 mg by mouth. 3. Schedule client for sigmoidoscopy.
Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: 1. Continues to have severe chest pain. 2. Can identify risk factors for MI. 3. Participates in a cardiac rehabilitation walking program. 4. Can perform personal self-care activities without pain.
4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.
Crackles heard on lung auscultation indicate which of the following? 1. Cyanosis. 2. Bronchospasm. 3. Airway narrowing. 4. Fluid-filled alveoli.
4. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds. CN: Physiological adaptation; CL: Analyze
The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first: 1. Administer atropine 0.5 mg IV push. 2. Auscultate for abnormal heart sounds. 3. Prepare for transcutaneous pacing. 4. Take the client's blood pressure.
4. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.
Which activity would be appropriate to delegate to unlicensed personnel for a client diagnosed with a myocardial infarction who is stable? 1. Evaluate the lung sounds. 2. Help the client identify risk factors for CAD. 3. Provide teaching on a 2-g sodium diet. 4. Record the intake and output.
4. Unlicensed personnel are able to measure and record intake and output. The nurse is responsible for client teaching, physical assessments, and evaluating the information collected on the client. CN: Management of care; CL: Synthesize
A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? 1. Serum potassium is 3.5 mEq/L (3.5 mmol/L). 2. Blood pressure is 88/46. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61.
2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range. CN: Pharmacological and parenteral therapies; CL: Analyze
The nursing assistant reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 2 hours ago with a heart rate of 82; the nursing assistant reports that blood pressure is now 84/44 with a heart rate of 54 and the client stated, "I just don't feel good." Which of the following interventions should the nurse initiate? Select all that apply. 1. Confirm the client's vital signs and complete a quick assessment. 2. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. 3. Make a quick check on other assigned clients before spending the amount of time required to take care of this client. 4. Position client in semi-Fowler's position. 5. Stay with the client and reassure the client. 6. Call the physician and report the situation using SBAR format.
1, 2, 4, 5, 6. The nurse must have assessment data and verify vital signs if necessary in order to determine the action that is required. If there is a significant change in the client's condition, the charge nurse should be notified in order to help the nurse with both this client and the nurse's other assigned clients if necessary; most acute care facilities have a rapid response team that can also help assess and intervene with basic standing orders if necessary. Positioning the client in semi-Fowler's is a nursing action that may assist in breathing and relieve shortness of breath. It is important for the nurse to reassure the client by staying calm and remaining with the client. The physician must be notified of the change in client's condition; the nurse must have all information available and present it to the physician in a concise and accurate manner using SBAR format including a recommendation for treatment if indicated. The nurse should stay with this client and delegate checking on other assigned clients to the charge nurse or nursing assistant. CN: Management of care; CL: Synthesize
A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? Select all that apply. 1. Suggest that the client use ginger when taking the medication. 2. Ask the client what is causing the nausea. 3. Tell the client to use stool softeners to minimize constipation. 4. Offer to administer the medication by an intramuscular injection.
1, 2, 5. Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why the client does not want to take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice. The client can evaluate if this helps the nausea. Stool softeners should not be used in clients with iron deficiency anemia. Instead, constipation can be prevented by following a high-fiber diet. Administering iron intramuscularly is done only if other approaches are not effective. CN: Health promotion and maintenance; CL: Synthesize
The nurse should assess the client with left-sided heart failure for which of the following? Select all that apply. 1. Dyspnea. 2. Jugular vein distention (JVD). 3. Crackles. 4. Right upper quadrant pain. 5. Oliguria. 6. Decreased oxygen saturation levels
1, 3, 5, 6. Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure. CN: Physiological adaptation; CL: Apply
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first: 1. Assess for changes in vital signs. 2. Draw an arterial blood gas. 3. Evaluate heart sounds with the client leaning forward. 4. Obtain a 12-lead electrocardiogram
1. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function. CN: Physiological adaptation; CL: Synthesize
An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission which of the following should the nurse assess first? 1. Blood pressure. 2. Skin breakdown. 3. Serum potassium level. 4. Urine output.
1. It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable. CN: Reduction of risk potential; CL: Analyze
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: 1. Observe careful handwashing procedures. 2. Clean the incisional area with an antiseptic. 3. Use prepackaged sterile dressings to cover the incision. 4. Place soiled dressings in a waterproof bag before disposing of them
1. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
An older adult has chest pain and shortness of breath. The health care provider prescribes nitroglycerin tablets. What should the nurse instruct the client to do? 1. Put the tablet under the tongue until it is absorbed. 2. Swallow the tablet with 120 mL of water. 3. Chew the tablet until it is dissolved. 4. Place the tablet between the cheek and gums until it disappears.
1. The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The client should place the tablet under the tongue and wait until it is absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums. CN: Physiological adaptation; CL: Apply
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedural tasks? Select all that apply. 1. Administer all prescribed oral medications. 2. Check for iodine sensitivity. 3. Verify that written consent has been obtained. 4. Withhold food and oral fluids before the procedure. 5. Insert a urinary drainage catheter.
2, 3, 4. For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply. 1. Verify that the ABO and Rh of the 2 units are the same. 2. Infuse a unit of PRBCs in less than 4 hours. 3. Stop the transfusion if a reaction occurs, but keep the line open. 4. Take vital signs every 15 minutes while the unit is transfusing. 5. Inspect the blood bag for leaks, abnormal color, and clots. 6. Use a 22-gauge catheter for optimal flow of a blood transfusion.
2, 3, 5. The American Association of Blood Banks and Canadian Blood Services recommend that two qualified people, such as two registered nurses, compare the name and number on the identification bracelet with the tag on the blood bag. Verifying that the two units are the same is not a recommendation. Rather, the verification is always with the client, not with bags of blood. A unit of blood should infuse in 4 hours or less to avoid the risk of septicemia since no preservatives are used. When a blood transfusion reaction occurs, the blood transfusion should be stopped immediately, but the IV line should be kept open so that emergency medications and fluids can be administered. The unit of PRBCs should be inspected for contamination by looking for leaks, abnormal color, clots, and excessive air bubbles. When a unit of PRBCs is being transfused, vital signs are assessed before the transfusion begins, after the first 15 minutes, and then every hour until 1 hour after the transfusion has been completed. When PRBCs are being administered, a 20-gauge or larger needle is needed to avoid destroying the red blood cells (RBCs) passing through the lumen and to allow for maximal flow rate. CN: Pharmacological and parenteral therapies; CL: Synthesize
The nurse is developing a teaching plan for a client who will be starting a prescription for Zocor (simvastatin) 40 mg/day. The nurse should instruct the client about which of the following? Select all that apply. 1. "Take once a day in the morning." 2. "If you miss a dose, take it when you remember it, but do not double the dose if you do not remember to take it until it is time for your next dose." 3. "Limit greens such as lettuce in the diet to prevent bleeding." 4. "Be sure to take the pill with food." 5. "Report muscle pain or tenderness to your health care provider." 6. "Continue to follow a diet that is low in saturated fats."
2, 5, 6. Zocor (simvastatin) is used in combination with diet and exercise to decrease elevated total cholesterol. The client should take Zocor in the evening, and the nurse should instruct the client that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next scheduled dose. It is not necessary to take the pill with food. The client does not need to limit greens (limiting greens is appropriate for clients taking Coumadin), but the nurse should instruct the client to avoid grapefruit and grapefruit juice, which can increase the amount of the drug in the bloodstream. A serious side effect is myopathy, and the client should report muscle pain or tenderness to the health care provider.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse's next action should be to: 1. Call for the physician. 2. Start an IV infusion. 3. Obtain a portable chest radiograph. 4. Draw blood for laboratory studies.
2. Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line. CN: Physiological adaptation; CL: Synthesize
A client has a history of heart failure and has been furosemide (Lasix), digoxin (Lanoxin), and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows firstdegree atrioventricular block. The nurse should assess the client for signs of which of the following? 1. Hyperkalemia. 2. Digoxin toxicity. 3. Fluid deficit. 4. Pulmonary edema.
2. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following prescriptions from the health care provider should the nurse verify before implementing? 1. Call for urine output less than 30 mL/h for 2 consecutive hours. 2. Metoprolol (Lopressor) 5 mg IV push. 3. Prepare for a pulmonary artery catheter insertion. 4. Titrate dobutamine (Dobutrex) to keep systolic BP greater than 100.
2. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock. CN: Physiological adaptation; CL: Synthesize
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) and oxygen at 2 L/min. The nurse's first course of action should be to: 1. Increase the IV infusion rate. 2. Notify the physician promptly. 3. Increase the oxygen concentration. 4. Administer a prescribed analgesic
2. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability. CN: Physiological adaptation; CL: Synthesiz
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? 1. Fluid balance. 2. Anaphylactic reaction. 3. Pain. 4. Altered level of consciousness.
2. The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion immediately, but leave the IV line intact, and notify the physician. Usually, an antihistamine such as diphenhydramine hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood administration. The administration should not cause pain unless it is extravasating out of the vein, in which case the IV administration should be stopped. Administration of a unit of blood should not affect the level of consciousness. CN: Pharmacological and parenteral therapies; CL: Analyze
The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should: 1. Begin chest compressions. 2. Call the rapid response team. 3. Remove the family from the room. 4. Ventilate the client with a bag-mask device.
2. The rapid response team should be called immediately to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. If the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided.
When assessing a client for early septic shock, the nurse should assess the client for which of the following? 1. Cool, clammy skin. 2. Warm, flushed skin. 3. Increased blood pressure. 4. Hemorrhage.
2. Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock. CN: Physiological adaptation; CL: Analyze
Which is the most important initial postprocedural nursing assessment for a client who has had a cardiac catheterization? 1. Monitor the laboratory values. 2. Observe neurologic function every 15 minutes. 3. Observe the puncture site for swelling and bleeding. 4. Monitor skin warmth and turgor.
3. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required. CN: Reduction of risk potential; CL: Analyze
The nurse should teach the client who is receiving warfarin sodium that: 1. Partial thromboplastin time values determine the dosage of warfarin sodium. 2. Protamine sulfate is used to reverse the effects of warfarin sodium. 3. International Normalized Ratio (INR) is used to assess effectiveness. 4. Warfarin sodium will facilitate clotting of the blood.
3. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.
As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: 1. Antispasmodic effects on the pericardium. 2. Causing an increased myocardial oxygen demand. 3. Vasodilation of peripheral vasculature. 4. Improved conductivity in the myocardium.
3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium
The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. The nurse should do the following in which order from first to last? 1. Obtain a history of which drugs the client has used recently. 2. Administer the prescribed dose of morphine. 3. Position electrodes on the chest. 4. Take vital signs.
3. Position electrodes on the chest. 4. Take vital signs. 2. Administer the prescribed dose of morphine. 1. Obtain a history of which drugs the client has used recently.
A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following? 1. Cardiac output. 2. Right atrial blood flow. 3. Left end-diastolic pressure. 4. Cardiac index
3. When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area, and is considered a more accurate reflection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective? 1. Ninety percent of clients have not gained weight. 2. Seventy-five percent of the clients viewed the educational DVD. 3. Eighty percent of the clients reported that they are taking their medications. 4. Five percent of the clients required hospitalization in the last 90 days.
4. The goals of managing clients outside of the hospital are for the clients to maintain health and prevent readmission, thus interventions, such as monitoring and teaching, appear to have contributed to the low readmission rate in this group of clients. Although it is important that clients do not gain weight, view educational material, and continue to take their medication, the primary indicator of effectiveness of the program is the lack of re-hospitalization. CN: Management of care; CL: Evaluate
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: 1. Discontinue the IV catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 minutes of infusion
4. The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established IV line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution. CN: Pharmacological and parenteral therapies; CL: Synthesize
Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss? 1. Pulse rate less than 60 bpm. 2. Respiratory rate of 4 breaths/min. 3. Pupils unequally dilated. 4. Systolic blood pressure less than 90 mm Hg.
4. Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury. CN: Physiological adaptation; CL: Analyze
