Cardio - PassPoint
A nurse who is caring for a client in labor with a history of rheumatic heart disease should gather what data to determine fetal well-being? urinalysis other signs and symptoms of the client fetal heart tones laboratory test results of the mother
fetal heart tones Explanation: Fetal heart tones show how the fetus is responding to the environment. Assessing other signs and symptoms of the mother, including laboratory test results and urinalysis, can determine the effect on the mother only, not the fetus.
When gathering data from a client admitted with hypertension, the nurse should expect the client to report which symptom? headache epistaxis peripheral edema blurred vision
headache Explanation: An occipital headache is typical of hypertension owing to increased pressure in the cerebral vasculature. Blurred vision (due to arteriolar changes in the eye) and epistaxis (nosebleed) are far less common than headache, but can also be diagnostic signs. Peripheral edema can occur from an increase in sodium and water retention, but it's usually a latent sign.
A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and prescribes sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, the nurse should provide which instruction? "Be sure to take safety precautions because nitroglycerin may cause your blood pressure to drop when you change positions. "A burning sensation after administration indicates that the nitroglycerin tablets are are potent." "Replace leftover sublingual nitroglycerin tablets every 9 months to make sure they're fresh." "You may take a sublingual nitroglycerin tablet every 30 minutes, if needed, to a maximum of four doses."
"Be sure to take safety precautions because nitroglycerin may cause your blood pressure to drop when you change positions. Explanation: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina and may repeat the dose every 10 to 15 minutes for up to three doses; if this doesn't bring relief, the client should seek immediate medical attention.
A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse gathers data regarding the knowledge of the client regarding the prescribed cardiac rehabilitation program. What statement suggests that the client needs more instruction? "Client walks 4 miles (6.4 km) in 1 hour every day." "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." "Client verbalizes an understanding of the need to seek emergency help if the heart rate increases markedly while at rest." "Client performs relaxation exercises three times per day to reduce stress."
"Client walks 4 miles (6.4 km) in 1 hour every day." Explanation: Four weeks after an MI, a client's walking program should aim for a goal of 2 miles (3.2 km) in less than 1 hour. Walking 4 miles (6.4 km) in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. The other options indicate understanding of the cardiac rehabilitation program. The client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower the risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening dysrhythmia and increase myocardial oxygen demands.
The nurse is caring for a child that is undergoing cardiac surgery. Parents ask a nurse what the activity level for their child should be post-surgery. Which response would be best? "Climbing and contact sports are restricted for 1 week." "There are no exercise limitations." "Encourage a balance of rest and exercise." "The child may resume school in 3 days."
"Encourage a balance of rest and exercise." Explanation: Activity should be increased gradually each day, allowing for a sensible balance of rest and exercise. School and large crowds should be avoided for at least 2 weeks to prevent exposure to people with active infections. Sports and contact activities should be restricted for about 6 weeks, giving the sternum enough time to heal.
A client with high blood pressure is receiving an antihypertensive drug. The nurse knows that antihypertensive drugs commonly cause fatigue and dizziness, especially on rising. When developing a client teaching plan to minimize orthostatic hypotension, the nurse should include which instruction? "Flex your calf muscles, avoid alcohol, and change positions slowly." "Wear elastic stockings, change positions quickly, and hold onto a stationary object when rising." "Rest between demanding activities, eat plenty of fruits and vegetables, and drink plenty of fluids daily." "Avoid drinking alcohol and straining at stool, and eat a low-protein snack at night."
"Flex your calf muscles, avoid alcohol, and change positions slowly." Explanation: Measures that minimize orthostatic hypotension include flexing the calf muscles to boost blood return to the heart, avoiding alcohol and straining at stool, changing positions slowly, eating a high-protein snack at night, wearing elastic stockings, and holding onto a stationary object when rising. Although the client should rest between demanding activities and consume plenty of fluids and fiber (contained in fruits and vegetables) to maintain a balanced diet, these measures don't directly relieve orthostatic hypotension.
A client with chronic heart failure is receiving digoxin, 0.25 mg by mouth daily, and furosemide, 20 mg by mouth twice daily. Which statements by the client indicate that further teaching is needed regarding digoxin toxicity? Select all that apply. "I should report a metallic taste in my mouth to my health care provider." "I should report if I am unable to completely empty my bladder to my health care provider." "I should report nausea, vomiting, or diarrhea to the health care provider." "I should report any sleep disturbances to my health care provider." "I should report double vision to my health care provider immediately."
"I should report a metallic taste in my mouth to my health care provider." "I should report if I am unable to completely empty my bladder to my health care provider." "I should report any sleep disturbances to my health care provider." Explanation: Digoxin toxicity may cause visual disturbances (such as flickering light flashes, colored or halo vision, photophobia, blurring, diplopia, and scotomata); central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability, and, if profound, seizures, delusions, hallucinations, and memory loss); and cardiovascular abnormalities (abnormal heart rate and arrhythmias). Taste and smell alterations aren't associated with digoxin toxicity. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide, especially if the client takes the second daily dose in the evening, which may cause diuresis at night.
A nurse is caring for a client with a new prescription of digoxin. Which client statement would indicate the need for further teaching about digoxin? Select all that apply. "I will take my pulse before each dose of digoxin." "If I forget a dose, I will catch up by doubling the next dose." "I will notify my doctor if experiencing increased fatigue or muscle weakness." "I understand that I will need annual blood work to check therapeutic levels." "I will take the digoxin with my antacids at night." "I will take the digoxin at 9 a.m. daily."
"I will take the digoxin with my antacids at night." "If I forget a dose, I will catch up by doubling the next dose." "I understand that I will need annual blood work to check therapeutic levels." Explanation: Digoxin is a cardiac glycoside that slows and strengthens the heart, providing a more regular rhythm. Digoxin has a narrowed therapeutic window requiring serum blood level monitoring initially at every 2 weeks to monthly. It is usually helpful for a client to take digoxin at a specific time each day to establish its blood level and routine for administration. The nurse should teach the client to take the pulse before each dose of digoxin and to notify the practitioner if the rate or rhythm changes, specifically if the rate drops to less than 60 beats/minute. The client should also be instructed to report increasing fatigue or muscle weakness immediately, as these are signs of digitalis (digoxin) toxicity. Antacids inhibit the absorption of digoxin, so digoxin should not be taken with these drugs. If the client forgets to take a dose of digoxin, he or she may take the missed dose only up to 12 hours later.
A client with a family history of heart disease is diagnosed with coronary artery disease. The client asks the nurse, "How can it affect my future health status?" What is an appropriate response? Select all that apply. "It can lead to a myocardial infarction." "It can lead to gastritis." "It can lead to hypertension." "It can lead to angina." "It can lead to heart failure."
"It can lead to hypertension." "It can lead to angina." "It can lead to a myocardial infarction." "It can lead to heart failure." Explanation: Coronary artery disease causes decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply. This can cause hypertension, angina, myocardial infarction, heart failure, and even death.
Which client statement given when obtaining data is consistent with the diagnosis of varicose veins? "My legs become numb and get weaker the farther I walk." "I have severe foot pain that awakens me, but it gets better if I dangle my foot off the edge of the bed." "My legs feel tired and have a dull ache, especially when I walk or stand for long periods." "After I walk a half mile, I get severe calf pain that goes away when I rest."
"My legs feel tired and have a dull ache, especially when I walk or stand for long periods." Explanation: Fatigue, aching, and pressure are classic symptoms of varicose veins, secondary to increased blood volume and edema. Severe foot pain that awakens the client, as well as severe calf pain after walking that's relieved with rest, are symptoms of decreased peripheral arterial blood flow. Numbness and weakness that increase as the client walks are consistent with spinal stenosis.
The nurse is explaining the use of transdermal nitroglycerin, which is to be applied twice daily. The client demonstrates understanding when he states: "I'm using the transdermal nitroglycerin to lower my blood pressure." "I will know the medication is working if I have a headache after applying it." "I should apply the patch in the same spot all the time." "My wife should be careful not to touch the patch with her fingers if she helps me."
"My wife should be careful not to touch the patch with her fingers if she helps me." Explanation: The client's wife should be careful to avoid getting the drug on her skin, where it's easily absorbed. The application site should be rotated for better absorption and to prevent skin irritation. Although some clients experience headache after applying this drug, this isn't a desired effect. Although transdermal nitroglycerin may lower blood pressure, its main indication is to prevent anginal attacks.
A nurse is screening clients for their risk of developing cardiovascular disease. The nurse identifies which client to be at the greatest risk? 40-year-old black female 50-year-old white male 40-year-old white female 50-year-old black male
50-year-old black male Explanation: Blacks are two to three times more likely to develop hypertension than whites are. Males have more myocardial infarctions (MIs) than do women until women reach postmenopause, when the risk of MI increases.
Which interventions are appropriate when caring for a client with acute thrombophlebitis? Increase the client's activity level and encourage leg exercises. Apply warm soaks and elevate the client's legs higher than the level of the heart. Wrap leg with cool cloth and keep the client's leg lower than the level of the heart. Administer nitroglycerin and oxygen at 2 LPM.
Apply warm soaks and elevate the client's legs higher than the level of the heart. Explanation: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.
The nurse is assigned to care for a client who had a myocardial infarction. When arriving in the client's room, the nurse finds the client unresponsive and without a pulse. What is the priority intervention by the nurse? Begin cardiopulmonary resuscitation (CPR). Administer epinephrine. Administer 2 L/min of oxygen by nasal cannula. Place a nitroglycerin tablet under the tongue.
Begin cardiopulmonary resuscitation (CPR). Explanation: When the nurse determines that the client is unresponsive and does not have a pulse, immediate resuscitation efforts should be instituted by starting CPR. The client will require oxygen delivery by endotracheal intubation or a bag-valve-mask and not at a low flow of 2 L/min by cannula. Administration of nitroglycerin under the tongue of an unresponsive client may cause aspiration if the pill is dislodged. Epinephrine may be administered at a later time, but is not a first intervention.
A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time? Disabled family coping related to deficient knowledge and a temporary change in family dynamics Hypothermia related to exposure to cold temperatures and a long cardiopulmonary bypass time Decreased cardiac output related to depressed myocardial function, deficient fluid volume, or impaired electrical conduction Anxiety related to an actual threat to health status, invasive procedures, and pain
Decreased cardiac output related to depressed myocardial function, deficient fluid volume, or impaired electrical conduction Explanation: For a client recovering from CABG surgery, Decreased cardiac output is the most important nursing diagnosis because myocardial function may be depressed from anesthetics or a long cardiopulmonary bypass time, leading to decreased cardiac output. Other possible causes of decreased cardiac output in this client include deficient fluid volume and impaired electrical conduction. The other options may be relevant but take lower priority at this time because maintaining cardiac output is essential to sustaining the client's life.
A nurse is caring for a hypertensive client who has been placed on a low-sodium diet. Which menu selection demonstrates the client's understanding of this diet? Tomato soup and bologna sandwich Broiled fish and Chinese vegetables Tapioca pudding and cheese sandwich Fresh green beans and chicken salad
Fresh green beans and chicken salad Explanation: Fresh vegetables and chicken salad are both low in sodium. Options 1, 2, and 3 all contain more that 150 mg of sodium and should be avoided by client's on sodium-restricted diets.
A client with a history of atrial arrhythmia is receiving propranolol, 10 mg by mouth three times per day. The nurse knows that propranolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located? Uterus Bronchi Heart Blood vessels
Heart Explanation: Beta1-receptor sites are mainly located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.
A white male, age 43, is admitted to an acute care facility with a tentative diagnosis of infective endocarditis. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis? Age Race History of diabetes mellitus History of aortic valve replacement
History of aortic valve replacement Explanation: A heart valve prosthesis, such as an aortic valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.
The physician prescribes digoxin for a client with heart failure. During digoxin therapy, which electrolyte imbalance may predispose the client to digoxin toxicity? Hypercalcemia Hypernatremia Hypermagnesemia Hypokalemia
Hypokalemia Explanation: Conditions that may predispose a client to digoxin toxicity include hypokalemia, hypomagnesemia, hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia, hypercalcemia, and hypernatremia aren't associated with a risk of digoxin toxicity.
The nurse is caring for a client with hypertension. What is the best action for the nurse to take when administering a new blood pressure medication to a client? Inform the client of the new medication, its name, its use, and the reason for the change. Administer the medication to the client without explanation. Administer the medication and inform the client that the health care provider will explain the medication later. Inform the client of the new drug only if the client asks about it.
Inform the client of the new medication, its name, its use, and the reason for the change. Explanation: Informing the client about the medication, its use, and the reason for the change is important in caring for the client. Educating the client about the treatment regimen promotes compliance. The other responses are inappropriate.
A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How should the nurse intervene? Administer I.V. fluids as ordered. Administer a vasodilator as prescribed. Insert an indwelling urinary catheter as ordered. Instruct the client to flex the calf muscles and then sit up for several minutes before standing.
Instruct the client to flex the calf muscles and then sit up for several minutes before standing. Explanation: To minimize the effects of orthostatic hypotension, the nurse should instruct the client to flex the calf muscles and then rise slowly to a standing position, such as by sitting up for several minutes first. Administering I.V. fluids would be inappropriate (unless the client is dehydrated) because it would counteract the effects of furosemide, possibly leading to fluid imbalance. Administering a vasodilator would further reduce the client's blood pressure, worsening orthostatic hypotension. Inserting an indwelling urinary catheter would aid urine output monitoring but wouldn't minimize the effects of orthostatic hypotension.
The nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms would suggest circulatory impairment? Redness, cool skin temperature, and swelling Numbness, cool skin temperature, and pallor Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness
Numbness, cool skin temperature, and pallor Explanation: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include warm skin with normal return of skin color after blanching and normal sensation.
A client comes to the emergency department diagnosed with a ruptured aortic aneurysm. What is the priority action for this client? Administer antihypertensive medication. Transport the client for an aortogram. Prepare the client for surgery. Administer beta-blocker.
Prepare the client for surgery. Explanation: When the vessel ruptures, surgery is the only intervention that can repair it. Administration of antihypertensive medications and beta-blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm.
An average-weight client reports of generalized steady abdominal pain. The nurse should suspect an abdominal aortic aneurysm, if the abdominal pain is accompanied by which finding? Elevated cardiac enzymes Pink, frothy sputum Pulsating mass in the periumbilical area Positive Babinski's sign
Pulsating mass in the periumbilical area Explanation: Signs of abdominal aortic aneurysm include gnawing, generalized, steady abdominal pain; lower back pain that's unaffected by movement; gastric or abdominal fullness; pulsating mass in the periumbilical area (if the client isn't obese), systolic bruit over the aorta on auscultation of the abdomen; bruit over the femoral arteries; and hypotension (with aneurysm rupture). Elevated cardiac enzymes indicate heart muscle damage. Positive Babinski's sign indicates damage to the pyramidal tract of the central nervous system. Pink, frothy sputum is a sign of pulmonary edema.
When assisting with an electrocardiogram (ECG), the nurse would expect to place the client in which position? Prone Supine Fowler's Lateral
Supine Explanation: The most appropriate position for a client undergoing an ECG is lying flat, as long as the client can tolerate being in a supine position. Otherwise, the client may be positioned with the head of the bed slightly elevated.
The nurse is caring for a client diagnosed with angina pain who underwent a cardiac catheterization. When observing the postprocedural dressing at the left femoral access site, the nurse sees bloody drainage soaking through the dressing. At what site should the nurse apply steady, consistent pressure until clotting occurs?
The X is placed approximately 2 inches (5 cm) above the femoral artery access site, where the femoral artery is punctured. Steady pressure assists the body in diminishing bleeding and improving clotting.
Which client is most at risk for developing deep vein thrombosis (DVT)? a 33-year-old male runner with Achilles tendonitis an ambulatory 70-year-old male who's recovering from pneumonia a 35-year-old female 2 days postpartum a 62-year-old female recovering from a total hip replacement
a 62-year-old female recovering from a total hip replacement Explanation: DVT is more common in immobilized clients who have had surgical procedures such as total hip replacement. Pregnancy can cause varicose veins, which can lead to venous stasis, but it isn't a primary cause of DVT. Clients who are recovering from an injury or pneumonia may have decreased mobility, but these clients don't have the highest risk of developing DVT.
The nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques: are helpful because stress stimulates the release of vasoconstricting catecholamines. are helpful only because they assist in smoking cessation. haven't proved useful in clients with peripheral vascular disease. are helpful because they distract the client from focusing on claudication pain.
are helpful because stress stimulates the release of vasoconstricting catecholamines. Explanation: Stress-reduction techniques help avoid the stress-induced release of vasoactive catecholamines, such as epinephrine, which causes vasoconstriction that directly aggravates peripheral vascular disease by intensifying the ischemic burden of the affected tissues. Vasoconstriction also indirectly aggravates atherogenesis by inducing hypertension. Stress-reduction techniques make it easier for clients to avoid bad habits, such as smoking; however, this isn't the only reason why they're useful. Claudication is a signal of muscle ischemia; its associated pain shouldn't be ignored.
The nurse is caring for an infant with suspected transposition of the great arteries (TGA). Which diagnostic test will the nurse prepare the infant and family for initially? echocardiogram cardiac catheterization chest radiography blood cultures
chest radiography Explanation: Chest radiography would be done first to visualize congenital heart diseases such as TGA. Blood cultures won't diagnose TGA. Cardiac catheterization and an echocardiogram would be done after TGA is seen on the chest radiograph.
An older adult client is newly diagnosed with left-sided heart failure. Which sign most commonly associated with this type of heart failure would the nurse expect to find when obtaining data for this client? arrhythmias hypotension hepatic engorgement crackles
crackles Explanation: Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with right- and left-sided heart failure. Hepatic engorgement is associated with right-sided heart failure. Left-sided heart failure causes hypertension secondary to an increased workload on the system.
The nurse is teaching a client how to take nitroglycerin to treat angina pectoris. The client verbalizes an understanding of the need to take up to three sublingual nitroglycerin tablets at 5-minute intervals, if necessary, and to notify the physician immediately if chest pain doesn't subside within 15 minutes. The nurse informs the client that nitroglycerin may cause: nausea, vomiting, depression, fatigue, and impotence. headache, hypotension, dizziness, and flushing. sedation, nausea, vomiting, constipation, and respiratory depression. flushing, dizziness, headache, and pedal edema.
headache, hypotension, dizziness, and flushing. Explanation: Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a beta-adrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic used to relieve pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker.
A client is diagnosed with prehypertension. Which treatment option would most likely be included in the client's treatment plan? diuretics angiotensin-converting enzyme (ACE) inhibitors lifestyle modification instructions beta-adrenergic blockers
lifestyle modification instructions Explanation: Prehypertension signals the need for teaching about lifestyle modifications to prevent hypertension. Lifestyle modifications may include making dietary changes, adopting relaxation techniques, exercising regularly, quitting smoking, limiting intake of alcohol, and restricting sodium and saturated fat intake. Diuretics, beta-adrenergic blockers, and ACE inhibitors are used to treat hypertension.
A client comes to the emergency department reporting chest pain. Upon further evaluation, the nurse suspects unstable angina. Which disease process should the nurse reinforce teaching this client about because it is directly related to unstable angina? angina decubitus myocardial infarction (MI) nocturnal angina abdominal aortic aneurysm (AAA)
myocardial infarction (MI) Explanation: Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months. Angina decubitus, angina, nocturnal angina, and AAA aren't associated with an increased risk of MI.
A newly hired graduate nurse and nurse mentor are discussing cardiac disease and its modifiable risks factors. The mentor knows the discussion was effective when the graduate nurse lists which factors as being modifiable? family history of heart disease obesity and smoking ethnic background age and gender
obesity and smoking Explanation: Modifiable risk factors (obesity and smoking) can be controlled or eliminated. Age, gender, ethnic background, and family history of heart disease are factors that cannot be controlled or eliminated; these are nonmodifiable risk factors for cardiac disease.
A client has been hospitalized with a diagnosis of acute arterial occlusive disease. After surgery, the health care provider orders heparin IV therapy for the client. What test does the nurse need to monitor for this client while on heparin? prostate-specific antigen (PSA) complete blood count (CBC) prothrombin time (PT) partial thromboplastin time (PTT) blood urea nitrogen (BUN)
partial thromboplastin time (PTT) Explanation: PTT is used to monitor response to heparin therapy and is used to evaluate all the clotting factors of the intrinsic pathway. Both are monitored whenever a client is on heparin. CBC is used to determine infection or inflammation. PSA is used to screen for prostate cancer in men. Blood urea nitrogen is used to evaluate kidney function.
A nursing student is observed by the instructor obtaining a blood pressure reading. The instructor immediately intervenes when the student: places the stethoscope over the brachial artery. washes her hands before taking a blood pressure reading. places the stethoscope over the brachiocephalic artery. uses the diaphragm of the stethoscope.
places the stethoscope over the brachiocephalic artery. Explanation: The brachial artery is typically used because of its easy accessibility and location. The brachiocephalic artery isn't accessible for blood pressure measurement. Students should use standard precautions by washing their hands whenever performing skills. The diaphragm is the correct part of the stethoscope to use when taking a blood pressure reading.
A client who has a deep vein thrombosis (DVT) reports dyspnea and chest pain and has diminished breath sounds. Which condition does the nurse prepare treatment for? pulmonary hypertension hemothorax pulmonary embolism pneumothorax
pulmonary embolism Explanation: The most common complication of a DVT is a pulmonary embolus. A pulmonary embolism is a thrombus that forms in a vein, travels to the lungs, and lodges in the pulmonary vasculature. Hemothorax refers to blood in the pleural space. Pneumothorax is caused by an opening in the pleura. Pulmonary hypertension is an increase in pulmonary artery pressure, which increases the workload of the right ventricle.
After experiencing a transient ischemic attack (TIA), a client is prescribed aspirin, 325 mg by mouth daily. The nurse should teach the client that this medication has been prescribed to: enhance the immune response. prevent intracranial bleeding. reduce platelet agglutination. control headache pain.
reduce platelet agglutination. Explanation: TIAs are considered forerunners of stroke. Because a stroke may result from a clot in a cerebral vessel, aspirin is prescribed to prevent clot formation by reducing platelet agglutination. A 325-mg dose of aspirin is inadequate to relieve headache pain in an adult. Aspirin has no effect on the body's immune response. Intracranial bleeding isn't associated with TIAs, and the action of aspirin probably would worsen any bleeding present.
A client with a history of severe angina is being seen in the emergency department for chest pain. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a: liver panel. creatine kinase level. hemoglobin (Hb) level. troponin level.
troponin level. Explanation: Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction (MI). It's the best serum indicator of MI and is more indicative of cardiac damage than creatine kinase. Hb values and liver panel components aren't as useful in the diagnosis of MI as a troponin level.
