Cardiovascular ATI
A nurse is planning a presentation for a group of clients who have hypertension. which of the following lifestyle modifications should the nurse include SATA - Tobacco cessation -Decreased magnesium intake -reduced potassium intake -regular exercise program -limited alcohol intake
- Tobacco Cessation -Regular exercise program -Limited alcohol intake Rationale: Limited alcohol intake is correct. Clients who have hypertension should limit alcohol intake.Regular exercise program is correct. Clients who have hypertension should develop a regular exercise program to help reduce blood pressure.Decreased magnesium intake is incorrect. Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include.Reduced potassium intake is incorrect. Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include.Tobacco cessation is correct. Clients who have hypertension should have a goal of tobacco cessation because tobacco use exacerbates hypertension.
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. which of the following instructions should the nurse include in the teaching. A- Place the patch on an area of skin away from skin folds and joints B- Apply the new patch to the same site as the previous patch C- Replace the patch at the onset of angina D- Keep the patch on 24 hr per day
A- Place the patch on an area of skin away from skin folds and joints Rationale: The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.
A nurse is assessing a client who has pulmonary edema related to heart failure. which of the following findings indicates effective treatment of the clients condition A- Decreased Respiratory rate at rest B- Absence of adventitious breath sounds C- Presence of nonproductive Cough D- SaO2 86% on room air
B- Absence of Adventitious breath sounds Rationale: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.
A nurse is caring for a client who had an onset of chest pain 24hr ago. the nurse recognize that an increase in which of the following is diagnostic of myocardial infarction (MI) A- C Reactive protein B- Myoglobin C- Creatine Kinase- MB D-Homocysteine
C- Creatine Kinase- MB Rationale: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.
A nurse is teaching a client who is starting to take an ace inhibitor to treat hypertension . the nurse should instruct the client to notify his provider if he experiences which of the following adverse effects of this medication A- Persistent Cough B- Frequent Urination C- Constipation D- Tendon Pain
A - Persistent Cough Rationale: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. which of the following statements by the client requires the nurse to contact the provider for possible rescheduling A- I smoked a cigarette this morning to calm my nerves about having this procedure B-I didn't take my heart pills this morning because my doctor told me not to C- I have had chest pain a couple of times since I saw my doctor in the office last week D- Im still hungry after the bowl of cereal I ate at 7 am
A- I smoked a cigarette this morning to calm my nerves about having this procedure Rationale: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. the nurse should plan to monitor for and report which of the following findings to the provider immediately A- slurred speech B- persistent fatigue C- Irregular pulse D- Dependent edema
A- Slurred Speech Rationale: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
a nurse is providing health teaching for a group of clients which of the following clients is at risk for developing peripheral arterial disease A- a client who has diabetes mellitus B- a client who has hypothyroidism C- a client who consumes two 12-oz bottles of beer a day D- a client whose daily caloric intake consists of 25% fat
A- a client who has diabetes mellitus Rationale: Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.
A nurse is caring for a client who is 8 hr postoperative following a coronary artery graft. which of the following client findings should the nurse report A- Temp 98.8 B- BP 160/80 C- Potassium 4.0 D- Mediastinal drainage 100 ml/hr
B- BP 160/80 Rationale: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.
A nurse in an emergency room is assessing a client who has bradydysrhythmia. which of the following findings should the nurse monitor for? A- Friction Rub B- Confusion C-Dry Skin D-Hypertension
B- Confusion Rationale: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.
A nurse is assessing a client who has a history of DVT and is receiving warfarin. the nurse should identify that which of the following findings indicates the mediation is effective A- Hemoglobin 14 g/dl B- INR 2.0 C- Minimal bruising of Extremities D- Decreased blood pressure
B- INR 2.0 Rationale: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.
A nurse is caring for a client who is being rated for heart failure and has a prescription for furosemide. the nurse should plan to monitor for which of the following as an adverse effect of this medication A- Metallic taste B- Lightheadedness C- Dry Cough D- Shortness of breath
B- Lightheadedness Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.
A nurse is caring for client who is receiving heparin therapy and develops hematuria. which of the following actions should the nurse take if the clients aPTT is 96 seconds A- Request a Prothrombin time (PT) B- Stop the heparin infusion C- Continue to monitor the heparin infusion as prescribed D- Increase the heparin infusion flow rate by 2ml/hr
B- Stop the Heparin infusion Rationale: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.
A nurse is monitoring a client ECG monitor and notes the clients rhythm has change from normal signs rhythm to supraventricular tachycardia. the nurse should prepare to assist with which of the following interventions A- Administration of atropine IV B- Vagal Stimulation C- Defibrillation D- Delivery of precordial Thump
B- Vagal Stimulation Rationale: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.
a nurse is caring for a client who has endocarditis. which of the following findings should the nurse recognize as a potential complication A- Guillain- Barre syndrome B- Valvular Disease C- Ventricular Depolarization D- Myelodysplastic syndrome
B- Valvular Disease Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is assessing a client who has Left-Sided heart failure. which of the following manifestations should the nurse expect to find A- Increased Abdominal Girth B-Weak Peripheral Pulses C- Dependent Edema D- Jugular Venous Neck Distention
B- Weak Peripheral Pulses Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.
A nurse in an emergency department is caring for a client who had an anterior MI . the clients history reveals she Is 1 week postoperative following an open cholecystectomy . the nurse should recognize that which of the following interventions is contraindicated. A- administering IV Morphine Sulfate B- Assisting with thrombolytic therapy C- administering oxygen at 2 L/min via nasal cannula D-helping the client to the bedside commode
B- assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
A nurse in an emergency department s caring for a client who has a blood pressure of 254/139 mm hg. the nurse recognizes that the client is in a hypertensive crisis. which of the following actions should the nurse take first. A- tell the client to report vision changes B- elevate the head of the clients bed C- Start a peripheral IV D- Initiate Seizure precautions
B- elevate the head of the client's bed Rationale: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.
a nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. the nurse should plan to provide dietary teaching for the client who has which of the following laboratory values A- Cholesterol 195 HDL 55 LDL 125 B-Cholesterol 185 HDL 50 LDL 120 C- Cholesterol 190 HDL 25 LDL 160 D- Cholesterol 180 HDL 70 LDL 90
C- Cholesterol 190 HDL 25 LDL 160 Rationale: These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.
A nurse is caring for a client following insertion of a permanent pacemaker. which of the following client statements indicates a potential complication of the insertion procedure A- I feel dizzy when I stand B- my incision site stings C- I cant get rid of these Hiccups D- I have a headache
C- I cannot get rid of these hiccups Rationale: Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hours. which of the following client statements indicates a need for further clarification by the nurse A- my arthritis is really bothering me because I haven't taken my aspirin in a week B- I will check my blood sugar because I took a reduced does of insulin this morning C- I took my warfarin last night according to my usual schedule D- my blood pressure shouldn't be high because I took my blood pressure medication this morning
C- I took my warfarin last night according to my usual schedule Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.
A nurse is preparing a client for coronary angiography. the nurse should report which of the following findings to the provider prior to the procedure A- Hemoglobin 14.4 g/dl B- History of peripheral arterial disease C- Previous allergic reaction to shellfish D- Urine output 200ml/4hr
C- Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.
A nurse is providing discharge teaching for a client who has a heart failure. the nurse should instruct the client to report which of the following findings immediately to the provider A- increase of 10 mm/hg in systolic blood pressure B- dizziness when rising quickly C- weight gain of 0.9KG or 2lb in 24 hr D- dyspnea with exertion
C- weight gain of 0.9Kg or 2lb in 24 hrs Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.
A nurse is providing teaching for a client who is 2 days postoperative following a heart transplant. which of the following statements should the nurse include in the teaching A- " your level of activity intolerance will not change" B- " you will be able to stop taking immunosuppressant's after 12 months C- " after 6 months you will no longer need to restrict your sodium intake" D- "You might no longer be able to feel chest pain"
D- "You might no longer be able to feel chest pain" Rationale: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. the nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer. A- ask if the client has had a recent infection B- Explore the clients family history of peripheral vascular disease C- Note the presence of absence of pain at the ulcer site D- inquire about the presence or absence of claudication
D- Inquire about the presence or absence of claudication Rationale: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. the client is experiencing weakness and an irregular hear rate. which of the following actions should the nurse take first? A- obtain clients current weight B-Determine the time of the last digoxin dose C- Check the clients urine output D- Review serum electrolyte Values
D- Review serum electrolyte Values Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
a nurse is assessing a client who has dilated cardiomyopathy. which of the following findings should the nurse expect A-weight loss B- pericardial rub C- tracheal deviation D- dyspnea on exertion
D- dyspnea on exertion Rationale: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.
A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. which of the following findings can indicate shock and should be reported to the provider A- urine output of 20ml/hr B- Severe pain with coughing C- Serosanguineous drainage on dressing D- increase in temperature from 98.2 to 99.5
Urine output of 20ml/hr Rationale: Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
