Chapter 21- Prep U
The nurse admits an adult female client with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. What response by the nurse will be most appropriate? A. "A woman's heart is smaller and has smaller arteries that become occluded more easily." B. "It takes longer for an electrical impulse to travel from the sinoatrial node to the atrioventricular node in a woman." C. "A woman's resting heart rate is lower than a man's." D. "The stroke volume from a woman's heart is lower than from a man's heart."
A. "A woman's heart is smaller and has smaller arteries that become occluded more easily." Rationale: Because the coronary arteries of a woman are smaller, they become occluded from atherosclerosis more easily. The resting rate, stroke volume, and ejection fraction of a woman's heart are higher than those of a man. The electrical impulses from the sinoatrial node to the atrioventricular node are not different in the genders.
You are doing an admission assessment on a client who is having outpatient testing done for cardiac problems. What should you ask this client during your assessment? A. "Have you had any episodes of dizziness or fainting?" B. "Have you had any episodes when you are to nauseous?" C. "Have you had any episodes of mottling in your hands?" D. "Have you had any episodes of pain radiating into your lower extremities?"
A. "Have you had any episodes of dizziness or fainting?" Rationale: Ask if the client has episodes of dyspnea, dizziness, or fainting. Options B, C, and D are incorrect. Being nauseous, mottling of the hands, and pain radiating into the lower extremities are not indications of cardiac problems.
The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response? A. "The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." B. "Having an orgasm is very strenuous and your husband must be in excellent physical shape before attempting it." C. "The medications will prevent your husband from having an erection." D. "It is usually better to just give up sex after a heart attack."
A. "The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." Rationale: The physiologic demands are greatest during orgasm. The level of activity is equivalent to walking 3 to 4 miles per hour on a treadmill. Sexuality is an important quality of life, so the healthcare provider will be determining when it is safe to have intercourse. Erectile dysfunction may be a side effect of beta-blockers, but other medications may be substituted.
The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first? A. Assess the client. B. Call the physician with a report. C. Reposition the client. D. Assess for mechanical dysfunction.
A. Assess the client. Rationale: When a nurse notes an abnormal rhythm on a telemetry monitor, the first action is to assess the client. After client assessment, the nurse is able to make an informed decision on the next nursing action.
The nurse is providing discharge education for a client going home after cardiac catheterization. What information is a priority to include when providing discharge education? A. Avoid tub baths, but shower as desired. B. Expect increased bruising to appear at the site over the next several days. C. Do not ambulate until the healthcare provider indicates it is appropriate. D. Returning to work immediately is okay.
A. Avoid tub baths, but shower as desired. Rationale: Guidelines for self-care after hospital discharge following a cardiac catheterization include showering as desired (no tub baths) and avoiding bending at the waist and lifting heavy objects. The healthcare provider will indicate when it is okay to return to work. The client should notify the healthcare provider right away if bleeding, new bruising, swelling, or pain are noted at the puncture site. The client will be able to ambulate after the puncture site has clotted.
The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure? A. Baroreceptors B. Chemoreceptors C. Sympathetic nerve fibers D. Vagus nerve
A. Baroreceptors Rationale: Baroreceptor sense pressure in nerve endings in the walls of the atria and major blood vessels. The baroreceptors respond accordingly to raise or lower the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood. Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the heart rate.
The clinic nurse caring for a client with a cardiovascular disorder is performing an assessment of the client's pulse. Which of the following steps is involved in determining the pulse deficit? A. Count the heart rate at the apex. B. Count the radial pulse for 20 to 25 seconds. C. Calculate the palpated volume. D. Calculate the pauses between pulsations.
A. Count the heart rate at the apex. Rationale: The nurse determines the pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. The pulse quality refers to its palpated volume. Pulse rhythm is the pattern of the pulsations and the pauses between them.
A client reports chest pain. Which questions related to the client's history are most important to ask? Select all that apply. A. Do you have any children? B. Are you allergic to any medications or foods? C. How would you describe your symptoms? D. How did your mother die?
A. Do you have any children? B. Are you allergic to any medications or foods? D. How did your mother die? Rationale: During initial assessment, the nurse should obtain important information about the client's history that focuses on a description of the symptoms before and during admission, family medical history, prescription and nonprescription drug use, and drug and food allergies.
A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following a therapeutic regimen? A. High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. B. Total cholesterol level increases from 250 mg/dl to 275 mg/dl. C. Low density lipoproteins (LDL) increase from 180 mg/dl to 190 mg/dl. D. Triglycerides increase from 225 mg/dl to 250 mg/dl.
A. High density lipoproteins (HDL) increase from 25 mg/dl to 40 mg/dl. Rationale: The goal of treating hyperlipidemia is to decrease total cholesterol and LDL levels while increasing HDL levels. HDL levels should be greater than 35 mg/dl. This client's increased HDL levels indicate that a therapeutic regimen has been followed. Recommended total cholesterol levels are below 200 mg/dl. LDL levels should be less than 160 mg/dl, or, in clients with known coronary artery disease (CAD) or diabetes mellitus, less than 70 mg/dl. Triglyceride levels should be between 100 and 200 mg/d.
The nurse receives a laboratory report indicating the client's magnesium level is 5.2 mEq/L. What symptoms is the client at risk to experience? Select all that apply. A. Hypotension B. Irregular heartbeat C. Headache D. Ventricular tachycardia E. Atrial tachycardia
A. Hypotension B. Irregular heartbeat C. Headache Rationale: The normal serum magnesium level is 1.5-2.5 mEq/L. Hypermagnesemia can cause nausea, headache, hypotension and irregular heartbeat. Hypomagnesemia can cause ventricular and atrial tachycardia.
The nurse reviews a client's lab results and notes a serum calcium level of 7.9 mg/dL. It is most appropriate for the nurse to monitor the client for what condition? A. Impaired myocardial contractility B. Inclination to ventricular fibrillation C. Increased risk of heart block D. Enhanced sensitivity to digitalis
A. Impaired myocardial contractility Rationale: Normal serum calcium is 8.9 to 10.3 mg/dL. A reading of 7.9 is below normal. Hypocalcemia is associated with slow nodal functioning and impaired myocardial contractility, which can increase the risk of heart failure.
The nurse is caring for a client who is scheduled for a transesophageal echocardiogram. What nursing intervention is a priority after the procedure? A. Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. B. Observe for bloody urine and stools. C. Monitor the puncture site and assess the affected extremity. D. Keep the client turned to the right side and watch for bleeding from the site.
A. Keep the head of the bed elevated 45 degrees and keep NPO until return of the gag reflex. Rationale: During the recovery period, the client must have the head of the bed elevated 45 degrees to avoid aspiration. The nurse should restrict food and fluids until the return of the gag reflex and the client is fully awake and alert. There will be no puncture site after an transesophageal echocardiogram. There is no need to turn the client on the right side or watching for bleeding from the esophagus. There are no anticoagulants given during this procedure, so bloody stools or urine should not occur.
The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? A. Obtain an oxygen saturation level. B. Assess the client for pitting edema. C. Assess the client's capillary refill. D. Obtain a 12-lead ECG tracing.
A. Obtain an oxygen saturation level. Rationale: Clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased oxygen supply) and is associated with congenital heart disease. The nurse should assess the client's O2 saturation level and intervene as directed. The other assessments are not indicated.
A patient recently diagnosed with pericarditis asks the nurse to explain what area of the heart is involved. How does the nurse best describe the pericardium to the client? A. Thin fibrous sac that encases the heart. B. Heart's muscle fibers. C. Inner lining of the heart and valves. D. Exterior layer of the heart.c
A. Thin fibrous sac that encases the heart. Rationale: The pericardium is a thin, fibrous sac that encases the heart. It is composed of two layers, the visceral and the parietal pericardium. The space between these two layers is filled with fluid.
What does decreased pulse pressure reflect? A. reduced stroke volume B. tachycardia C. reduced distensibility of the arteries D. elevated stroke volume
A. reduced stroke volume Rationale: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? A. wheezes with wet lung sounds B. stridor C. high-pitched sounds D. laborious breathing
A. wheezes with wet lung sounds Rationale: If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. For abnormal and normal breath sounds, the nurse auscultates the lungs. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. With left-sided congestive heart failure, auscultation does not reveal a high pitched sound.
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include? A. "If any discharge occurs at the puncture site, call 911 immediately." B. "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." C. "Contact your primary care provider if you develop a temperature above 102°F." D. "You can take a tub bath or a shower when you get home."
B. "Do not bend at the waist, strain, or lift heavy objects for the next 24 hours." Rationale: The nurse should instruct the client to follow these guidelines: For the next 24 hours, do not bend at the waist, strain, or lift heavy objects if the artery of the groin was used; contact the primary provider if swelling, new bruising or pain from the procedure puncture site, or a temperature of 101°F or more occur. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding, call 911. The client should not drive to the hospital.
The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following? A. Atrioventricular tendons B. Chordae tendineae C. Semilunar tendineae D. Papillary tendons
B. Chordae tendineae Rationale: Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Atrioventricular tendons, semilunar tendineae, and papillary tendons do not hold the tricuspid valve in place.
The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmia. Which of the following assessment considerations is essential when caring for this client? A. Dyspnea B. Digoxin level C. Activity level D. Cardiac output
B. Digoxin level Rationale: The action of Digoxin slows and strengthens the heart rate. Assessment of the pulse rate is essential prior to administration in all clients. Due to decreased perfusion common in geriatric clients, toxicity may occur more often. The nurse must monitor Digoxin levels in the body. Monitoring symptoms reflecting cardiac output, activity level, and dyspnea are also important assessment considerations for all clients.
A nurse is completing a head to toe assessment on a client diagnosed with right-sided heart failure. To assess peripheral edema, which of the following areas should be examined? A. Under the sacrum B. Feet and ankles C. Shoulders and elbows D. Lips and earlobes
B. Feet and ankles Rationale: When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.
The nurse is reviewing the results of the patient's echocardiogram and observes that the ejection fraction is 35%. The nurse anticipates that the patient will receive treatment for what condition? A. Pulmonary embolism B. Heart failure C. Pericarditis D. Myocardial infarction
B. Heart failure Rationale: An ejection fraction of less than 40% indicates that the patient has decreased left ventricular function and likely requires treatment for heart failure.
A critically ill client is admitted to the ICU. The health care provider decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize? A. Signs and symptoms of esophageal varices B. Perfusion distal to the insertion site C. Signs and symptoms of compartment syndrome D. Fluctuations in core body temperature
B. Perfusion distal to the insertion site Rationale: The radial artery is the usual site selected. However, placement of a catheter into the radial artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in temperature and the development of esophageal varices or compartment syndrome are not high risks.
The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient? A. Hyperlipidemia B. Positive family history C. Obesity D. Stress
B. Positive family history Rationale: The health history provides an opportunity for the nurse to assess patients' understanding of their personal risk factors for coronary artery, peripheral vascular, and cerebrovascular diseases and any measures that they are taking to modify these risks. Risk factors are classified by the extent to which they can be modified by changing one's lifestyle or modifying personal behaviors. Stress, obesity, and hyperlipidemia are all risk factors that can be modified by personal behaviors. Family history is a nonmodifiable risk factor, because it cannot be changed.
The clinic nurse is assessing a client's pulse before outpatient diagnostic testing. What should the nurse document when assessing the client's pulse? A. Quality, volume, and rate B. Rate, quality, and rhythm C. Rate, rhythm, and volume D. Pressure, rate, and rhythm
B. Rate, quality, and rhythm Rationale: Assess apical and radial pulses, noting rate, quality, and rhythm. Pulse pressure and volume are not assessed in this instance.
The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider? A. These values show a risk for dysrhythmias. B. The client is at risk for renal failure due to the contrast agent that will be given during the procedure. C. The client is at risk for bleeding. D. The client is overhydrated, which puts him at risk for heart failure during the procedure.
B. The client is at risk for renal failure due to the contrast agent that will be given during the procedure. Rationale: The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment, indicated by the increased BUN and creatinine, the risk for contrast agent-induced nephropathy and renal failure is high. Renal impairment is not usually associated with dysrhythmias. The increased BUN and creatinine do not indicate overhydration, but decreased kidney function. The BUN and creatinine levels do not interfere with coagulability or bleeding.
The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? A. The ventricles B. The sinoatrial node C. The Purkinje fibers D. The AV node
B. The sinoatrial node Rationale: The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body (Weber & Kelley, 2010).
For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which data is necessary to collect if the client is experiencing chest pain? A. blood pressure in the left arm B. description of the pain C. pulse rate in upper extremities D. sound of the apical pulses
B. description of the pain Rationale: If the client is experiencing chest pain, a history of its location, frequency, and duration is necessary. A description of the pain is also needed, including if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the client and measures vital signs. The nurse may measure blood pressure in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities.
A 52-year-old female patient is going through menopause and asks the nurse about estrogen replacement for its cardioprotective benefits. What is the best response by the nurse? A. "That's a great idea. You don't want to have a heart attack." B. "Current research determines that estrogen replacement protects heart health for most women after menopause." C. "Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks." D. "You need to research hormone replacement therapy and determine what you want to do."
C. "Current evidence indicates that estrogen replacement is not effective at preventing cardiovascular disease and carries some risks." Rationale: In the past, hormone therapy was routinely prescribed for postmenopausal women with the belief that it would deter the onset and progression of coronary artery disease (CAD). However, based on results from the multisite, prospective, longitudinal Women's Health Initiative study, the American Heart Association (AHA) no longer recommends the use of hormone therapy to prevent cardiovascular disease. However, hormone replacement therapy has not been shown to be harmful for all women, and it may be a good choice for some women seeking to reduce symptoms of menopause.
A nurse is preparing a client for cardiac catheterization. The nurse knows that which nursing intervention must be provided when the client returns to the room after the procedure? A. Restrict fluids for 6 hours after the procedure. B. Inform the client that he or she may experience numbness or pain in the leg. C. Assess the puncture site frequently for hematoma formation or bleeding. D. Withhold analgesics for at least 6 hours after the procedure.
C. Assess the puncture site frequently for hematoma formation or bleeding. Rationale: Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as ordered and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client's system.
A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing? A. Lanoxin B. Cardiolite C. Dipyridamole D. Thallium 201
C. Dipyridamole Rationale: If the patient is unable to exercise, a pharmacologic stress test is performed by injecting a vasodilating agent, dipyridamole or adenosine, to mimic the physiologic effects of exercise. The stress test may be combined with an echocardiogram or radionuclide imaging techniques to examine myocardial function during exercise and rest. Digoxin would not be used for stress testing. Thallium 201 and Cardiolite are radioisotopes used in myocardial perfusion scanning.
You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels? A. WBC B. RBC C. Enzymes D. Platelets
C. Enzymes Rationale: When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage. After an MI, RBCs and platelets should not be elevated. WBCs would only be elevated if there was a bacterial infection present.
The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure? A. Insist that the family members leave the room if they must speak to each other while the nurse is auscultating heart sounds. B. Ask the client to sit on the edge of the bed and hold breath while the nurse listens. C. Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard. D. Ask the client to take deep breaths through the mouth while the nurse auscultates heart sounds.
C. Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard. Rationale: During auscultation, the client remains supine and the room should be as quiet as possible while the nurse listens to heart sounds. The client should breathe normally during the examination. Sitting on the edge of the bed is not the preferred client position. The room should be quiet so asking the families to remain quiet is acceptable. The client does not need to take deep breaths during heart auscultation.
The nurse is completing a cardiac assessment. Upon auscultation, the nurse hears a grating sound using the diaphragm of the stethoscope. How will the nurse best document this finding? A. Murmur B. Snap C. Friction rub D. Click
C. Friction rub Rationale: In pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A murmur is created by turbulent flow of blood. A cause of the turbulence may be a critically narrowed valve. An opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. An ejection click is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve.
The nurse is reviewing the morning laboratory test results for a client with cardiac problems. Which finding is a priority to report to the healthcare provider? A. Mg++ 2 mEq/L B. Na+ 140 mEq/L C. K+ 3.1 mEq/L D. Ca++ 9 mg/dL
C. K+ 3.1 mEq/L Rationale: All laboratory levels are within normal limits except for the K+, which is low. A low K+ level can cause ventricular tachycardia or fibrillation.
After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. When auscultating a murmur, what does the nurse expect to hear? A. Quiet but readily heard. B. Very loud; can be heard with the stethoscope half-way off the chest. C. Loud and may be associated with a thrill sound similar to (a purring cat). D. Easily heard with no palpable thrill.
C. Loud and may be associated with a thrill sound similar to (a purring cat). Rationale: Heart murmurs are characterized by location, timing, and intensity. A grading system is used to describe the intensity or loudness of a murmur. A grade 1 is very faint and difficult to describe, whereas a grade 6 is extremely loud. Refer to Box 12-3 in the text for a description of grades 1 to 6.
While the nurse is preparing a client for a cardiac catheterization, the client states that they have allergies to seafood. Which of the following medications may the nurse give prior to the procedure? A. Lorazepam B. Phenytoin C. Methylprednisolone D. Furosemide
C. Methylprednisolone Rationale: Prior to cardiac catheterization, the patient is assessed for previous reactions to contrast agents or allergies to iodine-containing substances, as some contrast agents contain iodine. If allergic reactions are of concern, antihistamines or methylprednisolone (Solu-Medrol) may be administered to the patient before angiography is performed. Furosemide, Lorazepam, and Phenytoin do not counteract allergic reactions.
The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin? A. Assess for hypokalemia. B. Administer calcium supplements. C. Report any incident of bloody urine, stools, or both. D. Assess for clubbing of the fingers.
C. Report any incident of bloody urine, stools, or both. Rationale: The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both. Clients taking enoxaparin will not need to take calcium supplements or have potassium imbalances related to the medication. The clubbing of fingers may occur with chronic pulmonary diseases.
The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response? A. Stroke volume controls the heart rate. B. Preload controls the heart rate. C. The autonomic nervous system controls the heart rate. D. Force of contractility controls the heart rate.
C. The autonomic nervous system controls the heart rate. Rationale: The autonomic nervous system primarily controls the heart rate. When the sympathetic branch is stimulated, heart rate increases. When the parasympathetic branch is stimulated, heart rate decreases. Stroke volume is the amount of blood pumped out of the ventricle with each contraction and depends on three factors: preload, afterload, and contractility.
Within the heart, several structures and several layers all play a part in protecting the heart muscle and maintaining cardiac function. The inner layer of the heart is composed of a thin, smooth layer of cells, the folds of which form heart valves. What is the name of this layer of cardiac tissue? A. epicardium B. pericardium C. endocardium D. myocardium
C. endocardium Rationale: The inner layer, the endocardium, is composed of a thin, smooth layer of endothelial cells. Folds of endocardium form the heart valves. The middle layer, the myocardium, consists of muscle tissue and is the force behind the heart's pumping action. The pericardium is a saclike structure that surrounds and supports the heart. The outer layer, the epicardium, is composed of fibrous and loose connective tissue.
A client's chart indicates an S4 heart sound, and is scheduled for a cardiac workup. The nurse is aware that this client may have which cardiac condition? A. diseased heart valves B. heart failure C. hypertensive heart disease D. pericarditis
C. hypertensive heart disease Rationale: An S4 sound is often associated with hypertensive heart disease. An S3, although normal in children, is often an indication of heart failure in an adult. A friction rub may cause a rough, grating, or scratchy sound that is indicative of pericarditis. Murmurs and clicks caused by turbulent blood flow through diseased heart valves.
The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate? A. partial thromboplastic time (PTT) B. Sodium C. international normalized ratio (INR) D. complete blood count (CBC)
C. international normalized ratio (INR) Rationale: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of warfarin.
The nurse prepares to apply ECG electrodes to a male client who requires continuous cardiac monitoring. Which action should the nurse complete to optimize skin adherence and conduction of the heart's electrical current? A. Apply baby powder to the client's chest prior to placing the electrodes. B. Clean the client's chest with alcohol prior to application of the electrodes. C. Once the electrodes are applied, change them every 72 hours. D. Clip the client's chest hair prior to applying the electrodes.
D. Clip the client's chest hair prior to applying the electrodes. Rationale: The nurse should complete the following actions when applying cardiac electrodes: (1) Clip (do not shave) hair from around the electrode site, if needed; (2) if the client is diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode; (3) debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer); (4) change the electrodes every 24 to 48 hours (or as recommended by the manufacturer); (5) examine the skin for irritation and apply the electrodes to different locations.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? A. Encourage the client to perform isometric leg exercise to improve circulation in the legs. B. Slow the I.V. fluid to prevent any more swelling at the puncture site. C. Document findings and check the client again in 1 hour. D. Contact the health care provider and report the findings.
D. Contact the health care provider and report the findings. Rationale: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the health care provider immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.
The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer? A. Diltiazem B. Amiodarone C. Propafenone D. Metoprolol
D. Metoprolol Rationale: Patients may receive beta-blockers prior to the scan to control heart rate and rhythm.
What is considered the pacemaker of the heart? A. The AV node B. The bundle of HIS C. The Purkinje fibers D. The SA node
D. The SA node Rationale: The SA node is called the pacemaker of the heart, because it initiates the electrical impulses that cause the atria and ventricles to contract. Normally, it produces between 60 and 100 impulses per minute; the average is approximately 72 impulses per minute. Therefore, options A, B, and C are incorrect.
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse? A. diastole B. repolarization C. depolarization D. contractility
D. contractility Rationale: Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell. Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. Diastole is the period of ventricular relaxation resulting in ventricular filling.
The nurse auscultates the apex beat at which anatomical location? A. 2.5 cm to the left of the xiphoid process B. 5 cm to the left of the lower end of the sternum C. midsternum D. fifth intercostal space, midclavicular line
D. fifth intercostal space, midclavicular line Rationale: The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. The right ventricle lies anteriorly, just beneath the sternum. Use of inches to identify the location of the apex beat is inappropriate based upon variations in human anatomy. Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.
