EAQ Cardiovascular Quiz

he nurse is evaluating the client's cardiac rhythm and measures a PR interval of 0.08 seconds (two small boxes). How should the nurse interpret this finding?

Abnormally fast conduction When the PR interval is shorter than normal, the speed of conduction is abnormally fast. The PR interval measures the time it takes for the impulse to depolarize the atria, travel to the AV node, and dwell there briefly before entering the bundle of His. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide. When the PR interval is longer than normal, the speed of conduction is delayed in the AV node. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval.

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Begin chest compressions According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, it has been established the client has no pulse (cardiopulmonary arrest); therefore chest compressions are initiated. Do not leave the client to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?

Constriction of the peripheral vessels increases the force of flow. Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.

A client who had injection sclerotherapy for varicose veins is advised to wear compression (support) stockings. What is most important for the nurse to explain to the client about compression stockings?

Don the stockings before getting out of bed in the morning. To prevent distention of the veins, stockings should be applied before the legs are placed in a dependent position. Stockings should be used preventively before the discomfort associated with venous pressure and edema occurs. Knee-high stockings should end 2 inches (5.1 cm) below the knee to avoid popliteal pressure, which limits venous return. Stockings apply uniform pressure. Elastic bandages may slip or develop wrinkles, creating uneven pressure and constriction; edema may result.

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?

Emboli

A client had a total knee replacement several days ago and has been receiving warfarin sodium (Coumadin) therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the health care provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. The next action the nurse should take is to:

Maintain the client on bed rest until the health care provider reviews the laboratory results

A client with squamous cell carcinoma of the tongue is to be treated with interstitially implanted radon seeds. Which consideration is priority when the nurse is planning room placement?

Place the client in a private room. Radon seeds emit radiation; the client should be isolated in a private room to decrease radiation to others. Assigning the client to any type of room is inappropriate and unsafe because the treatment emits radiation. A semiprivate room is contraindicated because this will expose other clients to radiation. A room with clients receiving the same therapy is contraindicated because this will expose other clients to radiation.

An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid, and the serum electrolyte value demonstrates hyponatremia. What would the nurse concludes was the element that most likely contributed to the hyponatremia?

Fluid Intake Hemodilution has occurred because the 1500 mL of intravenous fluid has lowered the serum sodium level. An increase in salt intake is not the cause of the hyponatremia; in addition, the client has not eaten for several days. A decreased, not increased, reabsorption of sodium occurs in acute renal failure. A decreased, not increased, glomerular filtration rate occurs with renal failure.

Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?

Lower extremity color Checking color and temperature, part of the neurovascular assessment, provides data about current perfusion of the extremity and the possibility of graft occlusion/blockage. Although pain assessment is essential, incisional pain does not provide data about the neurovascular status of the extremity; a dramatic increase in pain or severe continuous, aching pain is indicative of graft occlusion. Although the presence and quality of the pedal pulse provide data about peripheral circulation, it is not necessary to count the popliteal rate. Clients with peripheral arterial disease experience loss of extremity hair, which will not change suddenly because of surgery.

A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction?

This prevents further fluid accumulation, which increases the workload of the heart. An increase in total body fluid causes an increase in intravascular volume and cardiac workload. Salt in the diet contributes to fluid retention and edema. Fluid in the interstitial compartment will not increase blood pressure. Excess fluid in the intravascular compartment will increase blood pressure. Limiting sodium will not have a diuretic effect; it will reduce additional fluid retention. Diuretics, not a sodium-restricted diet, reduce the amount of edema present, which interferes with heart action.