LP 1 Cardiac

34. A patient is scheduled to have CABG surgery. What does the nurse explain to him that is involved with the procedure? a. A synthetic graft will be used as a tube for blood flow from the aorta to a coronary artery distal to an obstruction. b. A stenosed coronary artery will be resected and a synthetic arterial tube graft will be inserted to replace the diseased artery. c. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis. d. Reversed segments of a saphenous artery from the aorta will be anastomosed to the coronary artery distal to an obstruction.

Ans c. The most common method of coronary artery bypass involves leaving the internal mammary artery attached to its origin from the subclavian artery but dissecting it from the chest wall and anastomosing it distal to an obstruction in a coronary artery. Synthetic grafts are not commonly used as coronary bypass grafts, although research continues to investigate this option. Saphenous veins are used for bypass grafts when additional conduits are needed.

66. The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds.

Ans: 1 1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade. 2. Cardiac enzymes may be slightly elevated because of the inflammatory process, but evaluation of these would not be ordered to treat or evaluate cardiac tamponade. 3. A 12-lead ECG would not help treat the medical emergency of cardiac tamponade. 4. Assessment by the nurse is not collaborative; it is an independent nursing action.

62. The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub.

Ans: 1 1. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider. 2. Distended, not nondistended, jugular veins would warrant immediate intervention. 3. Decreasing quality of peripheral pulses, not bounding peripheral pulses, would warrant immediate intervention. 4. A pericardial friction rub is a classic symptom of acute pericarditis, but it would not warrant immediate intervention.

37. A client is being seen in the clinic to R/O mitral valve stenosis. Which assessment data would be most significant? 1. The client complains of shortness of breath when walking. 2. The client has jugular vein distention and 3" pedal edema. 3. The client complains of chest pain after eating a large meal. 4. The client's liver is enlarged and the abdomen is edematous.

Ans: 1 1. Dyspnea on exertion (DOE) is typically the earliest manifestation of mitral valve stenosis. 2. Jugular vein distension (JVD) and 3+ pedal edema are signs/symptoms of right-sided heart failure and indicate worsening of the mitral valve stenosis. These signs would not be expected in a client with early manifestations of mitral valve stenosis. 3. Chest pain rarely occurs with mitral valve stenosis. 4. An enlarged liver and edematous abdomen are late signs of right-sided heart failure that can occur with long-term untreated mitral valve stenosis.

46. The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement? 1. Restrict the client's fluids as ordered. 2. Keep the client in the supine position. 3. Maintain oxygen saturation at 90%. 4. Monitor the total parenteral nutrition.

Ans: 1 1. Fluid intake may be restricted to reduce the cardiac workload and pressures within the heart and pulmonary circuit. 2. The head of the bed should be elevated to help improve alveolar ventilation. 3. Oxygen saturation should be no less than 93%; 90% indicates an arterial oxygen saturation of around 60 (normal is 80-100) 4. Total parenteral nutrition would not be prescribed for a client with mitral valve replacement. It is ordered for clients with malnutrition, gastrointestinal disorders, or conditions in which increased calories are needed, such as burns.

45. The client with a mechanical valve replacement asks the nurse, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nurse is most appropriate? 1. "You are at risk of developing an infection in your heart." 2. "Your teeth will not bleed as much if you have antibiotics." 3. "This procedure may cause your valve to malfunction." 4. "Antibiotics will prevent vegetative growth on your valves."

Ans: 1 1. The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure. 2. Antibiotics have nothing to do with how much the teeth bleed during a cleaning. 3. Teeth cleaning will not cause the valve to malfunction. 4. Vegetation develops on valves secondary to bacteria that cause endocarditis, but the client will not understand vegetative growth on the valves; therefore, this is not the most appropriate answer.

23. The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bed rest.Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

Ans: 1 1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form. 2. The nurse should talk to the client in layman's terms, not medical terms. Medical terminology is a foreign language to most clients. 3. This is not answering the client's question. The nurse should take any opportunity to teach the client. 4. This is a condescending response, and telling the client that he or she is not out of danger is not an appropriate response.

41. The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's International Normalized Ratio (INR) is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Prepare to administer vitamin K (AquaMephyton). 3. Hold the medication and notify the HCP. 4. Assess the client for abnormal bleeding.

Ans: 1 1. The therapeutic range for most clients' INR is 2-3, but for a client with a mechanical valve replacement it is 2-3.5. The medication should be given as ordered and not withheld. 2. Vitamin K is the antidote for an overdose of warfarin, but 2.7 is within therapeutic range. 3. This laboratory result is within the therapeutic range, INR 2-3, and the medication does not need to be withheld. 4. There is no need for the nurse to assess for bleeding because 2.7 is within therapeutic range.

8. The nurse on the telemetry unit has just received the A.M. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

Ans: 1 1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. 2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure.

20. The intensive care department nurse is assessing the client who is 12 hours postmyocardial infarction. The nurse assesses a S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

Ans: 1 1. An S3 indicates left ventricular failure and should be reported to the health-care provider. It is a potential life-threatening complication of a myocardial infarction. 2. Elevating the head of the bed will not do anything to help a failing heart. 3. This is not a normal finding; it indicates heart failure. 4. Morphine is administered for chest pain, not for heart failure, which is suggested by the S3 sound.

6. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation-perfusion (V/Q) scan

Ans: 1 1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF. 2. An elevated CK-MB would indicate a myocardial infarction, not severe CHF. CK-MB is an isoenzyme. 3. A positive D-dimer would indicate a pulmonary embolus. 4. A positive ventilation-perfusion (V/Q) scan (ratio) would indicate a pulmonary embolus.

1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time <3 seconds.

Ans: 1 1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status. 2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. 3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. 4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status.

70. The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery.

Ans: 1 1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health. 2. Occupational therapy addresses activities of daily living. The client should be referred to physical therapy to develop a realistic and progressive plan of activity. 3. The client with pericarditis is not usually prescribed oxygen and 2 L/min is a low dose of oxygen that is prescribed for a client with chronic obstructive pulmonary disease (COPD). 4. Endocarditis, not pericarditis, may lead to surgery for valve replacement.

42. Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply. 1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough. 4. Pericardial friction rub. 5. Pulsus paradoxus.

Ans: 1, 2, 3 1. Paroxysmal nocturnal dyspnea is a sudden attack of respiratory distress usually occurring at night because of the reclining position and occurs in valvular disorders. 2. This is an abnormal condition in which a client must sit or stand to breathe comfortably and occurs in valvular disorders. 3. Coughing occurs when the client with long-term valvular disease has difficulty breathing when walking or performing any type of activity. 4. Pericardial friction rub is a sound auscultated in clients with pericarditis, not valvular heart disease. 5. Pulsus paradoxus is a marked decrease in amplitude during inspiration. It is a sign of cardiac tamponade, not valvular heart disease.

71. The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position.

Ans: 1,2,3,4 1. The nurse should monitor the vital signs for any client who has just undergone surgery. 2. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds involves entering the pericardial sac and allows assessment for cardiac failure. 3. The pericardial fluid is documented as output. 4. Evaluating the client's cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardial centesis. 5. The client should be in the semi-Fowler's position, not in a flat position, which increases the workload of the heart.

47. Which client would the nurse suspect of having a mitral valve prolapse? 1. A 60-year-old female with congestive heart failure. 2. A 23-year-old male with Marfan syndrome. 3. An 80-year-old male with atrial fibrillation. 4. A 33-year-old female with Down syndrome

Ans: 2 1. Congestive heart failure does not predispose the female client to having a mitral valve prolapse. 2. Clients with Marfan syndrome have lifethreatening cardiovascular problems, including mitral valve prolapse, progressive dilation of the aortic valve ring, and weakness of the arterial walls, and they usually do not live past the age of 40 because of dissection and rupture of the aorta. 3. Atrial fibrillation does not predispose a client to mitral valve prolapse. 4. A client with Down syndrome may have congenital heart anomalies but not mitral valve prolapse

7. The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking medication with food.

Ans: 2 1. If a cough develops, the client should notify the health-care provider because this is an adverse reaction and the HCP will discontinue the medication. 2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored. 3. ACE inhibitors may cause the client to retain potassium; therefore, the client should not increase potassium intake. 4. An ACE inhibitor should be taken one (1) hour before meals or two (2) hours after a meal to increase absorption of the medication.

60. Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.

Ans: 2 1. Not every cardiac dysrhythmia causes alteration in comfort; angina is caused by decreased oxygen to the myocardium. 2. Any abnormal electrical activity of the heart causes decreased cardiac output. 3. Impaired gas exchange is the result of pulmonary complications, not cardiac dysrhythmias. 4. Not all clients with cardiac dysrhythmias have activity intolerance.

72. The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bed rest with bathroom privileges.

Ans: 2 1. The nurse must obtain blood cultures prior to administering antibiotics. 2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify. 3. An echocardiogram allows visualization of vegetations and evaluation of valve function. However, antibiotic therapy is priority before diagnostic tests, and blood cultures must be obtained before administering medication. 4. Bed rest should be implemented, but the first intervention should be obtaining blood cultures so that antibiotic therapy can be started as soon as possible.

48. The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate that just completed orientation to the medical floor? 1. The client admitted for diagnostic tests to rule out valvular heart disease. 2. The client three (3) days post-myocardial infarction who is being discharged tomorrow. 3. The client exhibiting supraventricular tachycardia (SVT) on telemetry. 4. The client diagnosed with atrial fibrillation who has an INR of five (5).

Ans: 2 1. This client requires teaching and an understanding of the pre-procedure interventions for diagnostic tests; therefore a more experienced nurse should be assigned to this client. 2. Because this client is being discharged, it would be an appropriate assignment for the new graduate. 3. Supraventricular tachycardia (SVT) is not life threatening, but the client requires intravenous medication and close monitoring and therefore should be assigned to a more experienced nurse. 4. A client with atrial fibrillation is usually taking the anticoagulant warfarin (Coumadin) and the therapeutic INR is 2-3. An INR of 5 is high and the client is at risk for bleeding

63. The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family history of carditis?" 4. "What over-the-counter (OTC) medications do you take?"

Ans: 2 1. A sore throat in the last month would not support the diagnosis of carditis. 2. Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of the people 3. Carditis is not a genetic or congenital disease process. 4. This is an appropriate question to ask any client, but OTC medications do not cause carditis.

2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care.

Ans: 2 1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. 2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure that could be life threatening. 3. This is a nursing intervention, not a shortterm goal, for this client. 4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output.

14. Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Mid-epigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

Ans: 2 1. Mid-epigastric pain would support a diagnosis of peptic ulcer disease; pyrosis is belching. 2. Sweating is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin. 3. Intermittent claudication is leg pain secondary to decreased oxygen to the muscle, and pallor is paleness of the skin as a result of decreased blood supply. Neither is an early sign of MI. 4. Jugular vein distension (JVD) and dependent edema are signs/symptoms of congestive heart failure, not of MI.

68. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus. 2. Decreased urine output. 3. Hemoptysis. 4. Deep vein thrombosis.

Ans: 2 1. Pulmonary embolus would occur with an embolization of vegetative lesions from the tricuspid valve on the right side of the heart. 2. Bacteria enter the bloodstream from invasive procedures and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys, or peripheral tissues. 3. Coughing up blood (hemoptysis) occurs when the vegetation breaks off the tricuspid valve in the right side of the heart and enters the pulmonary artery. 4. Deep vein thrombosis is a complication of immobility, not of a vegetative embolus from the left side of the heart.

11. The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

Ans: 2 1. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels. 2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium. 3. Weight gain is monitored in clients with CHF and elevating the legs would decrease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps. 4. Ambulating frequently and performing leg stretching exercises will not be effective in alleviating the leg cramps.

18. The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

Ans: 2 1. The nurse should medicate the client as needed, but it is not the first intervention. 2. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery. 3. Turning will help decrease complications from immobility, such as pneumonia, but it will not help relieve the client's pain. 4. The nurse, not a machine, should always take care of the client.

38. Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency? 1. A loud S1, S2 split, and a mitral opening snap. 2. A holosystolic murmur heard best at cardiac apex. 3. A mid-systolic ejection click or murmur heard at the base. 4. A high-pitched sound heard at the 3rd left intercostal space.

Ans: 2 1. This would be expected with mitral valve stenosis. 2. The murmur associated with mitral valve insufficiency is loud, high-pitched, rumbling, and holosystolic (occurring throughout systole) and is heard best at the cardiac apex. 3. This would be expected with mitral valve prolapse. 4. This would be expected with aortic regurgitation.

16. The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.

Ans: 2,3 1. Morphine should be administered intravenously, not intramuscularly. 2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain. 4. The supine position will increase respiratory effort, which will increase myocardial oxygen consumption; the client should be in a semiFowler's position. 5. Nitroglycerin, a coronary vasodilator, is administered sublingually, not subcutaneously

3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which intervention should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

Ans: 2,3 1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. 2. The client should not take digoxin if radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention. 4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. 5. Instruct client to take the diuretic in the morning to prevent nocturia.

39. The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching? 1. The client takes prophylactic antibiotics. 2. The client uses a soft-bristle toothbrush. 3. The client takes an enteric-coated aspirin daily. 4. The client alternates rest with activity.

Ans: 3 1. Prophylactic antibiotics before invasive procedures prevent infectious endocarditis. 2. The client is undergoing anticoagulant therapy and should use a soft-bristle toothbrush to help prevent gum trauma and bleeding. 3. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) interfere with clotting and may potentiate the effects of the anticoagulant therapy, which the client with a mechanical valve will be prescribed. Therefore, the client should not take aspirin daily. 4. The client should alternate rest with activity to prevent fatigue to help decrease the workload of the heart.

64. The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."

Ans: 3 1. Steroids, such as prednisone, not NSAIDs, must be tapered off to prevent adrenal insufficiency. 2. NSAIDs will not make clients drowsy. 3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain. 4. NSAIDs should be taken regularly around the clock to help decrease inflammation, which, in turn, will decrease pain.

67. The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."

Ans: 3 1. The full course of antibiotics must be taken to help ensure complete destruction of streptococcal infection. 2. Antibiotics kill bacteria but also destroy normal body flora in the vagina, bowel, and mouth, leading to a superinfection. 3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur. 4. A throat culture is taken to diagnose group A beta hemolytic streptococcus and is positive in 25%-40% of clients with acute rheumatic fever.

24. The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

Ans: 3 1. These vital signs are within normal limits and would not require any immediate intervention. 2. The groin dressing should be dry and intact. 3. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention. 4. The nurse must check the neurovascular assessment, and paresthesia would warrant immediate intervention, but no numbness and tingling is a good sign.

52. The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for an insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

Ans: 3 1. A thrombolytic medication is administered for a client experiencing a myocardial infarction. 2. Assessment is an independent nursing action, not a collaborative treatment. 3. The client is symptomatic and will require a pacemaker. 4. Synchronized cardioversion is used for ventricular tachycardia with a pulse or atrial fibrillation.

19. The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

Ans: 3 1. After PTCA, the client must keep the right leg straight for at least six (6) to eight (8) hours to prevent any arterial bleeding from the insertion site in the right femoral artery. 2. A pressure dressing is applied to the insertion site to help prevent arterial bleeding. 3. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot. 4. A bounding pedal pulse indicates that adequate circulation is getting to the right foot; therefore, this would not require immediate intervention.

13. Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine phosphokinase (CPK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBC).

Ans: 3 1. CPK-MB elevates in 12 to 24 hours. 2. LDH elevates in 24 to 36 hours. 3. Troponin is the enzyme that elevates within 1 to 2 hours. 4. WBC elevates as a result of necrotic tissue, but this is not a cardiac enzyme.

22. The client diagnosed with a myocardial infarction is on bed rest. The unlicensed nursing assistant is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the assistant to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the nursing assistant for encouraging the client to move legs. 4. Take no action concerning the nursing assistant's behavior.

Ans: 3 1. Leg movement is an appropriate action, and the assistant should not be told to stop encouraging it. 2. This behavior is not unsafe or dangerous and should not be reported to the charge nurse. 3. The nurse should praise and encourage assistants to participate in the client's care. Clients on bed rest are at risk for deep vein thrombosis, and moving the legs will help prevent that. 4. The nurse should praise subordinates for appropriate behavior, especially when it is helping to prevent life-threatening complications.

65. The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer.

Ans: 3 1. Oxygen may be needed, but it is not the first intervention. 2. This would be appropriate to determine if the urine output is at least 30 mL/hr, but it is not the first intervention. 3. The nurse must assess the client to determine if the pain is expected pain secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider. 4. Using the incentive spirometer will increase the client's alveolar ventilation and help prevent atelectasis, but it is not the first intervention.

5. The nurse is assessing the client diagnosed with congestive heart failure. Which signs/ symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform activities of daily living without dyspnea. 4. The client has minimal jugular vein distention

Ans: 3 1. Pitting edema from 3"to 4"indicates a worsening of the CHF. 2. The client's ability to take the radial pulse would evaluate teaching, not medical treatment. 3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs. 4. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment.

15. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs.

Ans: 3 1. The nurse must assume the chest pain is secondary to decreased oxygen to the myocardium and administer a sublingual nitroglycerin, which is a coronary vasodilator, but this is not the first action. 2. An ECG should be ordered, but it is not the first intervention. 3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain. 4. Assessment is often the first nursing intervention, but when the client has chest pain and a possible MI, the nurse must first take care of the client. Taking vital signs would not help relieve chest pain.

17. The client is diagnosed with a myocardial infarction. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapist

Ans: 3 1. The social worker addresses financial concerns or referrals after discharge, which is not indicated for this client. 2. Physical therapy addresses gait problems, lower-extremity strength building, and assisting with transfer, which is not required for this client. 3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation, which includes progressive exercise, diet teaching, and classes on modifying risk factors. 4. Occupational therapy addresses the client in regaining activities of daily living and covers mainly fine motor activities.

10. The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough.

Ans: 3 1. This client is stable because discharge is scheduled for the following day. Therefore, this client does not need to be assigned to the most experienced registered nurse. 2. This client requires more custodial nursing care than care from the most experienced registered nurse. Therefore the charge nurse could assign a less experienced nurse to this client. 3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client. 4. These complaints usually indicate muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration. This client does not require the care of an experienced nurse as much as does the client with signs of shock

9. The nurse and an unlicensed nursing assistant are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse delegate to the unlicensed nursing assistant? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the Intensive Care Unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done.

Ans: 4 1. Allowing the unlicensed assistive personnel (UAP) to take a client down to smoke is not cost effective and is not supportive of the medical treatment regimen that discourages smoking. 2. The client going to the ICU would be unstable, and the nurse should not delegate to an UAP any nursing task that involves an unstable client. 3. The nurse cannot delegate teaching. 4. The UAP can assist the x-ray technician in positioning the client for the portable xray. This does not require judgment.

43. The client is being evaluated for valvular heart disease. Which information would be most significant? 1. The client has a history of coronary artery disease. 2. There is a family history of valvular heart disease. 3. The client has a history of smoking for ten (10) years. 4. The client has a history of rheumatic heart disease.

Ans: 4 1. An acute myocardial infarction can damage heart valves, causing tearing, ischemia, or damage to heart muscles that affects valve leaflet function, but coronary heart disease does not cause valvular heart disease. 2. Valvular heart disease does not show a genetic etiology. 3. Smoking can cause coronary artery disease, but it does not cause valvular heart disease. 4. Rheumatic heart disease is the most common cause of valvular heart disease.

40. The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biologic tissue valve replacement? 1. The client must take lifetime anticoagulant therapy. 2. The client's infections are easier to treat. 3. There is a low incidence of thromboembolism. 4. The valve has to be replaced frequently

Ans: 4 1. An advantage of having a biologic valve replacement is that no anticoagulant therapy is needed. Anticoagulant therapy is needed with a mechanical valve replacement. 2. This is an advantage of having a biologic valve replacement; infections are harder to treat in clients with mechanical valve replacement. 3. This is an advantage of having a biologic valve replacement; there is a high incidence of thromboembolism in clients with mechanical valve replacement. 4. Biologic valves deteriorate and need to be replaced frequently; this is a disadvantage of them. Mechanical valves do not deteriorate and do not have to be replaced often.

61. The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.

Ans: 4 1. Pulsus paradoxus is the hallmark of cardiac tamponade; a paradoxical pulse is markedly decreased in amplitude during inspiration. 2. Fatigue and arthralgias are nonspecific signs/ symptoms that usually occur with myocarditis. 3. Petechiae on the trunk, conjunctiva, and mucous membranes and hemorrhagic streaks under the fingernails or toenails occur with endocarditis. 4. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements (deep inspiration, coughing), changes in body position, and swallowing.

69. Which nursing diagnosis would be priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function

Ans: 4 1. Anxiety is a psychosocial nursing diagnosis, which is not a priority over a physiological nursing diagnosis. 2. Antibiotic therapy does not result in injury to the client. 3. Myocarditis does not result in valve damage (endocarditis does), and there would be decreased, not increased, cardiac output. 4. Activity intolerance is priority for the client with myocarditis, an inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.

12. The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

Ans: 4 1. Measuring the intake and output is an appropriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity. 2. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity. 3. Daily weighing monitors fluid volume status, not activity tolerance. 4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.

44. The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the recovery room nurse implement? 1. Assess the client's chest tube output. 2. Monitor the client's chest dressing. 3. Evaluate the client's endotracheal (ET) lip line. 4. Keep the client's affected leg straight.

Ans: 4 1. Percutaneous balloon valvuloplasty is not an open-heart surgery; therefore, the chest will not be open and the client will not have a chest tube. 2. This is not an open-heart surgery; therefore, the client will not have a chest dressing. 3. The endotracheal (ET) tube is inserted if the client is on a ventilator, and this surgery does not require putting the client on a ventilator. 4. In this invasive procedure, performed in a cardiac catheterization laboratory, the client has a catheter inserted into the femoral artery. Therefore, the client must keep the leg straight to prevent hemorrhaging at the insertion site.

21. The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62.

Ans: 4 1. The apical pulse is within normal limits—60 to 100 beats per minute. 2. The serum calcium level is not monitored when calcium channel blockers are given. 3. Occasional PVCs would not warrant immediate intervention prior to administering this medication. 4. The client's blood pressure is low, and a calcium channel blocker would cause the blood pressure to bottom out.

4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

Ans: 4 1. Sponging the client's forehead would be appropriate, but it is not the first intervention. 2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention. 3. Taking the vital signs would be appropriate, but it is not the first intervention. 4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.

12. What are manifestations of acute coronary syndrome (ACS) (select all that apply)? a. Dysrhythmia b. Stable angina c. Unstable angina d. ST-segment-elevation myocardial infarction (STEMI) e. Non-ST-segment-elevation myocardial infarction (NSTEMI)

Ans: C,D,E Unstable angina, ST-segment-elevation myocardial infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI) are conditions that are manifestations of acute coronary syndrome (ACS). The other options are not manifestations of ACS

1. A 20-year-old patient has acute infective endocarditis. While obtaining a nursing history, what should the nurse ask the patient about (select all that apply)? a. Renal dialysis b. IV drug abuse c. Recent dental work d. Cardiac catheterization e. Recent urinary tract infection

Ans: a, b, c, d, e. Recent dental, urologic, surgical, or gynecologic procedures and history of IV drug abuse, heart disease, cardiac catheterization or surgery, renal dialysis, and infections all increase the risk of infective endocarditis

1. Which statements accurately describe heart failure (select all that apply)? a. A common cause of diastolic failure is left ventricular hypertrophy. b. A primary risk factor for heart failure is coronary artery disease (CAD). c. Systolic heart failure results in a normal left ventricular ejection fraction. d. Systolic failure is characterized by abnormal resistance to ventricular filling. e. Hypervolemia precipitates heart failure by decreasing cardiac output and increasing oxygen consumption

Ans: a, b. Diastolic failure is characterized by abnormal resistance to ventricular filling. Coronary artery disease (CAD), advanced age, and hypertension are all risk factors for heart failure (HF). Ejection fraction is decreased in systolic HF. Dysrthythmia precipitates HF with decreased cardiac output (CO) and increased workload and oxygen requirements of the myocardium

33. When performing discharge teaching for a patient with any type of CMP, what should the nurse instruct the patient to do (select all that apply)? a. Eat a low-sodium diet. b. Go to the gym every day. c. Engage in stress reduction activities. d. Abstain from alcohol and caffeine intake. e. Avoid strenuous activity and allow for periods of rest. f. Suggest that caregivers learn cardiopulmonary resuscitation (CPR)

Ans: a, c, d, e, f. These topics can apply to any patient with CMP.

2. A patient has an admitting diagnosis of acute left-sided infective endocarditis. What is the best test to confirm this diagnosis? a. Blood cultures b. Complete blood count c. Cardiac catheterization d. Transesophageal echocardiogram

Ans: a. Blood cultures are the primary diagnostic tool for infective endocarditis. Although a complete blood count (CBC) will reveal a mild leukocytosis, this is a nonspecific finding. Transesophageal echocardiograms can identify vegetations on valves but are used when blood cultures are negative. Cardiac catheterizations are used when surgical intervention is being considered.

6. Which initial physical assessment finding would the nurse expect to be present in a patient with acute left-sided heart failure? a. Bubbling crackles and tachycardia b. Hepatosplenomegaly and tachypnea c. Peripheral edema and cool, diaphoretic skin d. Frothy blood-tinged sputum and distended jugular veins

Ans: a. Clinical manifestations of acute left-sided heart failure are those of interstitial edema, with bubbling crackles and tachycardia, as well as tachypnea. Later frothy, bloodtinged sputum; severe dyspnea; and orthopnea develop with alveolar edema. Severe tachycardia and cool, clammy skin are present as a result of stimulation of the sympathetic nervous system from hypoxemia. Systemic edema reflected by jugular vein distention, peripheral edema, and hepatosplenomegaly are characteristic of right-sided heart failure

37. The nurse recognizes that thrombolytic therapy for the treatment of an MI has not been successful when the patient displays which manifestation? a. Continues to have chest pain b. Has a marked increase in CK enzyme levels within 3 hours of therapy c. Develops major gastrointestinal (GI) or genitourinary (GU) bleeding during treatment d. Develops premature ventricular contractions and ventricular tachycardia during treatment

Ans: a. If chest pain is unchanged, it is an indication that reperfusion was not successful. Indications that the occluded coronary artery is patent and blood flow to the myocardium is reestablished following thrombolytic therapy include return of ST segment to baseline on the ECG; relief of chest pain; marked, rapid rise of the CK enzyme within 3 hours of therapy; and the presence of reperfusion dysrhythmias.

38. When the patient who is diagnosed with an MI is not relieved of chest pain with IV nitroglycerin, which medication will the nurse expect to be used? a. IV morphine sulfate b. Calcium channel blockers c. IV amiodarone (Cordarone) d. Angiotensin-converting enzyme (ACE) inhibitors

Ans: a. Morphine sulfate decreases anxiety and cardiac workload as a vasodilator and reduces preload and myocardial O2 consumption, which relieves chest pain. Calcium channel blockers, amiodarone, and ACE inhibitors will not relieve chest pain related to an MI

3. Which manifestation of infective endocarditis is a result of fragmentation and microembolization of vegetative lesions? a. Petechiae b. Roth's spots c. Osler's nodes d. Splinter hemorrhages

Ans: a. Petechiae are seen as small hemorrhages in the conjunctiva, lips, and buccal mucosa and over the ankles, feet, and antecubital and popliteal areas. Roth's spots are hemorrhagic retinal lesions seen with funduscopic examination. Osler's nodes are lesions on the fingertips or toes. The cause of Roth's spots and Osler's nodes is not clear. Splinter hemorrhages are black longitudinal streaks that occur on nail beds. They may be caused by vessel damage from vasculitis or microemboli.

16. The health care provider prescribes spironolactone (Aldactone) for the patient with chronic heart failure. What diet modifications related to the use of this drug should the nurse include in the patient teaching? a. Decrease both sodium and potassium intake b. Increase calcium intake and decrease sodium intake c. Decrease sodium intake and increase potassium intake d. Decrease sodium intake and the use of salt substitutes for seasoning

Ans: a. Spironolactone is a potassium-sparing diuretic and when it is the only diuretic used in the treatment of heart failure, moderate to low levels of potassium intake should be maintained to prevent development of hyperkalemia. Sodium intake is usually reduced to at least 2400 mg/day in patients with heart failure but salt substitutes cannot be freely used because most contain high concentrations of potassium. Calcium intake is not increased

41. A patient with an MI is exhibiting anxiety while being taught about possible lifestyle changes. The nurse evaluates that the anxiety is relieved when the patient states a. "I'm going to take this recovery one step at a time." b. "I feel much better and am ready to get on with my life." c. "How soon do you think I will be able to go back to work?" d. "I know you are doing everything possible to save my life."

Ans: a. This patient is indicating positive coping with a realization that recovery takes time and that lifestyle changes can be made as needed. The patient who is "just going to get on with life" is probably in denial about the seriousness of the condition and the changes that need to be made. Nervous questioning about the expected duration and effect of the condition indicates the presence of anxiety, as does the statement regarding the health care professional's role in treatment

42. Priority Decision: A patient hospitalized for evaluation of unstable angina experiences severe chest pain and calls the nurse. Prioritize the interventions below from 1 (highest priority) to 6 (lowest priority). The appropriate medical orders and protocols are available to the nurse. a. Notify the physician b. Obtain a 12-lead ECG c. Check the patient's vital signs d. Administer oxygen per nasal cannula e. Perform a focused assessment of the chest f. Assess pain (PQRST) and medicate as ordered

Ans: a. 6; b. 4; c. 3; d. 1; e. 5; f. 2. A patient having chest pain needs to have the pain assessed and relieved as quickly as possible. The administration of oxygen may help to relieve the pain. Following an assessment of the pain, medication may be administered. It is important to know if the pain is accompanied by a change in vital signs and if any other manifestations or ECG changes exist before the report is given to the physician.

13. Myocardial ischemia occurs as a result of increased oxygen demand and decreased oxygen supply. What factors and disorders result in increased oxygen demand (select all that apply)? a. Hypovolemia or anemia b. Increased cardiac workload with aortic stenosis c. Narrowed coronary arteries from atherosclerosis d. Angina in the patient with atherosclerotic coronary arteries e. Left ventricular hypertrophy caused by chronic hypertension f. Sympathetic nervous system stimulation by drugs, emotions, or exertion

Ans: b, d, e, f. Increased oxygen demand is caused by increasing the workload of the heart, including left ventricular hypertrophy with hypertension, sympathetic nervous stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply.

11. What explains the measurement of pulsus paradoxus with cardiac tamponade (select all that apply)? a. A difference of less than 10 mm Hg occurs. b. A difference of greater than 10 mm Hg occurs. c. It is measured with an automatic sphygmomanometer. d. Rapidly inflate the cuff until you hear sounds throughout the respiratory cycle. e. Subtract the number when sounds are heard in the respiratory cycle from the number when the first Korotkoff sound during expiration is heard.

Ans: b, e. Pulsus paradoxus is measured with a manually operated sphygmomanometer. The cuff is deflated slowly until the first Korotkoff sound during expiration is heard and the number is noted. The slow deflation of the cuff is continued until sounds are heard throughout the respiratory cycle and that number is subtracted from the first number. When the difference is >10 mm Hg, cardiac tamponade may be present. The difference is normally <10 mm Hg.

30. The patient is admitted post-radiation therapy with symptoms of cardiomyopathy (CMP). Which type of CMP should the nurse suspect that the patient is experiencing? a. Dilated b. Restrictive c. Takotsubo d. Hypertrophic

Ans: b. A secondary cause of restrictive cardiomyopathy (CMP) is radiation treatment to the thorax with stiffness of the ventricular wall occurring. Dilated CMP may have a genetic link, follow infectious myocarditis, or be related to an autoimmune process or excess alcohol ingestion. Takotsubo CMP is an acute stress-related syndrome that mimics acute coronary syndrome. It is most common in postmenopausal women. Hypertrophic CMP has a genetic link in about one half of all cases and is frequently seen in young athletic individuals.

23. The patient is admitted with angina, syncope, and dyspnea on exertion. In the assessment, the nurse notes a systolic murmur with a prominent S4 .What will the nurse suspect is occurring with this patient? a. Mitral valve stenosis b. Aortic valve stenosis c. Acute mitral valve regurgitation d. Chronic mitral valve regurgitation

Ans: b. Aortic valve stenosis is identified with the triad of angina, syncope, and dyspnea on exertion, as well as the systolic murmur and prominent S4 heart sound. Mitral valve stenosis manifests as exertional dyspnea, hemoptysis, fatigue, atrial fibrillation, and a diastolic murmur. Acute mitral valve regurgitation has a new systolic murmur with pulmonary edema and cardiogenic shock rapidly developing. Chronic mitral valve regurgitation is identified with weakness, fatigue, exertional dyspnea, palpitations, an S3 gallop, and holosystolic murmur

19. The patient has used sublingual nitroglycerin and various long-acting nitrates but now has an ejection fraction of 38% and is considered at a high risk for a cardiac event. Which medication would first be added for vasodilation and to reduce ventricular remodeling? a. Clopidogrel (Plavix) c. Diltiazem (Cardizem) b. Captopril (Capoten) c. Diltiazem (Cardizem) d. Metoprolol (Lopressor)

Ans: b. Captopril (Capoten) would be added. It is an angiotensinconverting enzyme (ACE) inhibitor that vasodilates and decreases endothelial dysfunction and may prevent ventricular remodeling. Clopidogrel (Plavix) is an antiplatelet agent used as an alternative for a patient unable to use aspirin. Diltiazem (Cardizem), a calcium channel blocker, may be used to decrease vasospasm but is not known to prevent ventricular remodeling. Metoprolol (Lopressor) is a β-adrenergic blocker that inhibits sympathetic nervous stimulation of the heart

5. A patient with infective endocarditis of a prosthetic mitral valve develops a left hemiparesis and visual changes. What should the nurse expect to be included in collaborative management of the patient? a. Embolectomy b. Surgical valve replacement c. Administration of anticoagulants d. Higher than usual antibiotic dosages

Ans: b. Early valve replacement followed by prolonged antibiotic and anticoagulant therapy is recommended for these patients. Drug therapy for patients who develop endocarditis of prosthetic valves is often unsuccessful in eliminating the infection and preventing embolization

28. During the assessment, the nurse identifies crackles in the lungs and an S3 heart sound. Which complication of MI should the nurse suspect and further investigate? a. Pericarditis b. Heart failure c. Ventricular aneurysm d. Papillary muscle dysfunction

Ans: b. Heart failure, which can escalate to carrdiogenic shock, initially occurs with mild dyspnea, restlessness, agitation, pulmonary congestion with crackles, S3 or S4 heart sounds, and jugular vein distention. Pericarditis is a common complication identified with chest pain that is aggravated by inspiration, coughing, and moving the upper body. Ventricular aneurysm is manifested with heart failure, dysrhythmias, and angina. Papillary muscle dysfunction is suspected with a new systolic apical murmur.

5. What is the pathophysiologic mechanism that results in the pulmonary edema of left-sided heart failure? a. Increased right ventricular preload b. Increased pulmonary hydrostatic pressure c. Impaired alveolar oxygen and carbon dioxide exchange d. Increased lymphatic flow of pulmonary extravascular fluid

Ans: b. In left-sided heart failure, blood backs up into the pulmonary veins and capillaries. This increased hydrostatic pressure in the vessels causes fluid to move out of the vessels and into the pulmonary interstitial space. When increased lymphatic flow cannot remove enough fluid from the interstitial space, fluid moves into the alveoli, resulting in pulmonary edema and impaired alveolar oxygen and carbon dioxide exchange. Initially the right side of the heart is not involved.

12. The patient with acute pericarditis is having a pericardiocentesis. Postoperatively what complication should the nurse monitor the patient for? a. Pneumonia b. Pneumothorax c. Myocardial infarction (MI) d. Cerebrovascular accident (CVA)

Ans: b. Pneumothorax may occur as a needle is inserted into the pericardial space to remove fluid for analysis and relieve cardiac pressure with pericardiocentesis. Other complications could include dysrhythmias, further cardiac tamponade, myocardial laceration, and coronary artery laceration.

10. A patient with acute pericarditis has markedly distended jugular veins, decreased BP, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes that these symptoms occur when what happens? a. The pericardial space is obliterated with scar tissue and thickened pericardium b. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling c. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction d. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction

Ans: b. The patient is experiencing a cardiac tamponade that consists of excess fluid in the pericardial sac, which compresses the heart and the adjoining structures, preventing normal filling and cardiac output. Fibrin accumulation, a scarred and thickened pericardium, and adherent pericardial membranes occur in chronic constrictive pericarditis

14. When obtaining a nursing history for a patient with myocarditis, what should the nurse specifically question the patient about? a. Prior use of digoxin for treatment of cardiac problems b. Recent symptoms of a viral illness, such as fever and malaise c. A history of coronary artery disease (CAD) with or without an MI d. A recent streptococcal infection requiring treatment with penicillin

Ans: b. Viruses are the most common cause of myocarditis in the United States and early manifestations of myocarditis are often those of systemic viral infections. Myocarditis may also be associated with systemic inflammatory and metabolic disorders as well as with other microorganisms, drugs, or toxins. The patient with myocarditis is predisposed to drug-related dysrhythmias and toxicity with digoxin, so it is used very cautiously, if at all, in treatment of the condition.

26. At what point in the healing process of the myocardium following an infarct does early scar tissue result in an unstable heart wall? a. 2 to 3 days after MI b. 4 to 10 days after MI c. 10 to 14 days after MI d. 6 weeks after MI

Ans: c. At 10 to 14 days after MI, the myocardium is considered especially vulnerable to increased stress because of the unstable state of healing at this point, as well as the increasing physical activity of the patient. At 2 to 3 days, removal of necrotic tissue is taking place by phagocytic cells. By 4 to 10 days, the necrotic tissue has been cleared and a collagen matrix for scar tissue has been deposited. Healing with scar-tissue replacement of the necrotic area is usually complete by 6 weeks

10. Which diagnostic test is most useful in differentiating dyspnea related to pulmonary effects of heart failure from dyspnea related to pulmonary disease? a. Exercise stress testing b. Cardiac catheterization c. B-type natriuretic peptide (BNP) levels d. Determination of blood urea nitrogen (BUN)

Ans: c. B-type natriuretic peptide (BNP) is released from the ventricles in response to increased blood volume in the heart and is a good marker for heart failure. If BNP is elevated, shortness of breath is due to heart failure; if BNP is normal, dyspnea is due to pulmonary disease. BNP opposes the actions of the renin-angiotensin-aldosterone system, resulting in vasodilation and reduction in blood volume. Exercise stress testing and cardiac catheterization are more important tests to diagnose coronary artery disease and although the blood urea nitrogen (BUN) may be elevated in heart failure, it is a reflection of decreased renal perfusion. (See Table 32-6.)

35. Collaborative care of the patient with NSTEMI differs from that of a patient with STEMI in that NSTEMI is more frequently initially treated with what? a. PCI b. CABG c. Acute intensive drug therapy d. Reperfusion therapy with thrombolytics

Ans: c. Because an NSTEMI is an acute coronary syndrome that indicates a transient thrombosis or incomplete coronary artery occlusion, treatment involves intensive drug therapy with antiplatelets, glycoprotein IIb/IIIa inhibitors, antithrombotics, and heparin to prevent clot extension. In addition, IV nitroglycerin is used. Reperfusion therapy using thrombolytics, CABG, or PCI is used for treatment of STEMI.

36. During treatment with reteplase (Retavase) for a patient with a STEMI, which finding should most concern the nurse? a. Oozing of blood from the IV site b. BP of 102/60 mm Hg with an HR of 78 bpm c. Decrease in the responsiveness of the patient d. Presence of intermittent accelerated idioventricular dysrhythmias

Ans: c. Decreasing level of consciousness (LOC) may reflect hypoxemia resulting from internal bleeding, which is always a risk with thrombolytic therapy. Oozing of blood is expected, as are reperfusion dysrhythmias. BP is low but not considered abnormal because the pulse is within normal range

32. Which treatment is used first for the patient with a confirmed MI to open the blocked artery within 90 minutes of arrival to the facility? a. Stent placement b. Coronary artery bypass graft (CABG) c. Percutaneous coronary intervention (PCI) d. Transmyocardial laser revascularization (TMR)

Ans: c. Emergent percutaneous coronary intervention (PCI) is the first treatment for patients with a confirmed MI within 90 minutes of arriving at the facility with an interventional cardiac catheterization lab. Stent placement, CABG, and TMR are usually done to facilitate circulation in nonemergency situations

21. What accurately describes mitral valve prolapse? a. Rapid onset prevents left chamber dilation b. May be caused by pulmonary hypertension c. Ballooning of valve into left atrium during ventricular systole d. Rapid development of pulmonary edema and cardiogenic shock

Ans: c. Mitral valve prolapse is the ballooning of the valve leaflets into the left atrium during ventricular systole. The rapid onset that prevents left chamber dilation and the rapid development of pulmonary edema and cardiogenic shock occur with acute mitral regurgitation. Pulmonary hypertension may contribute to tricuspid valve disease.

12. A patient is admitted to the emergency department with acute decompensated heart failure (ADHF). Which IV medication would the nurse expect to administer first? a. Digoxin (Lanoxin) b. Morphine sulfate c. Nesiritide (Natrecor) d. Bumetanide (Bumex)

Ans: c. Nesiritide (Natrecor) is a recombinant form of a natriuretic peptide that decreases preload and afterload by reducing pulmonary artery wedge pressure (PAWP) and systolic BP which decreases the workload of the heart for short-term emergency treatment of acute decompensated heart failure (ADHF). Digoxin (Lanoxin) requires a loading dose and time to work, so it is not recommended for emergency treatment of ADHF. Morphine sulfate relieves dyspnea but has more adverse events and mortality. Bumetanide (Bumex) will decrease fluid volume but also will decrease potassium levels and activate the sympathetic nervous system and renin-angiotensin-aldosterone system, which can exacerbate HF symptoms.

32. When planning care for the patient with hypertrophic CMP, what should the nurse include? a. Ventricular pacing b. Administration of vasodilators c. Teach the patient to avoid strenuous activity and dehydration d. Surgery for cardiac transplantation will need to be done soon

Ans: c. Nursing interventions for the patient with hypertrophic CMP are to improve ventricular filling by reducing ventricular contractility and relieving left ventricular outflow obstruction to relieve symptoms and prevent complications. Strenuous activity and dehydration will increase systemic vascular resistance and should be avoided. Atrioventricular pacing will allow the septum to move away from the left ventricular wall and reduce the degree of outflow obstruction. Vasodilators may decrease venous return and further increase obstruction of blood flow from the heart. The surgery that could be done involves cutting into the thickened septal wall and removing some of the ventricular muscle

20. The nurse determines that treatment of heart failure has been successful when the patient experiences a. weight loss and diuresis. b. warm skin and less fatigue. c. clear lung sounds and decreased HR. d. absence of chest pain and improved level of consciousness (LOC).

Ans: c. Successful treatment of heart failure is indicated by an absence of symptoms of pulmonary edema and hypoxemia, such as clear lung sounds and a normal HR. Weight loss and diuresis, warm skin, less fatigue, and improved LOC may occur without resolution of pulmonary symptoms. Chest pain is not a common finding in heart failure unless coronary artery perfusion is impaired

6. A patient with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. What should the nurse suspect that the patient is experiencing? a. Pulmonary embolization from valve vegetations b. Vegetative embolization to the coronary arteries c. Valvular incompetence with resulting heart failure d. Nonspecific manifestations that accompany infectious diseases

Ans: c. The dyspnea, crackles, and restlessness that the patient is manifesting are symptoms of heart failure and decreased cardiac output (CO) that occurs in up to 80% of patients with aortic valve endocarditis as a result of aortic valve incompetence. Vegetative embolization from the aortic valve occurs throughout the arterial system and may affect any body organ. Pulmonary emboli occur in right-sided endocarditis

27. To detect and treat the most common complication of MI, what should the nurse do? a. Measure hourly urine output. b. Auscultate the chest for crackles. c. Use continuous cardiac monitoring. d. Take vital signs every 2 hours for the first 8 hours.

Ans: c. The most common complication of MI is cardiac dysrhythmias. Continuous cardiac monitoring allows identification and treatment of dysrhythmias that may cause further deterioration of the cardiovascular status or death. Measurement of hourly urine output and vital signs is indicated to detect symptoms of the complication of cardiogenic shock. Crackles, dyspnea, and tachycardia may indicate the onset of heart failure. 28. b. Heart failure, which can escalate to car

9. A patient is admitted to the hospital with a suspected acute pericarditis. To establish the presence of a pericardial friction rub, how should the nurse listen to the patient's chest? a. While timing the sound with the respiratory pattern b. With the bell of the stethoscope at the apex of the heart c. With the diaphragm of the stethoscope at the lower left sternal border of the chest d. With the diaphragm of the stethoscope to auscultate a high-pitched continuous rumbling sound

Ans: c. The stethoscope diaphragm at the left sternal border with the patient leaning forward is the best method to use to hear the high-pitched, grating sound of a pericardial friction rub. The sound does not radiate widely and occurs with the heartbeat. To differentiate a pericardial friction rub from a pleural friction rub, have the patient hold his or her breath. The rub will still be heard if it is cardiac in nature

26. A patient is scheduled for a percutaneous transluminal balloon valvuloplasty. The nurse understands that this procedure is indicated for which patient? a. Any patient with aortic regurgitation b. Older patients with aortic regurgitation c. Older patients with stenosis of any valve d. Young adult patients with mild mitral valve stenosis

Ans: c. This procedure has been used for repair of mitral, tricuspid, and pulmonic stenosis and less often for aortic stenosis. It is usually used for older patients and for those patients who are poor surgical risks because it is relatively easy and has good results and few complications

14. What causes the pain that occurs with myocardial ischemia? a. Death of myocardial tissue b. Dysrhythmias caused by cellular irritability c. Lactic acid accumulation during anaerobic metabolism d. Elevated pressure in the ventricles and pulmonary vessels

Ans: c. When the coronary arteries are occluded, contractility ceases after several minutes, depriving the myocardial cells of glucose and oxygen for aerobic metabolism. Anaerobic metabolism begins and lactic acid accumulates, irritating myocardial nerve fibers that then transmit a pain message to the cardiac nerves and upper thoracic posterior roots. The other factors may occur during vessel occlusion but are not the source of pain.

31. What accurately describes dilated CMP (select all that apply)? a. Characterized by ventricular stiffness b. The least common type of cardiomyopathy c. The hyperdynamic systolic function creates a diastolic failure d. Echocardiogram reveals cardiomegaly with thin ventricular walls e. Often follows an infective myocarditis or exposure to toxins or drugs f. Differs from chronic heart failure in that there is no ventricular hypertroph

Ans: d, e, f. Dilated CMP, the most common type of CMP, reveals cardiomegaly with thin ventricular walls on echocardiogram, as there is no ventricular hypertrophy, and may follow an infective myocarditis. As well, stasis of blood in the ventricles may contribute to systemic embolization. Restrictive CMP is the least common type and is characterized by ventricular stiffness. Hypertrophic CMP has hyperdynamic systolic function creating a diastolic failure, is characterized by massive thickening of intraventricular septum and ventricular wall, and may result in syncope during increased activity resulting from an obstructed aortic valve outflow

22. What causes a sudden onset of cardiovascular collapse? a. Mitral stenosis b. Tricuspid valve disease c. Pulmonic valve stenosis d. Acute aortic regurgitation

Ans: d. Acute aortic regurgitation causes a sudden cardiovascular collapse. With mitral valve stenosis dyspnea is a prominent symptom and embolization may result from chronic atrial fibrillation. With tricuspid and pulmonic valve diseases, stenosis occurs more often than regurgitation. Tricuspid valve stenosis results in right atrial enlargement and elevated systemic venous pressures. Pulmonic valve stenosis results in right ventricular hypertension and hypertrophy.

17. Tachycardia that is a response of the sympathetic nervous system to the pain of ischemia is detrimental because it increases oxygen demand and a. increases cardiac output. b. causes reflex hypotension. c. may lead to atrial dysrhythmias. d. impairs perfusion of the coronary arteries

Ans: d. An increased heart rate (HR) decreases the time the heart spends in diastole, which is the time of greatest coronary blood flow. Unlike other arteries, coronary arteries are perfused when the myocardium relaxes and blood backflows from the aorta into the sinuses of Valsalva, which have openings to the right and left coronary arteries. Thus the heart has a decreased oxygen supply at a time when there is an increased oxygen demand. Tachycardia may also lead to ventricular dysrhythmia. The other options are incorrect

15. What is the most important role of the nurse in preventing rheumatic fever? a. Teach patients with infective endocarditis to adhere to antibiotic prophylaxis. b. Identify patients with valvular heart disease who are at risk for rheumatic fever. c. Encourage the use of antibiotics for treatment of all infections involving a sore throat. d. Promote the early diagnosis and immediate treatment of group A streptococcal pharyngitis.

Ans: d. Initial attacks of rheumatic fever and the development of rheumatic heart disease can be prevented by adequate treatment of group A streptococcal pharyngitis. Because streptococcal infection accounts for only about 20% of acute pharyngitis, cultures should be done to identify the organism and direct antibiotic therapy. Viral infections should not be treated with antibiotics. Prophylactic therapy is indicated in those who have valvular heart disease or have had rheumatic heart disease

4. What describes Janeway's lesions that are manifestations of infective endocarditis? a. Hemorrhagic retinal lesions b. Black longitudinal streaks in nail beds c. Painful red or purple lesions on fingers or toes d. Flat, red, painless spots on the palms of hands and soles of feet

Ans: d. Janeway's lesions are flat, painless, small red spots found on the palms of the hands and the soles of the feet. Black streaks on the nails are splinter hemorrhages. Hemorrhagic retinal lesions are Roth's spots. Painful lesions on the fingers and toes are Osler's nodes

8. When instructing a patient with endocarditis how to prevent recurrence of the infection, what should the nurse teach the patient? a. Start on antibiotic therapy when exposed to persons with infections. b. Take one aspirin a day to prevent vegetative lesions from forming around the valves. c. Always maintain continuous antibiotic therapy to prevent the development of any systemic infection. d. Obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures (e.g., dental cleaning).

Ans: d. Prophylactic antibiotic therapy should be initiated before invasive dental, medical, or surgical procedures to prevent recurrence of endocarditis. Continuous antibiotic therapy is indicated only in patients with implanted devices or ongoing invasive procedures. Symptoms of infection should be treated promptly but antibiotics are not used for exposure to infection.

13. A patient with acute pericarditis has a nursing diagnosis of pain related to pericardial inflammation. What is the best nursing intervention for the patient? a. Administer opioids as prescribed on an around-the-clock schedule. b. Promote progressive relaxation exercises with the use of deep, slow breathing. c. Position the patient on the right side with the head of the bed elevated 15 degrees. d. Position the patient in Fowler's position with a padded over-the-bed table for the patient to lean on.

Ans: d. Relief from pericardial pain is often obtained by sitting up and leaning forward. Pain is increased by lying flat. The pain has a sharp, pleuritic quality that changes with respiration and patients take shallow breaths. Antiinflammatory medications may also be used to help control pain but opioids are not usually indicated.

7. A patient hospitalized for 1 week with subacute infective endocarditis is afebrile and has no signs of heart damage. Discharge with outpatient antibiotic therapy is planned. During discharge planning with the patient, what is it most important for the nurse to do? a. Plan how his needs will be met while he continues on bed rest. b. Encourage the use of diversional activities to relieve boredom and restlessness. c. Teach the patient to avoid crowds and exposure to upper respiratory infections. d. Assess the patient's home environment in terms of family assistance and hospital access.

Ans: d. The patient with outpatient antibiotic therapy requires vigilant home nursing care and it is most important to determine the adequacy of the home environment for successful management of the patient. The patient is at risk for life-threatening complications, such as embolization and pulmonary edema, and must be able to access a hospital if needed. Bed rest will not be necessary for the patient without heart damage. Avoiding infections and planning diversional activities are indicated for the patient but are not the most important factors while he is on outpatient antibiotic therapy

25. A 52-year-old man is admitted to the emergency department with severe chest pain. On what basis would the nurse suspect an MI? a. He has pale, cool, clammy skin. b. He reports nausea and vomited once at home. c. He says he is anxious and has a feeling of impending doom. d. He reports he has had no relief of the pain with rest or position change

Ans: d. The subjective report of the pain from an MI is usually severe. It usually is unrelieved by nitroglycerin, rest, or position change and usually lasts more than the 15 or 20 minutes typical of angina pain. All of the other symptoms may occur with angina as well as with an M

19. What is an effect of valvular regurgitation? a. It causes a pressure gradient difference across an open valve. b. A pericardial friction rub is heard on the right sternal border of the chest. c. It leads to decreased flow of blood and hypertrophy of the preceding chamber. d. There is a backward flow of blood and volume overload in the preceding chamber

Ans: d. Valvular regurgitation causes a backward flow of blood and volume overload in the preceding chamber. Without treatment, eventually hypertrophy of that chamber occurs. Stenosis causes a pressure gradient difference and decreased blood flow and hypertrophy of the preceding chamber. A pericardial friction rub is not related to valvular regurgitation but would be heard at the lower left sternal border of the chest.