Med-Surg Cardiovascular

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury (AKI) ? A. Serum creatinine 1.8mg/dL B. Serum osmolality 290 mOsm/kg H2O C. Blood urea nitrogen (BUN) 20mg/dL D. Magnesium 2.0 mEq/L

A. Serum creatinine 1.8mg/dL Rationale: An indication that the client is at risk for developing AKI is a creatinine level that is 1.5 times greater than the expected range. In an older female client, the expected range for creatinine is 0.5-1.2 mg/dL

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs B. Request a dietitian consult C. Suggest that the client rests before eating the meal D. Request an order for an antiemetic

A. Check the client's vital signs Rationale: It's possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. Withhold medication and call provider if client's heart rate is >60bpm

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately? A. Slurred speech B. Irregular pulse C. Dependent edema D. Persistent fatigue

A. Slurred speech Rationale: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

A nurse is in a client's groom when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side B. Check the client's motor strength C. Loosen the clothing around the client's waist D. Document the time the seizure began

A. Turn the client's head to the side Rationale: The first action the nurse should take when using the ABC's approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribed warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements would the nurse make? A. Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level B. I will call the provider to get a prescription for discontinuing the IV heparin today C. Both heparin and warfarin work together to dissolve the clots D. The IV heparin increase the effects of the warfarin and decreases the length of your hospital stay

A. Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulants can be achieved by warfarin alone, usually 1-5 day.

A nurse is caring for a client who reports a new onset of chest pressure severe epigastric distress. The physician prescribes monitoring of the creatine kinsase (CK) isoenzymes. When should the nurse anticipate the CK isoenzymes will begin to rise if the client has had a MI (Select all that apply) A. 1 hr B. 2 hr C. 3 hr D. 24 hr

B, C. 2 hr. 3 hr. Rationale: Creatine kinase is an isoenzyme that is found in skeletal muscles, the heart, and the brain. The isoenzyme specific to heart is CK-MB, which can accurately detect tissue necrosis or injury within a few hours of onset. One of the earliest markers of an MI is myoglobin, which begins to rise within 2 hrs of injury. However, it is not specific to heart tissues and has limited diagnostic usefulness

A nurse is caring for a client who is 8hr postoperative following a coronary artery bypass graft (CABG). Which of the following findings should the nurse report? A. Mediastinal drainage 100mL/hr B. Blood pressure 160/80 mmHg C. Temperature 37.1C (98.8F) D. Potassium 4.0 mEq/L

B. Blood pressure 160/80 mmHg Rationale: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet

B. MRI of the chest Rationale: A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? A. Hyperthermia B. Hypotension C. Ototoxicity D. Muscle pain

B. Hypotension Rationale: Verapamil is a calcium channel blocker & can be used to control supraventricular tachyarrhythmias. It also decrease BP and acts as a coronary vasodilator and anti-anginal agent. BP and pulse must be monitored before and during parenteral admin.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. DIC is controllable with lifelong heparin usage B. DIC is characterized by an elevated platelet count C. DIC is caused by abnormal coagulation involving fibrinogen D. DIC is a genetic disorder involving vitamin K deficiency

C. DIC is caused by abnormal coagulation involving fibrinogen Rationale: DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing risk for hemorrhage

A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds? A. Increase the heparin infusion flow rate by 2mL/hr B. Continue to monitor the heparin infusion as prescribed C. Request a prothrombin time (PT) D. Stop the heparin infusion

D. Stop the heparin infusion Rationale: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following indicates effective treatment? A. Absence of adventitious breath sounds. B. Presence of a nonproductive cough C. Decrease in respiratory rate at rest D. SaO2 86% on room air

A. Absence of adventitious breath sounds. Rationale: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? A. Place the client in protective isolation B. Minimize environmental stimuli C. Elevate the head of the client's bed 45 degrees D. Limit the client's ambulation to once a day

B. Minimize environmental stimuli Rationale: A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights

A nurse is caring for a client who has a history of angina and is schedules for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I'm still hungry after the bowl of cereal I ate at 7 a.m." B. "I didn't take my heart pills this morning because the doctor told me not to." C. "I have had chest pain a couple of times since I saw my doctor in the office last week." D. "I smoked a cigarette this morning to calm my nerves about having this procedure."

D. "I smoked a cigarette this morning to calm my nerves about having this procedure." Rationale: smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.

A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following findings should indicate to the nurse that the medication is effective? A. Hemoglbin 14g/dL B. Minimal bruising of extremities C. Decreased blood pressure D. INR 2.0

D. INR 2.0 Rationale: The nurse should identify that an INR of 2.0 is within the desired range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and stroke.

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medication should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety B. If facilitates the client's deep breathing C. It enhances the client's ability to sleep D. It reduces the client's blood pressure

B. If facilitates the client's deep breathing Rationale: When using the ABC approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief.

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? A. The client cannot travel by air due to security screening B. The client should hold his cell phone on the side opposite the ICD C. The client should avoid the use of small electric devices D. The client can carry his ICD in a small pocket

B. The client should hold his cell phone on the side opposite the ICD Rationale: Close proximity could interfere with the ICD's function

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should identify that an increase in which of the following values is diagnostic of a myocardial infarction (MI)? A. Myoglobin B. C-reactive protein C. Creatine kinase-MB D. Homocysteine

C. Creatine kinase-MB Rationale: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? A. It usually takes heparin at least 2-3 days to reach a therapeutic blood level B. A pharmacist is the right person to answer that question C. Heparin does not dissolve clots. It stops new clots from forming D. The oral medication you will take after this IV will dissolve the clot.

C. Heparin does not dissolve clots. It stops new clots from forming

A nurse is reviewing the laboratory values of a client who had a MI 3 hrs ago. The nurse should expect which of the following values to be elevated? A. Aspartate aminotransferase (AST) B. Unconjugated bilirubin C. Troponin I D. Serum amylase

C. Troponin I Rationale: Troponin I and Troponin T are biochemical markers that are specific to myocardial cell injury. A client who has MI cell damage can have elevated troponin levels within 2-3hrs. Troponin I levels pearl in 10-24 hrs and stay elevated 10-14 days

A nurse is caring for a client who has endocarditis. Which of the following should the nurse recognize as a potential complication? A. Ventricular-depolarization B. Guillain-Barré syndrome C. Myelodysplastic syndrome D. Valvular disease

D. Valvular disease Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. Cryoprecipitates B. Platelets C. Albumin D. Packed RBC's

D. Packed RBC's Rationale: Packed RBC's are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock Cryoprecipitates are administered to clients who have hemophilia or von Willebrand disease Platelets are administered to clients who have thrombocytopenia Albumin is administered to clients who have hypoproteinemia and burns

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours B. Manifestations preceded by a severe headache C. Maintains consciousness D. History fo neurological deficits lasting less than 1 hr.

B. Manifestations preceded by a severe headache Rationale: A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden severe headache is an expected initial manifestation.

A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find? A. Increase abdominal girth B. Weak peripheral pulses C. Jugular venous neck distention D. Dependent edema

B. Weak peripheral pulses Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. All other answers result from right-sided heart failure.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. Pulse and blood pressure findings B. Behavioral indicators and effects C. Scheduled treatments and client illness D. A self-report pain rating scaled

D. A self-reporting pain rating scale Rationale: Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally.

A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals they are 1 week postoperative following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated? A. Administering IV morphine sulfate B. Administering oxygen at 2L/min via nasal cannula C. Helping the client to the bedside commode D. Assisting with thrombolytic therapy

D. Assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy

A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. I'm still hungry after the bowl of cereal I ate at 7 a.m. B. I didn't take my heart pills this morning because the doctor told me not to. C. I have had chest pain a couple of times since I saw my doctor in the office las week D. I smoked a cigarette this morning to calm my nerves about having this procedure.

D. I smoked a cigarette this morning to calm my nerves about having this procedure. Rationale: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the clients should indicate to the nurse the need for further teaching? A. A weight loss program can decrease my LDL cholesterol level B. Exercising regularly will increase HDL cholesterol levels C. Adding foods containing omega-3 fatty acids to my diet can lower my risk D. Increase my intake of foods containing trans-fatty acids can lower my risk

D. Increase my intake of foods containing trans-fatty acids can lower my risk Rationale: Increasing dietary intake of trans-fatty acids can cause increase in LDL cholesterol, which increase the risk of developing cardiovascular disease.

A nurse is preparing a client for coronary angiography. Which of the following findings should the nurse report to the provider prior the the procedure? A. Hemoglobin 14.4 g/dL B. History of peripheral arterial disease C. Urine output 200ml/4hr D. Previous allergic reaction to shellfish

D. Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heartbeat with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A. First-degree AV block B. Atrial fibrillation C. Sinus bradycardia D. Sinus tachycardia

B. Atrial fibrillation Rationale: A-fib causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit First-degree AV block is a regular rhythm w/ a prolonged P-R interval. A pulse deficit doesn't occur. Sinus bradycardia is a slow heart rate w/ a regular rhythm. A pulse deficit doesn't occur. Sinus tachycardia is a rapid heart rate w/ a regular rhythm. A pulse deficit doesn't occur.

A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin patches. Which of the following instructions should the nurse include in the teaching? A. Apply the new patch to the same site as the previous patch B. Place the patch on an area of skin away from skin folds and joints C. Keep the patch on 24hr per day D. Replace the patch at the onset of angina

B. Place the patch on an area of skin away from skin folds and joints Rationale: The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Initiate seizure precautions B. Tell the client to report vision changes C. Elevate the head of the client's bed D. Start a peripheral IV

C. Elevate the head of the client's bed Rationale: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation

A nurse is caring for a client who has a-fib and is receiving heparin. Which of the following findings is the nurse's priority? A. The client's ECG tracing shows irregular heart rate without P waves B. The client has an aPTT of 80 seconds C. The client experiences sudden weakness of one arm and leg D. The client's urine output is cloudy and odorous

C. The client experiences sudden weakness of one arm and leg Rationale: Sudden weakness or numbness of the face and one arm or leg can indicate the client is at greatest risk for stroke. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a MI (select all that apply) A. Troponin I B. Troponin T C. Plasma low-density (LDL) D. CPK E. Myoglobin

A, B, D, E, Troponin I, Troponin T, CPK, Myoglobin Rationale: Troponin I and Troponin T are myocardial muscle proteins that release when there's injury to cardiac muscle. Levels are elevated 2-3 hrs following MI. CPK is an enzyme that is elevated in the presence of muscle injury. Not specified to MI damage, but used in conjunction with other diagnostic tests. Myoglobin levels increase significantly within 3 hrs following MI

A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? (Select all that apply) A. Limited alcohol intake B. Regular exercise program C. Decrease magnesium intake D. Reduced potassium intake E. Tobacco cessation

A, B, E. Rationale: Clients who have hypertension should limit alcohol intake, develop a regular exercise program to help reduce blood pressure, and have a goal of tobacco cessation because tobacco use exacerbates hypertension. Low magnesium and potassium intake is associated w/ hypertension and is not a lifestyle modification the nurse should include

A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? A. A client who has hypothyroidism B. A client who has diabetes mellitus C. A client whose daily caloric intake consists of 25% fat D. A client who consumes two 12-oz (0.35-L) bottles of beer a day

B. A client who has diabetes mellitus Rationale: Diabetes mellitus places the client at a risk for microvascular damage and progressive peripheral arterial disease.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? A. Mottled skin B. Blood pressure 115/68 mmHg C. Heart rate 160/min D. Hypokalemia

B. Blood pressure 115/68 mmHg Rationale: The sympathetic nervous system is stimulated, resulting in the release or epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure within normal limits during the compensatory stage of shock.

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication? A. Shortness of breath B. Lightheadedness C. Dry cough D. metallic taste

B. Lightheadedness Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.

A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify their provider if they experience which of the following adverse effects of this medication. A. Tendon pain B. Persistent cough C. Frequent urination D. Constipation

B. Persistent cough Rationale: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication Tendon pain is an adverse effect of fluoroquinolone antibiotics. Frequent urination is an expected outcome of this medication Constipation is an adverse effect of ACE inhibitors. However, the client doesn't need to discontinue use or report this to the provider.

A nurse on the intensive care unit is caring for a patient who has severe brain injury and a cerebral perfusion pressure (CPP) of 59mmHg. Which of the following actions should the nurse take? A. Provide warming measures for the client B. Hyperextend the client's neck C. Flex the client's hip D. Adjust the client's head of bed

D. Adjust the client's head of bed Rationale: The nurse should adjust the client's head of bed to keep CPP greater than 70mmHg The nurse should provide cooling measures to reduce brain metabolism The nurse should keep the client's neck midline, in a neutral position to reduce the client's ICP The nurse should avoid flexing the client's hip to reduce the client's ICP

A nurse is caring for a client following the insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? A. "I can't get rid of these hiccups." B. "I feel dizzy when I stand." C. "My incision site stings." D. "I have a headache."

A. "I can't get rid of these hiccups." Rationale: Hiccups indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulante independently. Which of the following responses should the nurse make? A. Yes, you are free to move around as you wish B. No, you are on strict bed rest and must not be up C. Please ring for assistance when you wish to get out of bed D. We will have to get a prescription from your provider

C. Please ring for assistance when you wish to get out of bed Rationale: With assistance, client can ambulante safely. Tinnitus, one-sided hearing loss and vertigo are all manifestations of Ménière's disease that can increase the client's risk of falls when ambulating

A nurse is caring for a client who is 1 hr postoperative following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? A. Serosanguineous drainage on dressing B. Severe pain with coughing C. Urine output of 20mL/hr D. Increase in temperature from 36.8C (98.2F) to 37.5C (99.5F)

C. Urine output of 20mL/hr Rationale: Urine output less than 30mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? A. Apply downward pressure while the client shrugs his shoulders upward. B. Apply resistance while the client lifts his legs from the bed C. Ask the client to grasp an object and form a fist D. Apply resistance while the client flexes his arms

A. Apply downward pressure while the client shrugs his shoulders upward Rationale: This assessment monitors function of C4 and C5 B: Monitors the motor function of L2 to L4 C: Monitors the motor function of C8 D: Monitors the motor function of C7

A nurse in an emergency department is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for? A. Confusion B. Friction rub C. Hypertension D. Dry skin

A. Confusion Rationale: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status. Also monitor client for hypotension and diaphoresis. Friction rub is an expected finding

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? A. Dyspnea on exertion B. Tracheal deviation C. Pericardial rub D. Weight loss

A. Dyspnea on exertion Rationale: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output

A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. These tests help determine the degree of damage to the heart tissues. B. Cardiac enzymes all identify the location of the MI C. These tests will enable the provide to determine the heart structure and the mobility of the heart valves. D. Cardiac enzymes assist in diagnosing the presence of pulmonary congestion

A. These tests help determine the degree of damage to the heart tissues. Rationale: Cardiacs enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise & fall pattern after an MI. It may take 4hrs or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak.

A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 0.9 kg (2lb) in 24 hr B. Increase of 10mmHg in systolic blood pressure C. Dyspnea with exertion D. Dizziness when rising quickly

A. Weight gain of 0.9 kg (2lb) in 24 hr Rationale: When using the urgent vs. non urgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 1.2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A nurse is providing teaching to a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching? A. You might no longer be able to feel chest pain B. Your level of activity intolerance will not change C. After 6 months, you will no longer need to restrict you sodium intake D. You will be able to stop taking immunosuppressants after 12 months

A. You might no longer be able to feel chest pain Rationale: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart

A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? A. Obtain the client's current weight B. Review serum electrolyte values C. Determine the time of the last digoxin dose D. Check the client's urine output

B. Review serum electrolyte values Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte review the client's values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia

A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventicular tachycardia. The nurse should prepare to assist with which of the following interventions? A. Initiate chest compressions B. Vagal stimulation C. Administration of atropine IV D. Defibrillation

B. Vagal stimulation Rationale: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider required clarification? A. Morphine sulfate 2mg IV bolus every 2hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% Normal saline IV at 50ml/hr continuous D. Bumetanide 1mg IV bolus every 12 hr

C. 0.9% Normal saline IV at 50ml/hr continuous Rationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift need in this client to reduce circulatory overload. This prescription requires clarification

A nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values? A. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL B. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL C. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL D. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL

C. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL Rationale: These laboratory values for HDL and LDL are outside expected range and indicate the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males, and above 55 mg/dL for females; and for LDL is less than 130 mg/dL

A nurse is caring for a client who is schedule for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? A. My arthritis is really bothering me because I haven't taken my aspirin in a week. B. My blood pressure shouldn't be high because I took my blood pressure medication this morning. C. I took my warfarin last night according to my usual schedule D. I will check my blood sugar because I took a reduced dose of insulin this morning

C. I took my warfarin last night according to my usual schedule Rationale: Clients who are schedule for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.

A nurse is admitting a client who has a leg ulcer and history of diabetes mellitus. Which the following focused assessments should the nurse use to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the client's family history of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection

C. Inquire about the presence or absence of claudication Rationale: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? A. Pacemaker spikes after each QRS complex B. Pacemaker spikes before each P wave C. Pacemaker spikes before each QRS complex D. Pacemaker spikes with each T wave

C. Pacemaker spikes before each QRS complex Rationale: The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred.