Med-Surg HESI EAQ - Heart Disease

A client with an abdominal aortic aneurysm is suddenly pale and reports feeling light-headed and having abdominal pain. Which action would the nurse take first? 1. Assess the respiratory rate for hyperventilation 2. Check the blood pressure for hypotension 3. Administer the prescribed morphine for pain 4. Inspect the abdomen for distension and firmness

2. Check the blood pressure for hypotension The history of abdominal aortic aneurysm, with new symptoms of pallor, lightheadedness, and abdominal pain, suggests bleeding or dissection of the aneurysm. The nurse would first check blood pressure and report hypotension immediately to the health care provider, anticipating the need to give intravenous fluids and prepare the client for emergency surgery. The other actions are also appropriate after the nurse has obtained the blood pressure. Hyperventilation may cause lightheadedness. Treatment of pain is appropriate if the blood pressure is stable, but morphine would further lower blood pressure if the client is hypotensive. Inspection of the abdomen would help confirm a diagnosis of bleeding or dissection but would not be first action.

**The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. 1. Daily weight 2. Intake and output 3. Monitor for edema 4. Daily pulse oximetry 5. Auscultate breath sounds

1, 2, 3, 4, 5 Daily weight at the same time, on the same scale, and in the same clothing is important as it is an indication of fluid gains or losses. The nurse would also record daily intake and output and report intake exceeding output. The nurse would monitor for peripheral edema and document the findings. It is important to obtain and record vital signs and daily pulse oximetry as improving results relate to effectiveness of furosemide. The nurse would also auscultate breath sounds, look for jugular venous distension, and report abnormal data.

**Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. 1. Fatigue 2. Orthopnea 3. Pitting edema 4. Dry hacking cough 5. 4-pound weight gain

1, 2, 3, 4, 5 Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.

**When the nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor, which intervention is the priority? 1. Defibrillate the client 2. Notify the rapid response team 3. Administer the IV epinepherine 4. Initiate CPR

1. Defib the client When ventricular fibrillation is verified, the first intervention is defibrillation; it is the only measure that will terminate this lethal dysrhythmia. Research indicates that early defibrillation is the strongest indicator for successful resuscitation. The Code 99 or Rapid Response Team will be notified, but the nurse will not wait to notify the team before attempting defibrillation. Epinephrine may be administered if defibrillation is initially unsuccessful, but is not the first action. Cardiopulmonary resuscitation will be started if a defibrillator is unavailable or if initial defibrillation is unsuccessful at ending the ventricular fibrillation.

**When caring for a client who has heart failure, with blood pressure 102/70 mm Hg, pulse 106 beats/minute, and bilateral lung crackles, which prescribed action would the nurse question? 1. Infuse normal saline at 100 mL/hr 2. Give furosemide 40 mg IV now 3. Administer potassium chloride 10 mEq orally now 4. Titrate oxygen by mask to keep oxygen saturation 93% or higher

1. Infuse normal saline at 100 mL/hr Because the likely cause of hypotension, tachycardia, and lung crackles in this client is decreased cardiac output and increased pulmonary congestion caused by heart failure, infusing normal saline would worsen the symptoms of fluid overload and should be questioned by the nurse. Administration of diuretics such as furosemide will decrease fluid overload in the left ventricle and improve cardiac output. Because furosemide does lead to lower potassium, the administration of potassium is appropriate. Titration of oxygen to assure adequate oxygen saturation is appropriate for a client with pulmonary congestion.

When a client is admitted to the coronary care unit with a diagnosis of ST segment elevation myocardial infarction, how will the nurse expect the client to describe the pain? 1. Severe, intense chest pain 2. Burning sensation of short duration 3. Sharp, stabbing chest pain with breathing 4. Squeezing chest pain, relieved by nitroglycerin

1. Severe, intense chest pain Classic pain with myocardial infarction is described as intense and severe. It is continuous, because it is caused by ongoing myocardial ischemia and injury. Burning pain is more consistent with gastric reflux of acid. Pain with myocardial infarction is not usually stabbing and is not associated with breathing, which would be more typical of pericarditis or pleurisy. Pain that is relieved by nitroglycerin indicates angina rather than myocardial infarction.

Which finding in a client who had coronary artery bypass graft (CABG) surgery 1 day previously is most important for the nurse to communicate to the health care provider? 1. Temperature of 102 F 2. 7/10 incisional pain (0-10 scale) 3. Sinus rhythm with PRI of 0.22 sec 4. 120 mL of blood in the chest tube collection chamber

1. Temperature of 102 F Although mild temperature elevations are common after surgery due to the inflammatory response, a high temperature may indicate wound infection and a need for actions such as blood cultures and antibiotic administration. Incisional pain is common after cardiac surgery and would be addressed by the nurse with prescribed postoperative analgesics and actions such as repositioning the client. The client's PR interval is mildly prolonged, but first-degree AV block does not affect cardiac output. A small amount of blood in the drainage device is common after cardiac or vascular surgery.

**Which findings will cause the nurse to suspect cardiac tamponade in a client who has had cardiac surgery? Select all that apply. 1. Hypertension 2. Pulsus paradoxus 3. Muffled heart sounds 4. JVD 5. Increased urine output

2, 3, 4 Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension, not hypertension, and a narrowed pulse pressure. As the cardiac output decreases, there is a decrease in kidney perfusion and a decrease in urine output.

**Which topics will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? Select all that apply. 1. Need for daily aspirin 2. Symptoms of infection 3. Use of pain medications 4. Wound care for leg incision 5. Purpose of anticoagulant medications

2, 3, 5 After mitral valve replacement, the nurse would teach the client about symptoms of infection and how to use prescribed pain medications to treat incisional pain. Clients with a mechanical mitral valve will need ongoing anticoagulation. Daily aspirin use would not be prescribed after mitral valve replacement, because there is no indication that this client has coronary artery disease. There is no leg incision with mitral valve replacement.

When teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider, which clinical manifestations would the nurse include? Select all that apply. 1. Weight loss 2. Extreme fatigue 3. Coughing at night 4. Excessive urination 5. Difficulty breathing

2, 3, 5 Fatigue is caused by a lack of adequate oxygenation of body cells caused by a decreased cardiac output. As the cardiac output decreases, pulmonary congestion increases, resulting in pulmonary edema; coughing, especially when lying down, and blood-tinged sputum occur. Dyspnea (difficulty breathing) is associated with pulmonary congestion that occurs as cardiac output decreases. Weight gain, not loss, occurs as fluid is retained by the kidneys. Fluid retention, not diuresis (excessive urination), occurs because of decreased circulation to the kidneys, resulting from decreased cardiac output.

After the nurse has finished teaching a 50-year-old female client about symptoms of coronary artery disease in women, which statement indicates that the teaching has been effective? 1. "I don't need to worry about symptoms like chest pain or pressure" 2. "I will call my health care provider about any unusual fatigue" 3. "Women have less risk of death from heart disease than men" 4. "Bad cholesterol levels are usually higher in women than men"

2. "I will call my health care provider about any unusual fatigue" Unusual fatigue is often the first symptom of coronary artery disease in women. The other statements indicate that more teaching is needed. Women do sometimes have chest pain or chest pressure as a symptom of coronary artery disease, although men have classic symptoms of cardiac disease more frequently than women. Coronary artery disease is the most common cause of death in both men and women. Low-density lipoprotein (LDL) cholesterol levels (= "bad" cholesterol) levels increase in women after menopause, but levels are not higher than those in men. Before menopause, women typically have lower LDL levels than men.

**Which nursing action is most important preoperatively for a client with an abdominal aortic aneurysm? 1. Administering supplemental oxygen 2. Maintaining a low blood pressure 3. Keeping the client in a supine position 4. Monitoring the femoral and pedal pulses

2. Maintaining a low BP Maintaining a low blood pressure reduces the risk of aortic rupture. Administering supplemental oxygen may or may not be necessary. Keeping the client in a supine position may or may not be necessary. Monitoring pulses distal to the aneurysm will help identify whether an aneurysm has ruptured, but it will not prevent rupture.

When caring for a client with acute coronary syndrome who has frequent premature ventricular complexes (PVCs), the nurse will be most concerned about PVCs occurring in which phase of the cardiac cycle? 1. P wave 2. T wave 3. P-R interval 4. QRS complex

2. T wave The T wave is the period of repolarization of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation. If a premature ventricular contraction strikes on the P wave, it will not cause ventricular fibrillation; the P wave represents atrial contraction. The P-R interval represents the time it takes the impulse to travel from the sinoatrial (SA) node to the ventricular musculature, and a PVC during the PR interval will not cause ventricular fibrillation. QRS complex is the term used to represent the entire phase of ventricular contraction.

When a client in the coronary care unit develops ventricular tachycardia, which action will the nurse take first? 1. Initiate immediate defibrillation 2. Perform synchronized cardioversion 3. Assess client pulse and blood pressure 4. Start cardiopulmonary resuscitation

3. Assess client pulse and blood pressure Because ventricular tachycardia (VT) can be stable or unstable, the nurse's first action will be to assess the client, including pulse and blood pressure. If the client is pulseless with the VT, defibrillation is used to try to end the rhythm. Synchronized cardioversion may be performed if the VT is stable and treatment with antidysrhythmic medications is unsuccessful. CPR may be initiated in pulseless VT if a defibrillator is not immediately available.

**When planning care for a client who has just returned to the nursing unit after placement of a coronary artery stent that was accomplished via access through the femoral artery, which complication is a priority for the nurse to prevent? 1. Infection 2. Urinary retention 3. Hematoma formation 4. Orthostatic hypotension

3. Hematoma formation Because blood in the femoral artery is at a high pressure and the catheter used for stenting is large, there is a high risk for hemorrhage and hematoma formation at the site of the catheter insertion. Frequent monitoring of the insertion site and vital sign checks are used to detect bleeding rapidly so that a hematoma does not occur. Infection is possible after insertion of the catheter through the femoral artery, but is not a common problem. Urinary retention and discomfort can occur because of the diuretic effect of the contrast dye used during cardiac catheterization and difficulty with voiding when clients are on bed rest postprocedure, but it is not a life-threatening complication. Orthostatic hypotension can occur because of the effect of several hours of bed rest and the diuretic effect of the contrast dye used during cardiac catheterization, but it is not as life threatening as hemorrhage and hematoma formation.

Which finding would the nurse expect when assessing a client who has right ventricular failure? 1. Slowed pulse rate 2. Pleural friction rub 3. Neck vein distention 4. Elevated temperature

3. Neck vein distention Neck vein distention is caused by hypervolemia and pulmonary hypertension. The pulse is likely to be rapid and bounding. Pleural friction rub occurs with inflammation of the pleura, but not with heart failure. Fever occurs with infectious or inflammatory problems, but not with heart failure.

**Which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker? 1. Shortness of breath 2. Substernal discomfort 3. Third-degree heart block 4. Premature ventricular contractions

3. Third-degree heart block The client in third-degree heart block will need a pacemaker to help support heart rate and cardiac output. Shortness of breath is not an indicator for pacemaker insertion. Substernal discomfort is not treated with pacing. Premature ventricular contractions are treated with medications, and a pacemaker is not indicated.

The nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess? 1. Proteinemia 2. Contractures 3. Tissue ischemia 4. Thrombus formation

3. Tissue ischemia Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia, and should be assessed first. Proteinemia and contractures are not complications resulting from long-term edema. Although thrombus formation may occur, the initial assessment is perfusion (tissue ischemia).

Which diagnostic test is most important to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome (ACS)? 1. Chest radiograph 2. Troponin T 3. Creatine kinase MB (CK-MB) 4. 12-lead ECG

4. 12-lead ECG With acute coronary syndrome, ECG changes indicating myocardial injury and infarction occur within minutes. Because treatment for ACS usually involves actions to restore blood flow to the myocardium as rapidly as possible, it is essential that the ECG be done and evaluated immediately. The other tests are also appropriate but will be done after the ECG. Changes in the chest radiograph will occur if there is cardiac enlargement, pericardial effusion, or heart failure secondary to myocardial infarction. Troponin T will increase in an average of 4 to 6 hours with myocardial infarction. CK-MB starts to increase at about 6 hours after myocardial infarction.

**The heartbeat assessment of four clients is given below. Which client is at an increased risk for right-sided heart failure? 1. Client A: RJVP- 2.5, LJVP- 3.0 2. Client B: RJVP- 2.0, LJVP- 1.5 3. Client C: RJVP- 1.5, LJVP- 1.0 4. Client D: RJVP- 3.0, LJVP- 1.0

4. Client D Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. This client is at risk for right-sided heart failure. One-sided pressure elevation is caused by obstruction, as observed in clients B, C, and D.

Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? 1. Obstructive 2. Neurogenic 3. Cardiogenic 4. Hypovolemic

4. Hypovolemic Hypovolemic shock occurs because of blood loss from the circulation when an abdominal aneurysm ruptures. Obstructive shock occurs from physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism. Neurogenic shock results from spinal cord or head injury, which cause vasodilation due to loss of sympathetic nervous system vasoconstrictor tone. Cardiogenic shock results from a decrease in cardiac output.

Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin? 1. Apical pulse rate 96 bpm 2. Bilateral foot and ankle pitting edema 3. Crackles heard at the base of both lungs 4. Potassium level of 2.3 mEq/L

4. Potassium level of 2.3 mEq/L Symptoms of digoxin toxicity, including life-threatening dysrhythmias, can occur when digoxin is administered to a client with hypokalemia. The nurse would hold the digoxin and notify the health care provider, anticipating that potassium supplements would be prescribed before administration of digoxin. An apical pulse of 96 beats per minute is at the upper end of normal and would not be a reason to hold digoxin. Lower extremity edema is a sign of heart failure, which would be improved with administration of digoxin. Crackles at the lung bases are common in clients with heart failure and not a reason to hold digoxin.

Test-taking tip

Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.