Med-surg Success Cardiac Disorders

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.

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. Wrong 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. TEST-TAKING HINT: In option "3," the word "no" is an absolute term, and usually absolutes, such as "no,""never,""always," and "only," are incorrect because there is no room for any other possible answer. If the test taker is looking for abnormal data, then the test taker should exclude the options that have normal values in them, such as eupnea, pulse rate of 90, and capillary refill time (CRT) <3 seconds.

26. The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1. This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain. Wrong 2. This is the explanation in medical terms that should not be used when explaining medical conditions to a client. 3. This explains congestive heart failure but does not explain why chest pain occurs. 4. Respiratory compromise occurs when the lungs cannot oxygenate the blood, such as occurs with altered level of consciousness, cyanosis, and increased respiratory rate.

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 the cardiac apex. 3. A midsystolic ejection click or murmur heard at the base. 4. A high-pitched sound heard at the third left intercostal space.

2. The murmur associated with mitral valve insufficiency is loud, highpitched, rumbling, and holosystolic (occurring throughout systole) and is heard best at the cardiac apex.

28. The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

2. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-thannormal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate. Wrong 1. This blood pressure is normal and the nurse would administer the medication. 3. A headache will not affect administering the medication to the client. 4. The potassium level is within normal limits, but it is usually not monitored prior to administering a beta blocker.

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.

2. Any abnormal electrical activity of the heart causes decreased cardiac output.

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.

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

56. The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.

2. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention.

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.

2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening. Wrong 1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. 3. This is a nursing intervention, not a short-term goal, for this client. 4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output. TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test taker must be sure that the answer selected addresses the problem. An answer option may be appropriate care for the disease process but may not fit with the problem or etiology. Remember, when given an etiology in a nursing diagnosis, the answer will be doing something about the problem (etiology). In this question the test taker should look for

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. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis.

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.

48. The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who 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 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).

2. Because this client is being discharged, it would be an appropriate assignment for the new graduate.

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 bedrest with bathroom privileges.

2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify.

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's syndrome. 3. An 80-year-old male with atrial fibrillation. 4. A 33-year-old female with Down syndrome.

2. Clients with Marfan's syndrome have life-threatening 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.

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

2. Diaphoresis (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. Wrong 1. Midepigastric pain would support a diagnosis of peptic ulcer disease; pyrosis is belching. 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.

29. Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication. Wrong 1. The nurse should always assess the apical (not radial) pulse, but the pulse is not affected by a loop diuretic. 3. The glucometer provides a glucose level, which is not affected by a loop diuretic. 4. The pulse oximeter reading evaluates peripheral oxygenation and is not affected by a loop diuretic.

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 the medication with food.

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. Wrong 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. 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.

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?"

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 people who develop it.

33. The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

2. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain). Wrong 33. 1. The client should take the coronary vasodilator nitroglycerin sublingually, but it is not the first intervention.3. The client should keep a diary of when angina occurs, what activity causes it, and how many nitroglycerin tablets are taken before chest pain is relieved. 4. If the chest pain (angina) is not relieved with three (3) nitroglycerin tablets, the client should call 911 or have someone take him to the emergency department. Notifying the HCP may take too long.

35. Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

2. The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid anyfried foods, especially meats, and bake, broil, or grill any meat. Wrong 1. According to the American Heart Association, the client should not eat more than three (3) eggs a week, especially the egg yolk.3. The client should drink low-fat milk, not whole milk. 4. Pork products (bacon, sausage, ham) are high in sodium, which is prohibited in a low-salt diet, not a low-cholesterol, lowfat diet. TEST-TAKING

3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions 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.

2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention. Wrong 3. 1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. 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 the client to take the diuretic in the morning to prevent nocturia. TEST-TAKING HINT: This is an alternativetype question—in this case, "select all that apply." If the test taker missed this statement, it is possible to jump at the first correct answer. This is one reason that it is imperative to read all options before deciding on the correct one(s). This could be a clue to reread the question for clarity. Another hint that this is an alternative question is the number of options. The other questions have four potential answers; this one has five. Numbers in an answer option are always important. Is one (1) enough pounds to indicate a problem that should be brought to the attention of the health-care provider? Content - Medical: Category of

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.

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. Wrong 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. 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.

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. Wrong The nurse should medicate the client as needed, but it is not the first intervention. 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.

27. The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position . 4. Assess the gag reflex prior to feeding the client.

2. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor. Wrong 27. 1. The client's right leg should be kept straight to prevent arterial bleeding from the femoral insertion site for the catheter used to perform the catheterization. 3. The head of the bed should be elevated no more than 10 degrees. The client should be kept on bedrest, flat with the affected extremity straight, to help decrease the chance of femoral artery bleeding. 4. The gag reflex is assessed if a scope is inserted down the trachea (bronchoscopy) or esophagus (endoscopy) because the throat is numbed when inserting the scope. A catheter is inserted in the femoral or brachial artery when performing a cardiac catheterization.

20. The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an 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.

20. 1. An S3 indicates left ventricular failure and should be reported to the healthcare provider. It is a potential lifethreatening complication of a myocardial infarction. Wrong 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. TEST-TAKING HINT:

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 bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

23. 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. Wrong 2. The nurse should talk to the client in layperson'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.

36. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

3. A new graduate should be able to complete a preprocedure checklist and get this client to the catheterization laboratory.

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.

3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain. Wrong 15. 1. The nurse must assume the chest pain is secondary to decreased oxygen to the myocardium and administer a sublingual nitroglycerin tablet, 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. 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.

19. The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary 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.

3. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot. Wrong 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. 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.

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.

3. Aspirin and nonsteroidal antiinflammatory 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.

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 ADLs without dyspnea. 4. The client has minimal jugular vein distention.

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. Wrong 5. 1. Pitting edema changing 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. 4. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment. TEST-TAKING HINT: When asked to determine whether treatment is effective, the test taker must know the signs and symptoms of the disease being treated. An improvement in the signs and symptoms indicates effective treatment.

17. The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.

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

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."

3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.

49. The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.

3. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the

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's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

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 Wrong 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.

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."

3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain.

31. The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

3. Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual activity. Wrong 31. 1. Bowel movements are important, but they are not pertinent to coronary artery disease. 2. Chest x-rays are usually done for respiratory problems, not for coronary artery disease. 4. Weight change is not significant in a client with coronary artery disease.

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 insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

3. The client is symptomatic and will require a pacemaker.

55. The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.

3. The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular fibrillation. If the client's heart is beating, the nurse would then administer lidocaine.

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.

3. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider.

50. The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation.

3. The nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol.

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

3. The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring. Wrong 1. Leg movement is an appropriate action, and the UAP 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. 4. The nurse should praise subordinates for appropriate behavior, especially when it is helping to prevent life-threatening complications.

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.

3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client. Wrong 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 is more in need of custodial nursing care than care from the most experienced registered nurse. Therefore, the charge nurse could assign a less experienced nurse to this client.4. These complaints usually indicate muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration.

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

3. Troponin is the enzyme that elevates within 1 to 2 hours. Wrong 1. CPK-MB elevates in 12 to 24 hours. 2. LDH elevates in 24 to 36 hours. 4. WBCs elevate as a result of necrotic tissue, but this is not a cardiac enzyme. TEST-TAKING HINT: The test taker should be aware of the words "cardiac enzyme," which would eliminate option "4" as a possible answer. The word in the stem is "first." This question requires the test taker to have knowledge of laboratory values.

32. The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40˚F. 4. Wear open-toed shoes when ambulating.

3. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside. Wrong 32. 1. Isometric exercises are weight lifting-type exercises. A client with CAD should perform isotonic exercises, which increase muscle tone, not isometric exercises. 2. The client should walk at least 30 minutes a day to increase collateral circulation. 4. The client should wear good supportive tennis shoes when ambulating, not sandals or other open-toed shoes.

30. Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

30. 1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. 2. Walking will help increase collateral circulation. 4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system. Wrong 3. Salt should be restricted in the diet of a client with hypertension, not coronary artery disease.

34. The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.

34. 1. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity. Wrong 2. The Holter monitor should not be removed for any reason. 3. All medications should be taken as prescribed. 4. The client should perform all activity as usual while wearing the Holter monitor so the HCP can get an accurate account of heart function during a 24-hour period.

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.

37. 1. Dyspnea on exertion (DOE) is typically the earliest manifestation of mitral valve stenosis. Wrong 2. Jugular vein distention (JVD) and 3+ pedal edema are signs/symptoms of right-sided heart failure and indicate worsening of the mitral valve stenosis. These signs wouldnot 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.

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.

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.

40. The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biological 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.

4. Biological 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.

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.

53. Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client.

4. If any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. Therefore, the nurse should shout "all clear."

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.

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.

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 10 years. 4. The client has a history of rheumatic heart disease.

4. Rheumatic heart disease is the most common cause of valvular heart disease.

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.

4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome. Wrong 3. Daily weighing monitors fluid volume status, not activity tolerance. 12. 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.

58. The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.

4. Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia. TEST-TAKING HINT: The test taker

9. The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 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.

4. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment. Wrong 9. 1. Allowing the 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 a UAP any nursing task that involves an unstable client. 3. The nurse cannot delegate teaching.

25. The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911. Wrong 1. If the tablets are not kept in a dark bottle, they will lose their potency. 2. The tablets should burn or sting when put under the tongue. 3. The client should keep the tablets with him in case of chest pain.

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.

4. The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out. Wrong Reduction of Risk Potential: Cognitive Level - Synthesis. 21. 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 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.

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 andcheck the pulse oximeter and then sponge the client's forehead. Wrong 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.

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.

41. 1. The therapeutic range for most clients' INR is 2 to 3, but for a client with a mechanical valve replacement it is 2 to 3.5. The medication should be given as ordered and not withheld.

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.

42. 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.

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."

45. 1. The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure.

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.

46. 1. Fluid intake may be restricted to reduce the cardiac workload and pressures within the heart and pulmonary circuit.

51. The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health-care provider to order for this client? 1. Lidocaine. 2. Atropine. 3. Digoxin. 4. Adenosine.

51. 1. Lidocaine suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias.

54. The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

54. 1. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.

57. The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

57. 1. Ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted. 3. Defibrillation is the treatment of choice for ventricular fibrillation. 4. The crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation. 5. Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias.

59. The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.

59. 1. The P wave represents atrial contraction, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.

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.

6. 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. Wrong 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. TEST-TAKING HINT: This question requires the test taker to discriminate between CHF, MI, and PE. If unsure of the answer

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.

62. 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.

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.

66. 1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade.

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.

70. 1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health.

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.

71. 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 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 pericardiocentesis.

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.

8. 1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. Wrong 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. TEST-TAKING HINT: Because the nurse will be assessing each client, the test taker must determine which client is a priority.