Med Surge Cardio Disorders

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? "A headache is an indication of an allergy to the medication." "A headache is an expected adverse effect of the medication." "A headache indicates tolerance to the medication." "A headache is likely due to the anxiety about the chest pain."

"A headache is an expected adverse effect of the medication." The vasodilation nitroglycerin induces increases blood flow to the head and typically results in a headache.

A nurse is caring for a client who had a myocardial infarction. Upon his first visit to the cardiac rehabilitation he tells the nurse that he doesn't understand why he needs to be there is nothing else to do as the damage has already been done. Which of the following is the correct nurse response? "Cardiac rehabilitation can not undo the damage of your heart but it can help you get back to your previous level of activity" "It's not unusual for you to feel that way at first but once you learn the routine, you'll enjoy it." "Exercise is good for you and good for your heart" "Your doctor is the expert here, and Im sure he would only recommend what is best for you"

"Cardiac rehabilitation can not undo the damage of your heart but it can help you get back to your previous level of activity" With this response, the nurse uses therapeutic communication technique of presenting reality by indicating her perception of the situation for the client

A nurse is teaching a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?

"Diuretics are the first type of medication to control hypertension" The nurse should include in the teaching that diuretic medication is the first type of medication to control hypertension by decreasing blood volume and lower blood pressure.

A nurse is providing teaching about a heart-healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching? "I may eat 10 ounces of lean protein each day." "Fresh fruits make a good snack option." "I will replace table salt with dried herbs." "I may thicken gravies with cornstarch as I cook."

"I may eat 10 punces of lean protein each day." Lean meats should be limited to 5 to 6 oz per day. This statement by a client requires additional teaching.

A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) 'I'must stop smoking." "I should limit my exercise." *I will stop consuming alcohol." 'I need to monitor my weight." "I am limiting my intake of fast foods." "I must stop smoking." is correct. Nicotine in tobacco causes peripheral vasoconstriction, which increases blood pressure, cardiac afterload, and oxygen consumption. Alterations in blood vessels contribute to atherosclerosis and the formation of clots. Smoking cessation can decrease the risk of coronary artery disease by as much as 80%. Clients also should avoid secondhand smoke. "I should limit my exercise." is incorrect. A sedentary lifestyle or lack of exercise can lead to obesity, which is a significant contributing factor to the development of hypertension and heart disease. Less active individuals have a 30-50% increased incidence of developing hypertension. Regular physical activity helps to maintain body weight, decrease the risk of hypertension, and optimize lipid levels. Physical activity and dietary modification have been positively associated with decreasing lipid and cholesterol levels. " will stop consuming alcohol." is incorrect. The client does not have to stop consuming alcohol. Consuming less than 3 oz per day can assist in decreasing the risk of coronary artery disease. However, consuming more than 3 oz per day has been associated with an increased risk of cardiac disease. "I need to monitor my weight." is correct. Obesity or an increase in weight is a significant factor in developing coronary artery disease. Weight management is vital to decreasing the risk of coronary artery disease. "I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease. An elevated cholesterol and serum lipid level predisposes a client to coronary artery disease. To promote cardiovascular health, clients should select healthier food options, such as fruits and vegetables, or foods prepared by baking or broiling.

"I must stop smoking." is correct. Nicotine in tobacco causes peripheral vasoconstriction, which increases blood pressure, cardiac afterload, and oxygen consumption. Alterations in blood vessels contribute to atherosclerosis and the formation of clots. Smoking cessation can decrease the risk of coronary artery disease by as much as 80%. Clients also should avoid secondhand smoke. "I should limit my exercise." is incorrect. A sedentary lifestyle or lack of exercise can lead to obesity, which is a significant contributing factor to the development of hypertension and heart disease. Less active individuals have a 30-50% increased incidence of developing hypertension. Regular physical activity helps to maintain body weight, decrease the risk of hypertension, and optimize lipid levels. Physical activity and dietary modification have been positively associated with decreasing lipid and cholesterol levels. " will stop consuming alcohol." is incorrect. The client does not have to stop consuming alcohol. Consuming less than 3 oz per day can assist in decreasing the risk of coronary artery disease. However, consuming more than 3 oz per day has been associated with an increased risk of cardiac disease. "I need to monitor my weight." is correct. Obesity or an increase in weight is a significant factor in developing coronary artery disease. Weight management is vital to decreasing the risk of coronary artery disease. "I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease. An elevated cholesterol and serum lipid level predisposes a client to coronary artery disease. To promote cardiovascular health, clients should select healthier food options, such as fruits and vegetables, or foods prepared by baking or broiling.

A nurse is performing an ECG on a patient complaining of chest pain. Which of the following statements should the nurse make? "You might feel a slight tingling while the test is being done" "The test will complete in 30 to 60 minutes" "I will apply electrodes to your chest and extremities" "The radioactivity from the dyes only lasts a few hours"

"I will apply electrodes to your chest and extremities" The nurse will apply the electrodes to the patient chest and extremities as these electrodes transmit electrical currents and allow for the recording of the heart's electrical activity

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 medications should the nurse identify as most important for the client's recovery? It decreases the client's level of anxiety. It facilitates the client's deep breathing. It enhances the client's ability to sleep. It reduces the client's blood pressure.

"It facilitates the client's deep breathing." When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client's has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain.

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication? "Take this medication after each meal and at bedtime." "Take one tablet every 15 min during an acute attack." "Take one tablet at the first indication of chest pain." "Take this medication with 8 ounces of water."

"Take one tablet at the first indication of chest pain." The client should take nitroglycerin as soon as he feels pain, pressure, or tightness in his chest and not wait until his chest pain is severe.

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make? "Perhaps you should discuss this with your physician" "Of course, you aren't going to die, at least not in the immediate future" "I recommend you exercise daily and avoid smoking" "Tell me more about these fears of dying from a heart attack"

"Tell me more about these fears of dying form a heart attack" With this response, the nurse uses the therapeutic communication technique of exploring to encourage further communication about the clients feelings.

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

"These tests help determine the degree of damage to the heart tissues." Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are PK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels.

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make? "Take only one dose of nitroglycerin to reduce the risk of getting a headache." "There's nothing that can be done to relieve the headaches that nitroglycerin causes." "Try taking a mild analgesic to relieve the headache." "We will ask the provider to prescribe a different medication for you."

"Try taking a mild analgesic to relieve the headache." Headache is a common side effect of nitroglycerin. The nurse should suggest conservative measures, such as taking aspirin, acetaminophen, or some other mild analgesic, to manage the headache. Generally, headaches that are a side effect of nitroglycerin are transient.

A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection? "You seem upset about taking your blood pressure medication." "Why do you feel afraid to take your medication?" "You won't get better until you take your medication?' "Did your symptoms occur before or after you took the medication?"

"You seem upset about taking your blood pressure medication." This statement is a reflective comment that describes the patient's feelings. A reflective comment repeats what a patient has said or describes the person's feelings.

A nurse on a medical unit is planning care for an older adult client who takes several medications. Which of the following prescribed medications places the client at risk for orthostatic hypotension? (Select all that apply.) Furosemide Telmisartan Duloxetine Clopidogrel Atorvastatin

- Furosemide is correct. This medication is used to reduce edema and hypertension, and an adverse effect is orthostatic hypotension. - Telmisartan is correct. This medication is used to control hypertension, and an adverse effect is orthostatic hypotension. - Duloxetine is correct. This medication is used to treat depression and anxiety disorder, and an adverse effect is orthostatic hypotension. - Clopidogrel is incorrect. This medication is used to reduce the risk of MI and stroke and does not cause orthostatic hypotension. - Atorvastatin is incorrect. This medication is used to decrease cholesterol and does not cause orthostatic hypotension.

Select the 5 findings that require immediate follow-up. Vital signs Respiratory assessment Renal function Cardiac enzymes BNP ECG results Neurologic status

- Vital signs is correct. The nurse should report the client's heart rate as elevated at 138/min. This finding indicates the client is experiencing atrial * fibrillation with rapid ventricular response (RV), which places them at a risk for further decompensation and stroke. If the client's blood pressure decreases further, the client could experience a systemic lack of perfusion. - Respiratory assessment is correct. The client is coughing pink-tinged sputum, which is an indication of pulmonary edema. The client is at risk of decompensation if the condition is not addressed promptly. - Renal function is correct. The BUN and creatinine levels are above the expected reference range, which inofcates possible impaired renal perfusion from weakened cardiac muscle contractions. - Cardiac enzymes is incorrect. The client's cardiac enzyme results are all within the expected reference range and indicate that the client has not experienced a myocardial infarction. BNP is correct. The client's BP is at a critical level, indicating worsening heart failure. - ECG results is correct. The ECG shows atrial fibrillation with RV which is a change in the client's medical condition. This places the client at a risk for further decompensation and stroke. - Neurologic status is incorrect. The client's current neurological status indicates no abnormalities that require immediate attention or reporting to the provider.

A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.) Hypotension Bradycardia Clubbing of the nail beds Weak pulses Murmur

-Hypotension is correct. Hypotension with aortic stenosis is a result of decreased cardiac output. -Bradycardia is incorrect. Children who have aortic stenosis have tachycardia, rather than bradycardia. -Clubbing of the nail beds is incorrect. Clubbing of the nail beds is a clinical manifestation of Tetralogy of Fallot, rather than aortic stenosis. -Weak pulses is correct. Weak pulses with aortic stenosis are a result of decreased cardiac output. -Murmur is correct. A narrowing of the aortic valve cause a characteristic murmur in children who have aortic stenosis.

A nurse is assessing four female clients for obesity. Which of the following clients have manifestations of obesity? A client who has a body fat of 22% A client who has a BMI of 28 A client who has a waist circumference of 81.3 cm (32 in) A client who weighs 28% above ideal body weight

A client who weighs 28% above ideal body weight For a female client, obesity is classified as a weight 20% greater than ideal weight. A client whose weight is 28% above ideal body weight is classified as obese.

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further? Diet-controlled Type 2 diabetes mellitus A history of left-sided heart failure A concurrent prescription for tadalafil Recently treated bilateral pneumonia

A history of left-sided heart failure The nurse should further investigate the client's history of heart failure. Although metoprolol can be used to treat heart failure, it can also cause heart failure, so this medication should be used with great caution with a client who has a history of heart failure. The nurse should teach the client to watch for signs of increasing left-sided heart failure, such as shortness of breath and weight gain indicating fluid retention, and report these findings to the provider.

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? Administer another nitroglycerin tablet. Initiate a peripheral IV. Call the Rapid Response Team. INCORRECT Obtain an ECG.

Administer another nitroglycerin tablet. Administration guidelines for sublingual nitroglycerin indicate that it is appropriate to administer another tablet 5 min after the first one if the client 15 still reporting pain

A client who has a history of MI is prescribed aspirin (325mg). The nurse recognizes that the aspirin is given due to which of the following actions of the medications. Analgesic Anti-inflammatory Antiplatelet aggregate antipyretic

Antiplatelet aggregate Aspirin is used to decrease the likelihood of blood clotting. It is also used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation reducing thrombus formation in an artery vein or heart.

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? Apply a new transdermal patch once a week. Apply the transdermal patch in the morning. Apply the transdermal patch in the same location as the previous patch. Apply a new transdermal patch when chest pain is experienced.

Apply the transdermal patch in the morning. CORRECT The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening.

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? Liver Milk Beans Eggs

Beans Any food that does not contain animal products does not contain cholesterol. Beans are a good source of protein for a client who follows a low-cholesterol diet.

A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication? Bradycardia Tremor Cough Constipation

Bradycardia Atenolol is a beta-blocker, which slows the heart rate. The nurse should instruct the client to monitor his pulse rate and report bradycardia.

A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action? (Select all that apply.) Oxygen saturation Temperature Blood pressure Urine output Weight Breath sounds

Breath sounds are correct. The client's breath sounds indicate pulmonary congestion. The nurse should report this finding to the provider and prepare to administer a diuretic to promote excretion of pulmonary fluid. Weight is correct. The client has gained 2.1 kg (5 lb) within 1 week indicating fluid retention. The nurse should report this finding to the provider and prepare to administer a diuretic to promote excretion of pulmonary fluid. Temperature is incorrect. The client's temperature is within the expected reference range. Therefore, this finding does not require follow-up. Urine output is incorrect. The client's urine output is greater than 30 mL/hr which indicates adequate perfusion to the kidnevs. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating decreased gas exchange and placing the client at risk for dysrhythmias. Blood pressure is correct. The client's blood pressure is significantly increased indicating the presence of fluid overload.

A nurse is caring for a client who has valvular heart disease and is at risk for developing left sided heart failure. Which if the following manifestations should alert hte nurse that the client is developing this condition? Anorexia Weight gain Breathlessness Distended Abdomen

Breathlessness Manifestation of left-sided heart failure includes crackles or wheezes and breathlessness due to pulmonary congestion

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? Check the client's vital signs Request a dietician consult Suggest the client rest before eating the meal Request an order for an antiemetic

Check the clients vital signs It is possible that the clients nausea is secondary to the digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of dig toxicity. The nurse should withhold the medication and contact the provider if the client's heart rate is less than 60bpm

A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? Apical pulse rate is different than the radial pulse rate Decrease in systolic pressure by more than 10 mm Hg during inspiration Increase in heart rate by 20% when moving from sitting to standing Drop in systolic BP by 20 mm Hg when changing positions

Decrease in systolic pressure by more than 10 mm Hg during inspiration The nurse should expect a client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or cardiac tamponade.

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? Different blood pressures in the upper limbs. Different apical and radial pulses. Differences between oral and axillary temperatures. Differences in upper and lower lung sounds.

Different apical and radial pulses. Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the atrium depolarizes too quickly and sends erratic impulses to the ventricles. The presence of a pulse deficit between the apical and radial pulses is an indication of atrial fibrillation. The nurse should assess further by obtaining an ECG or telemetry reading.

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider? Splinter hemorrhages to the nails Dyspnea Fever Clusters of petechiae in the mouth

Dyspnea The client who has infective endocarditis and develops dyspnea, tachycardia, or a cough might be developing heart failure or experiencing pulmonary emboli, two complications of the infection

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? Anorexia Dyspnea Fever Malaise

Dyspnea When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization.

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? Take aspirin if headaches develop. Eat foods that contain plenty of potassium. Expect some swelling in the hands and feet. Take the medication at bedtime.

Eat foods that contain plenty of potassium. Furosemide, a high-ceiling (loop) diuretic, can cause potassium loss. The client should add potassium-rich foods to his diet, such as nuts, dried fruits, bananas, and citrus fruits.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? Decreased brain natriuretic peptide (BNP). Elevated central venous pressure (CVP). Increased pulmonary artery wedge pressure (PAWP). Decreased specific gravity

Elevated central venous pressure (CVP). CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure.

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate? Withholding the medication if the heart rate is over 100bpm Instructing the client to eat foods that are low in potassium Measuring the apical rate for 30 seconds before administration Evaluating the client for nausea, vomiting, and anorexia

Evaluating the client for nausea, vomiting, and anorexia Loss of appetite, nausea, vomiting, and blurred vision or yellow vision may be signs of digoxin toxicity.

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? Exercise at least three times per week. Take diuretics early in the morning and before bedtime. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. Take naproxen for generalized discomfort.

Exercise at least three times per week. The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? The pain usually lasts longer than 20 min. The pain often radiates to the jaw or the back. The pain persists with rest and organic nitrates. Exertion and anxiety can trigger the pain.

Exertion and anxiety can trigger the pain. Exertion and anxiety can trigger the pain of angina, unless it is variant angina, which occurs at rest.

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? Pitting edema Fatigue Dyspnea Oliguria

Fatigue The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia.

A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin? Cranberry juice Aloe vera Feverfew Flaxseed

Feverfew The nurse should instruct the client to avoid taking feverfew with aspirin because it suppresses platelet aggregation and places the client at risk for bleeding when taken with aspirin.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? Frothy sputum Dependent edema Nocturnal polyuria Jugular distention

Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? Jugular venous distention Abdominal distension Dependent edema Hacking cough

Hacking cough A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? Asthma Aortic valve regurgitation Heart failure Aortic stenosis

Heart failure Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? Dry, hacking cough Hepatomegaly Dizziness Crackles in the lungs

Hepatomegaly liver enlargement is a manifestation of right sided heart failure

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) Genetic predisposition Hypercholesterolemia Hypertension Obesity Smoking

Hypercholesterolemia is correct. Cholesterol levels outside the healthful range increase clients' risk for heart disease, and they can change these levels. Hypertension is correct. Although it may not always be possible to eliminate hypertension, clients can change their blood pressure levels and thus reduce their risk for atherosclerosis. Obesity is correct. Clients who are overweight or obese can reduce their risk for heart disease by losing weight. Smoking is correct. Clients who smoke can reduce their risk for heart disease by quitting smoking.

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow up teaching on a low-cholesterol diet? I flavor my meat with a lemon juice I eat two eggs for breakfast each morning I cook my food with canola oil I take omega 2 supplements daily

I eat two eggs for breakfast each morning Clients should limit egg yolks to two to three per week

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? Attach the leads for a 12-lead ECG. Obtain a blood sample. Initiate oxygen therapy. Insert the IV catheter.

Initiate oxygen therapy. The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to administer oxygen to help minimize this possibility.

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk? Triglycerides 130 mg/dL Blood glucose 92 mg/dL LDL 172 mg/dL HDL 84 mg/dL

LDL 172 mg/dL The nurse should identify that an LDL of 172 mg/dL places the client at risk for peripheral arterial disease from atherosclerosis. The expected reference range for an adult is less than 130 mg/dL.

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? Offer the client a light snack. Measure the client's blood pressure. Measure the client's apical pulse. Weigh the client.

Measure the client's apical pulse. Digoxin decreases the heart rate, so the nurse should count the apical pulse for at least 1 min before administering. The nurse should hold the medication and notify the provider if the client's heart rate is below 60/min or if a change in heart rhythm is detected.

A nurse is teaching a client who has a new prescription for aspirin to prevent cardiovascular disease. Which of the following instructions should the nurse include in the teaching? Take the tablets on an empty stomach. Expect stools to turn black. Anticipate the tablets to smell like vinegar. Monitor for tinnitus.

Monitor for tinnitus. Tinnitus is a manifestation of salicylism, or aspirin toxicity. Other manifestations include sweating, headache, and dizziness.

A nurse in an emergency department is caring for a client who is having an acute myocardial infraction. The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? Nitroglycerin Aspirin Oxygen Morphine

Morphine morphine is the medication of choice for managing the pain and anxiety of an acute MI. By reducing preload and afterload, decreases the work of the heart.

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? Sudden lethargy. Muffled heart sounds Flattened neck veins. Bradycardia.

Muffled heart sounds Muffled heart sounds are a key indicator of cardiac tamponade because of the excess amount of fluid surrounding the heart.

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.) Orthopnea Headache Nausea Tachycardia Diaphoresis

Nausea Tachycardia Diaphoresis Orthopnea is incorrect. Orthopnea is a manifestation of heart failure, which can develop from an MI but is not a common manifestation of an acute MI. A client experiencing an MI typically manifests dyspnea. Headache is incorrect. Chest pain and sometimes jaw, back, and shoulder pain are manifestations of an acute MI. Nausea is correct. Nausea and vomiting are manifestations of an acute MI. Tachycardia is correct. Tachycardia and dvsrhythmias are manifestations of an acute MI. Tachycardia can also occur as a result of the client's anxiety. Diaphoresis is correct. Profuse sweating and anxiety are manifestations of an acute MI

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? High-density lipoprotein (HDL) level of 70 mg/dL A diet high in potassium Obstructive sleep apnea (OSA) Taking benazepril

Obstructive sleep apnea (OSA) The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? Suggest that the client use a salt substitute. Obtain a 12-lead ECG. Advise the client to add citrus juices and bananas to her diet. Obtain a blood sample for a serum sodium level.

Obtain a 12-lead ECG. This client's potassium level is above the expected reference range of 3.5-5.0 mE/L and is at risk for dysrhythmias as well as cardiac arrest. Therefore, the nurse should obtain a 12-lead ECG to monitor for cardiac changes.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? Obtain an EKG. Administer enteric-coated acetaminophen. Administer ibuprofen. Maintain oxygen saturations greater than or equal to 92%.

Obtain an EKG. The nurse should obtain an EKG to detect heart rhythm abnormalities within 10 min of the client's reported discomfort.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? Check the client's blood pressure. Auscultate heart tones Perform a 12-lead ECG Determine if the pain radiates to the left arm

Perform a 12-lead ECG The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? Wraps the blood pressure cuff snugly around the client's arm Places the client's arm above the level of the client's heart Checks the instrument gauge to ensure the reading starts at zero. Centers the cuff bladder over the client's brachial artery

Places the client's arm above the level of the client's heart The partner should place the client's arm at heart level to ensure accurate blood pressure readings.

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/84 mm Hg places him in which of the following categories? Within the expected reference range Prehypertension Stage 1 hypertension Stage 2 hypertension

Prehypertension A blood pressure of 124/84 mm Hg places this client in the prehypertension category. Prehypertension is indicated by a systolic pressure between 120 and 130 mm Hg and a diastolic pressure between 80 and 89 mm Hg

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? Hemoglobin (Hgb) Prothrombin time (PT) Bleeding time Activated partial thromboplastin time (aPTT)

Prothrombin time (PT) This test is used to monitor warfarin therapy. For a client receiving full anticoagulant therapy, the PT should typically be approximately two to three times the normal value, depending on the indication for therapeutic anticoagulation.

A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the following interventions is the nurse's priority? Provide the client with supplemental oxygen at 5 L/min via facemask. Place the client in high-Fowler's position with their legs in a dependent position. Give the client sublingual nitroglycerin. Administer morphine sulfate IV.

Provide the client with supplemental oxygen at 5 L/min via facemask. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to provide supplemental oxygen at 5 L/min via simple facemask to promote effective gas exchange and tissue perfusion and to prevent rebreathing of exhaled air. The client is exhibiting signs of respiratory distress, such as dyspnea at rest, crackles, and anxiousness. Therefore, this is the nurse's priority intervention because it would helps manage hypoxia related to pulmonary edema.

A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report? Dry Cough Swelling of the tongue Nausea Nasal Congestion

Swelling of the tongue When using the urgent vs non-urgent approach to client care the nurse determines that the priority finding is the swelling of the tongue which is a manifestation of angioedema. the nurse should withhold the medication and notify the provider immediately if the client reports swelling of the tongue or throat. Other manifestations include giant wheals and edema of the tongue, glottis, and pharynx.

A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide? Weigh weekly to monitor therapeutic effect. Take the medication on an empty stomach. Take the medication early in the day. Muscle pain is an expected adverse effect.

Take the medication early in the day. The nurse should instruct the client to take hydrochlorothiazide early in the day to avoid nocturia.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? The client will list foods that are high in calcium, which should be avoided. The client will walk for 30 min 5 days a week. The client will increase calorie intake by 200 cal per day. The client will replace cigarettes with smokeless tobacco products.

The client will walk for 30 min 5 days a week. CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe? Troponin Creatinine kinase (CK) Brain natriuretic peptide (BNP) C-reactive protein

Troponin Troponin is released by the myocardial muscle when injury occurs. Troponin is not present in the body at any other time, making it very specific to cardiac injury. Troponin levels in the blood can rise within 2 to 3 hr of the onset of an MI. This allows for a quick diagnosis and is the gold standard when treating client's who have suspected MI.

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

Troponin I Cardiac troponin I and cardiac troponin T are biochemical markers that are specific to myocardial cell injury. A client who has myocardial cell damage can have elevated troponin levels within 2 to 3 hr. Cardiac troponin I levels can peak in 10 to 24 hr and stay elevated for 7 to 10 days. Cardiac troponin T levels can peak within 10 to 24 hr stay elevated for 10 to 14 days.

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? Troponin I Lipase B-type natriuretic peptide (BNP) Aspartate aminotransferase (AST)

Troponin I The troponins (I and T) are proteins that only exist in cardiac muscle and enter the bloodstream within a few hours of myocardial injury. They are the most specific indicator of myocardial damage.

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 myocardial infarction? (Select all that apply.) Troponin I Troponin T Plasma low-density lipoproteins (LDL) СРК Myoglobin

Troponin I is correct. Troponin I is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. Troponin T is correct. Troponin T is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. CPK is correct. CPK. or creatine phosphokinase, is an enzyme that is elevated in the presence of muscle injury. Although CP is not specific for myocardial damage, it is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A CPK isoenzyme, CK-MB, is specific to cardiac muscle and a significant elevation in this isoenzyme indicates a myocardial infarction has occurred Myoglobin is correct. Elevation of myoglobin indicates myocardial injury. Myoglobin levels will significantly increase within approximately 3 hours following myocardial infarction. This test is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? Troponin is an enzyme that indicates damage to brain, heart, and skeletal Troponin is a lipid whose levels reflect the risk for coronary artery disease Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a protein that helps transport oxygen throughout the body.

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. ~ CORRECT My Answer Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.