NCLEX - PN Review - CARDIOVASCULAR

the nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL of 5% dextrose with 40 mEq of potassium chloride. which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? a) tall, peaked T waves b) ST segment depressions c) shortened P-R intervals d) shortening of the QRS complex

a) tall, peaked T waves rationale the symptoms of hyperkalemia relate to its effect on the myocardial muscle. these include changes noted on the ECG, such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia.

the nurse is monitoring a client following cardioversion. which observation should be of highest priority to the nurse? a) blood pressure b) status of airway c) oxygen flow rate d) level of consciousness

b) status of airway rationale nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysryhthmia detection. airway is the priority.

the nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for CAD. the nurse should determine the teaching is successful if the client states that which weight loss goal is safe? a) one half pound per day b) two pounds per week c) four pounds per week d) six pounds per week

b) two pounds per week rationale most people, including the mildly and moderately obese, can lose only about 2 pounds per week of weight from fat loss. weight loss beyond that level is probably due to protein and water loss alone

the nurse is monitoring a client with an abdominal aortic aneurysm (AAA). which finding is probably unrelated to the AAA? a) pulsatile abdominal mass b) hyperactive bowel sounds in the area c) systolic bruit over the area of the mass d) subjective sensation of "heart beating" in the abdomen

b) hyperactive bowel sounds in the area rationale not all clients with AAA exhibit symptoms. those who do may describe a feeling of the "heart beating" in the abdomen when supine, or being able to feel the mass throbbing. a pulsatile mass may be palpated in the middle and upper abdomen. a systolic bruit may be auscultated over the mass. hyperactive bowel sounds are not specifically related to an abdominal aortic aneurysm

a client has just completed an information session about measures to minimize the progression of CAD. which statement indicates an initial understanding of lifestyle alterations? a) i should take daily medication for life b) i should eat a diet that is low in fat and cholesterol c) i should continue to smoke to keep the metabolic rate high d) i should begin to exercise if diet is not sufficient to achieve weight loss

b) i should eat a diet that is low in fat and cholesterol rationale a diet that is low in fat and cholesterol helps slow the progression of CAD. this must be accompanied by regular exercise and cessation of smoking. if these measures are effective, the client may not need daily medications.

a client has experienced an episode of pulmonary edema. the nurse determines that the client's respiratory status is improving if which breath sounds are noted? a) rhonchi b) wheezes c) crackles in the lung bases d) crackles throughout the lung fields

c) crackles in the lung bases rationale pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy pink-tinged sputum. auscultation of the lungs reveals crackles throughout the lung fields. as the client's condition improves, the amount of fluid in the alveoli decreases and may be detected by crackles in the bases (clear lung sounds would indicate full resolution of the episode) wheezes and rhonchi are not associated with pulmonary edema.

the nurse is assisting a hospitalized client who is newly diagnosed with CAD to make appropriate selections from the dietary menu. the nurse encourages the client to select which meal? a) sausage, pancakes, and toast b) broccoli, buttered rice, and grilled chicken c) hamburger, baked apples and avocado salad d) fresh strawberries, steamed vegetables and baked fish

d) fresh strawberries, steamed vegetables and baked fish rationale diets high in saturated fats raise the serum lipid level, which, in turn, raises the blood cholesterol. over time, high blood cholesterol levels lead to the development of atherosclerosis and diseases such as coronary artery disease. a diet that is low in saturated fats is helpful in reducing the progression of atherosclerosis. meats and dairy products tend to be higher in fat than other food groups

a client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. as the client stands and begins to walk, the client begins to complain of chest pain. the nurse should take which action? a) assist the client to get back into bed b) report the chest pain episode to the HCP c) tell the client to stand still and take the client's blood pressure d) give a nitroglycerin tablet, and assist the client to the bathroom

a) assist the client to get back into bed rationale the client is assisted back to bed to put the client at rest. the nurse can then measure vital signs and administer nitroglycerin that is prescribed for as-needed (PRN) use. the nurse should then report the chest pain episode to the HCP. the nurse should not continue to assist the client into the bathroom because it places the client in danger because of continued myocardial oxygen demands.

a client has received instructions about an upcoming cardiac catheterization. the nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? a) chest pain b) urge to cough c) warm, flushed feeling d) pressure at the insertion site

a) chest pain rationale the client is taught before cardiac catheterization to immediately report chest pain or any unusual sensations. the client is taught that a warm, flushed feeling may accompany dye injection, occasional palpitations may occur, and the urge to cough may occur as the catheter tip touches the cardiac muscle. the client may be asked to cough or breathe deeply from time to time during the procedure. because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site

the nurse is providing discharge teaching for post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. the nurse determines that the client understands the use of this medication if the client makes which statement? a) i will take this medication every day b) i will take this medication every other day c) i will take this medication until i feel better d) i will take this medication only when i have pain

a) i will take this medication every day rationale a single daily dose of 1 baby aspirin (low-dose aspirin) may be a component of the standard treatment regimen for the client after an MI. Aspirin helps prevent clotting and may prevent a thrombosis that could cause a second MI. if the client cannot tolerate aspirin, then another antiplatelet medication may be prescribed. the other three options are unacceptable because the benefit comes in taking the medication on a daily basis.

the nurse determines that a client with CAD understands disease management if the client makes which statement? a) i will walk for one-half hour daily b) as long as i exercise i can eat anything i wish c) my weight has nothing to do with this disease d) it doesn't matter if my father had high cholesterol

a) i will walk for one-half hour daily rationale lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. the second and fourth options are incorrect because obesity and a diet high in fat can contribute to CAD. the last option is incorrect because genetic factors also contribute to CAD.

a client with infective endocarditis is at risk for heart failure. the nurse monitors the client for which signs and symptoms of heart failure? a) lung crackles, peripheral edema, and weight gain b) confusion, decreasing LOC, and aphasia c) respiratory distress, chest pain, and the use of accessory muscles d) flank pain with radiation to the groin, accompanied by hematuria

a) lung crackles, peripheral edema, and weight gain rationale the client with infective endocarditis may experience both left- and right-sided heart failure, and thus the nurse monitors the client for both pulmonary and peripheral symptoms, such as lung crackles, peripheral edema, and weight gain. the second and last option relate to disorders of the brain and kidney, respectively. the third option contains symptoms that occur with pulmonary embolism, which is not related to the subject of the question.

the nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. the nurse should do which intervention to effectively accomplish this goal? a) provide a quiet and low-stimulus environment b) encourage the family to come visit very frequently c) encourage the client to call friends and relatives each day d) recommend that the client watch TV as a constant diversion

a) provide a quiet and low-stimulus environment rationale chest pain can be minimized by a quiet, low-stimulus environment, which reduces factors that trigger chest pain, such as emotional excitement. each of the other options increases the amount of client stimulation, which increases the risk of an anginal episode

a student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (lanoxin) and heparin therapy. the nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? a) restricting the clients potassium intake b) encouraging the client to rest after meals c) administering the heparin with a 25-gauge needle d) holding the digoxin for a heart rate less than 60 bpm

a) restricting the clients potassium intake rationale clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. restricting potassium makes the client more prone to digoxin toxicity. digoxin should be held and the HCP notified when the clients heart rate is less than 60 bpm, unless otherwise prescribed. heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. resting after meals decreases the demands placed on the heart and should be encouraged

the nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. based on this finding, the nurse should implement which action? a) reviews the intake and output records for the last 2 days b) prescribes daily weights starting on the following morning c) changes the time of diuretic administration from morning to evening d) requests a sodium restriction of 1 g/day from the HCP

a) reviews the intake and output records for the last 2 days rationale edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg) to determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days. diuretics should be given in the morning whenever possible to avoid nocturia. strict sodium restrictions are reserved for clients with severe symptoms.

the nurse is asked to assist another health care member in providing care to a client who is placed in a modified trendelendburg's position. the nurse interprets that the client is likely being treated for which condition? a) shock b) kidney dysfunction c) respiratory insufficiency d) increased intracranial pressure

a) shock rationale a client in shock is placed in a modified trendelenburg's position that includes elevating the legs, leaving the trunk flat and slightly elevating the head and shoulders. this position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, which is vital to the treatment of shock. the remaining conditions would not benefit from and, in some cases, would worsen because of this position.

the nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. the nurse ensures that which priority item is available for emergency use? a) surgical tourniquet b) dry sterile dressings c) incentive spirometer d) over-the-bed trapeze

a) surgical tourniquet rationale monitoring for complications is an important aspect of initial postoperative care. vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. the wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. therefore, a surgical tourniquet needs to be readily available in case of acute bleeding. an over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. an incentive spirometer and dry sterile dressings also should be available, but these are not priority items.

a client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the HCP is going to perform carotid massage. the nurse responds that this procedure may stimulate which? a) vagus nerve to slow the heart rate b) vagus nerve to increase the heart rate c) diaphragmatic nerve to slow the heart rate d) diaphragmatic nerve to increase the heart rate

a) vagus nerve to slow the heart rate rationale carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysryhthmia. the other maneuvers are the valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.

a postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dl and a serum creatinine level of 2.2 mg/dl has a total 2-hour urine output of 25 ml. the nurse understands that the client is at risk for which? a) hypovolemia b) acute kidney injury c) glomerulonephritis d) urinary tract infection

b) acute kidney injury rationale the client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels. the client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.

a hospitalized client with a history of angina pectoris is ambulating in the corridor. the client suddenly complains of severe substernal chest pain. the nurse should take which action first? a) check the client's vital signs b) assist the client to sit or lie down c) administer sublingual nitroglycerin d) apply nasal oxygen at a rate of 2 L/min

b) assist the client to sit or lie down rationale chest pain is caused by an imbalance between myocardial oxygen supply and demand. during episodes of pain, the nurse first limits the clients activity and assists the client to a position of comfort, checks the vital signs, administers oxygen and medication according to protocol, and obtains a 12-lead electrocardiogram.

the nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. the nurse should stress to the client the importance of taking which measure? a) saving all chores for the end of the day b) avoiding exposure to either very hot or very cold weather c) eating large meals to reduce the work of the gastrointestinal tract d) keeping items stored above shoulder level to encourage exercise

b) avoiding exposure to either very hot or very cold weather rationale the client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. the client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. the client should eat smaller meals so less blood flow is diverted for the work of digestion. exercise is important, but the client should keep most items stored at the heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output

the nurse is planning a dietary menu for a client with heart failure being treated with digoxin (lanoxin) and furosemide (lasix) which should be the best dinner choice from the daily menu? a) beef ravioli; spinach souffle, and italian bread b) baked pollock, mashed potatoes, and carrot-raisin salad c) roasted chicken breast, brown rice, and stewed tomatoes d) beef vegetable soup, macaroni and cheese, and a dinner roll

b) baked pollock, mashed potatoes and carrot-raisin salad rationale furosemide depletes potassium, and a client on digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. hypokalemia may make the client more susceptible to digoxin toxicity. the recommended daily intake for potassium is 2000 mg. the last option is not the best choice because beef vegetable soup contains a high amount of sodium and a minimal amount of potassium. macaroni and cheese is also high in sodium and contains no potassium. the first option is not the best choice because beef ravioli is high in sodium and contains no potassium. spinach souffle is a good source of potassium but also contains sodium. the third option is not the best choice because roasted chicken breast, brown rice, and stewed tomatoes contain a minimal amount of potassium. the second option is the best choice because all three foods are high in potassium and low in sodium.

a client with myocardial infarction (MI) has been transferred from the CCU to the general medical unit with cardiac monitoring via telemetry. the nurse assisting in caring for the client expects to note which type of activity prescribed? a) strict bed rest for 24 hours b) bathroom privileges and self-care activities c) unrestricted activities because the client is monitored d) unsupervised hallway ambulation with distances less than 200 feet

b) bathroom privileges and self-care activities rationale upon transfer from the CCU, the client is allowed self-care activities and bathroom privileges. supervised ambulation in the hall for brief distances is encouraged with distances gradually increased (50, 100, 200 feet)

a client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. the nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? a) rhonchi b) crackles c) wheezes d) diminished breath sounds

b) crackles rationale pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. auscultation of the lungs reveals crackles. wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

an emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. the client states "i don't need that -- my dad takes that for his heart. there's nothing wrong with my heart." which description best describes the client's response? a) anger b) denial c) phobic d) obsessive-complusive

b) denial rationale denial is the most common reaction when a client has a myocardial infarction or anginal pain. no angry behavior was identified in the question. phobias and obsessive-compulsive disorders are mental health diagnoses

a client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. the nurse's response is based on which fact? a) most people love high-fat diets b) denial is a common occurrence early after MI c) the client probably wants to belittle the opinion of the staff d) the client is not motivated to learn about heart disease at this time.

b) denial is a common occurrence early after MI rationale an early initial coping response following MI is denial. the nurse uses this knowledge of this common response in planning care for the client. the first option is an opinion and not based on information in the question. there is no evidence in the question to support the last two options.

the nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. which nursing intervention should be included in the post-procedure plan of care? a) place the client's bed in the Fowler's position b) encourage the client to increase fluid intake c) instruct the client to perform range-of-motion exercises of the extremities d) hold regularly scheduled medications for 24 hours following the procedure

b) encourage the client increase fluid intake rationale immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. placing the client in the Fowler's position increases the risk of hemorrhage. fluids are encouraged to assist in removing the contrast medium from the body. asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. the regularly scheduled medication are needed to treat acute and chronic conditions

the nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of CAD. the client reveals having been under a great deal of stress recently. which should the nurse do next? a) ask whether the client wants to see a psychiatrist b) explore with the client the sources of stress in life c) reassure the client that everybody seems stressed these days d) ask the client to write down a list of stressors to be evaluated at a later time

b) explore with the client the sources of stress in life rationale the nurse should encourage the client to explore and verbalize stressors. later, the nurse can teach the client strategies for coping with stress, such as the basic relaxation techniques of deep breathing, progressive muscle relaxation, and visualization. the first option could be construed as excessive or insulting and puts the client's feelings on hold. the third option ignores the client's concerns. the fourth option places further data collection of this area on hold.

a client with known CAD begins to experience chest pain while getting out of bed. the nurse should take which action? a) get a prescription for pain medication b) have the client stop and lie back in bed c) report the complaint to the HCP d) have the client continue to get out of bed and into a chair

b) have the client stop and lie back down in bed rationale the pain associated with CAD is called angina pectoris, and it occurs because of myocardial tissue ischemia from insufficient blood flow to the heart. the nurse should first have the client stop the activity and lie back down to decrease the workload and oxygen demand on the heart. the first and third can be done after ensuring that the client is resting. the pain medication that is likely to be prescribed is nitroglycerin, which is a coronary vasodilator. the last option is contraindicated and will worsen the pain and possibly lead to myocardial infarction.

the nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. which statement by the client indicates an understanding of this information? a) i need to avoid pregnancy by taking oral contraceptives b) i should avoid sitting in one position for long periods of time c) i can finally stop wearing these support stockings that you gave me d) i will be sure to maintain my fluid intake to at least four glasses daily

b) i should avoid sitting in one position for long periods of time rationale avoidance of sitting or standing of a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. support stockings are used to promote venous return, to maintain normal coagulability, and to prevent injury to the endothelial wall. adequate hydration is maintained to prevent hypercoagulability, and four glasses daily are an inadequate amount of fluid.

the nurse determines that a client with CAD needs further teaching about disease management if the client makes which statement? a) i will watch my weight gain b) i will avoid walking for exercise c) i will monitor my cholesterol intake d) i will follow a low-fat, low-salt diet

b) i will avoid walking for exercise rationale lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. walking should be encouraged for 30 minutes a day. watching weight gain, monitoring cholesterol and following a low-fat, low-salt diet are accurate statements

the nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. which statement by the client indicates a need for further teaching? a) i will avoid using table salt with meals b) it is best to exercise once a week for an hour c) i will take nitroglycerin whenever chest discomfort begins d) i will use muscle relaxation to cope with stressful situations

b) it is best to exercise once a week for an hour rationale exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. other healthy habits include limiting salt and fat in the diet and using stress management techniques. the client also should be taught to take nitroglycerin before any activity that causes pain, and to take the medication at the first sign of chest discomfort.

the nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. the nurse prevents dislodgement of the pacing catheter by implementing which intervention? a) limiting movement and abduction of the left arm b) limiting movement and abduction of the right arm c) assisting the client to get out of bed and ambulate with a walker d) having the physical therapist do active range of motion to the right arm

b) limiting movement and abduction of the right arm rationale in the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is placing electrode dislodgment. the nurse helps prevent this complication by limiting the client's activities

the nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). which are characteristics of a therapeutic environment? a) no stimulus, no stress b) low stimulus, low stress c) high stimulus, low stress d) moderate stimulus, low stress

b) low stimulus, low stress rationale an environment that is low stimulus and low stress is needed to decrease anxiety and metabolic demands for the client after MI. nursing care is directed at promoting rest and assisting with ADLs. the first option cannot be provided, and the last two options are too high stimulus to be therapeutic.

the nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. the nurse determines that the client needs further teaching if the client states which? a) smoking cessation is very important b) moving to a warmer climate should help c) sources of caffeine should be eliminated from the diet d) taking nifedipine (Procardia) as prescribed will decrease vessel spasm

b) moving to a warmer climate should help rationale Raynaud's disease responds favorably to the elimination of nicotine and caffeine. medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. avoiding exposure to cold through a variety of means is very important. however, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather

the nurse is checking the neurovascular status of a client the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoillac bypass graft. the affected leg is warm, and the nurse notes redness and edema. the pedal pulse is palpable and unchanged from admission. the nurse interprets that the neurovascular status is which? a) moderately impaired, and the surgeon should be called b) normal, caused by increased blood flow through the leg c) slightly deteriorating, and should be monitored for another hour d) adequate from an arterial approach, but venous complications are arising

b) normal, caused by increased blood flow through the leg rationale an expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. the other options are incorrect.

a client is admitted to the hospital with a diagnosis of pericarditis. the nurse reviews the clients record for which sign and symptom that differentiates pericarditis from other cardiopulmonary problems? a) anterior chest pain b) pericardial friction rub c) weakness and irritability d) chest pain that worsens on inspiration

b) pericardial friction rub rationale a pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. anterior chest pain may be experienced with angina pectoris and myocardial infarction. weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders

the nurse is caring for a client who is developing pulmonary edema. the client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. as an immediate action before help arrives, the nurse should perform which action? a) suction the client vigorously b) place the client in high-Fowler's position c) begin assembling medications that are anticipated to be given d) call the respiratory therapy department to request a ventilator

b) place the client in high-Fowler's position rationale the client in pulmonary edema is placed in high-Fowler's position if the blood pressure is adequate. Vigorous suctioning may deplete the client of vital oxygen at a time when the respiratory system is compromised. assembling medications is useful but not critical to the immediate well-being of the client. the client may or may not need mechanical ventilation.

an older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. the nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea and syncopal episodes. the nurse plans to take which important action? a) monitor oxygen saturation levels b) place the client on a cardiac monitor c) measure blood pressure every 4 hours d) check capillary refill at least once per shift

b) place the client on a cardiac monitor rationale the client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. other cardiovascular data should be collected at least every 2 hours initially.

a client in pulmonary edema has a prescription to receive morphine sulfate intravenously. the LPN assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? a) increased pulse rate b) relief of apprehension c) decreased urine output d) increased blood pressure

b) relief of apprehension rationale morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. it also promotes peripheral vasodilation and causes blood to pool in the periphery. it decreases pulmonary capillary pressures, which reduces fluid migration into the alveoli. the client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when administered intravenously. the other options are unrelated to the action of morphine sulfate.

the nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. which educational outcome has the greatest impact on the client's long-term cardiac health? a) knowledge of when it is safe to resume sexual activity b) the ability to take an accurate pulse in either the wrist or neck c) an understanding of the importance of proper microwave oven usage d) an understanding of why vigorous arm and shoulder movement must be avoided intitially

b) the ability to take an accurate pulse in either the wrist or neck rationale the clients with permanent pacemakers must be able to accurately take their pulse in the wrist and/or neck. the client needs to identify any variation in the pulse rate or rhythm and immediately report the variation to the HCP. clients can safely operate microwave ovens, radios, electric blankets, lawn mowers, leaf blowers, and cars. sexual activity is not resumed until 6 weeks after surgery. the arms and shoulders should not be moved vigorously for 6 weeks after insertion. the remaining options do not have the same impact on long-term cardiac health as does the correct option.

a client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. on further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. how should the nurse best describe this type of anginal pain? a) stable angina b) variant angina c) unstable angina d) nonanginal pain

b) variant angina rationale variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. the data in the question is characteristic of a type of angina pain, and therefore, nonanginal pain is incorrect.

a client returns to the nursing unit after an above knee amputation of the right leg. in which position should the nurse place the client? a) prone with the head on a pillow b) with the foot of the bed elevated c) reverse trendelenburg's position d) with the residual limb flat on the bed

b) with the foot of the bed elevated rationale during the first 24 hours after amputation, the nurse elevates the foot of the bed ( but not the residual limb itself) to reduce edema. after the first 24 hours, the bed itself is kept flat to prevent hip flexion contractures. the HCP's postoperative prescriptions regarding positioning are always followed.

a client who has undergone femoropopliteal bypass grafting says to the nurse, "i hope i don't have any more problems that could make me lose my leg." i'm so afraid that i'll have gone through this for nothing." which is an appropriate nursing response? a) there is nothing to worry about b) you are concerned about losing your leg? c) there are many people with the same problem, and they are doing just fine d) you have the best HCP in the city, and your HCP will not let anything happen to you

b) you are concerned about losing your leg? rationale the appropriate response is the one that uses the therapeutic technique of restatement. the second option restates the client's concern and provides an opportunity for the client to further discuss the concern. the other options are inappropriate because they provide false reassurance and do not address the client's concern.

an adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. the nurse calls the HCP to verify a prescription for which medication that the client was taking before admission? a) NPH insulin b) regular insulin c) chlorpropamide d) acarbose (precose)

c) chlorpropamide rationale chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. it is a first-generation sulfonylurea. insulin does not cause or aggravate fluid retention. acarbose is a miscellaneous oral hypoglycemic agent.

the nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. the client is receiving oxygen via nasal cannula at 2 L. the client asks the nurse why the oxygen is necessary. the nurse bases the response on which information? a) oxygen assists in calming the client b) oxygen prevents the development of any thrombus formation c) deficient oxygenation to heart cells results in angina pectoris pain d) oxygen dilates the blood vessels, supplying more nutrients to the heart muscle

c) deficient oxygenation to heart cells results in angina pectoris pain rationale the pain associated with angina is derived from ischemic myocardial cells. the pain is often with activity that places more oxygen demand on heart muscle. supplemental oxygen helps meet the added demands on the heart muscle. oxygen does not dilate blood vessels, prevent thrombus formation, or directly calm the client.

the nurse is collecting data on a client with a diagnosis of right-sided heart failure. the nurse should expect to note which specific characteristic of this condition? a) dyspnea b) hacking cough c) dependent edema d) crackles on lung auscultation

c) dependent edema rationale right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. edema develops in the lower legs and ascends to the thighs and abdominal wall. other characteristics include jugular congestion, enlarged liver and spleen, anorexia and nausea, polyuria at night, and weight gain. left-sided heart failure produces pulmonary signs. these include dyspnea, crackles on lung auscultation, and a hacking cough.

an ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. the client suddenly develops chest pain. which question best assists the nurse to discriminate pain caused by a noncardiac problem? a) can you describe the pain to me b) have you ever had this pain before c) does the pain get worse when you breathe in d) can you rate the pain on a scale of 1 to 10, with 1- being the worst

c) does the pain get worse when you breathe in rationale chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). describing the pain, asking if it has occurred in the past, and rating the pain using a pain scale may or may not help determine the origin of pain. pain of pleuropulmonary origin usually worsens on inspiration

a client who experienced a MI tells the nurse that he is fearful about not being able to return to a normal life. which action by the nurse is therapeutic at this time? a) tell the client that his fears are not rational b) tell the client that his life has not changed c) explore the specific concerns with the client d) tell the client to talk it out with the significant other

c) explore the specific concerns with the client rationale the therapeutic action by the nurse is one that gathers more data. this then allows the nurse to formulate the appropriate response. each of the incorrect options is nontherapeutic because they place the client's feelings on hold and do not address them.

the nurse has reinforced dietary instructions to a client with coronary artery disease. which statement by the client indicates an understanding of the dietary instructions? a) i need to substitute eggs and milk for meat b) i will eliminate all cholesterol and fat from my diet c) i should routinely use polyunsaturated oils in my diet d) i need to seriously consider becoming a strict vegetarian

c) i should routinely use polyunsaturated oils in my diet rationale the client with CAD should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. these foods contribute to increases in low-density lipoproteins. the use of polyunsaturated oils is recommended to control hyperlipidemia. it is not necessary to eliminate all cholesterol and fat from the diet. it is not necessary to become a strict vegetarian.

the client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. the nurse takes which action before surgery to address this risk? a) having the client void before surgery b) completing a preoperative checklist c) marking the location of the pedal pulses on the right leg d) checking the results of any baseline coagulation studies

c) marking the location of the pedal pulses on the right leg rationale a problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. it is important to mark the location of any pulses that are palpated or auscultated. this provides a baseline for comparison in the postoperative period the other options are part of routine preoperative care.

the nurse is caring for a client diagnosed with Buerger's disease. which finding should the nurse determine is a potential complication associated with this disease? a) pain with diaphoresis b) discomfort in one digit c) numbness and tingling in the legs d) cramping in the foot while resting

c) numbness and tingling in the legs rationale Buerger's disease (thromboangitis obliterans) which affects men between 20 and 40 years of age, has an unknown etiology. it is a recurring inflammation of the small and medium sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. the other options are not complications of this disorder. the finding that can be interpreted as a complication of the disorder is numbness and tingling in the legs

the nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of CAD. the nurse should place highest priority on making sure that which is available at the bedside? a) bedside commode b) rolling shower chair c) oxygen tubing and flowmeter d) 12 lead ECG machine

c) oxygen tubing and flowmeter rationale CAD causes obstruction to blood flow through one or more major coronary arteries, cutting off oxygen and nutrients to the cardiac cells, and resulting in chest pain. providing oxygen to the client is important to help decrease pain and prevent its recurrence. a bedside commode and ECG machine may be helpful but are not the priority. a rolling shower chair has no value for this client because the client should be able to talk and shower if pain free and an activity prescription allows it

the LPN is assisting in caring for a client with a diagnosis of myocardial infarction (MI). the client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. the RN administers morphine sulfate to the client as prescribed by the HCP. following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? a) mental status b) urinary output c) respirations and blood pressure d) temperature and blood pressure

c) respirations and blood pressure rationale morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client who experienced an MI. although monitoring mental status is a component of the nurses's assessment, it is not the priority following administration of morphine sulfate. the nurse should monitor the client's respirations and blood pressure. signs of morphine toxicity include respiratory depression and hypotension. urinary output is unrelated to the administration of this medication. monitoring the temperature is also not associated with the use of this medication.

while the nurse is involved in preparing a client for a cardiac catheterization, the client says, "i don't want to talk with you. you're only the nurse. i want my doctor." which response by the nurse should be therapeutic? a) your doctor expects me to prepare you for this procedure b) that's fine, if that's what you want.. i'll call your HCP c) so you're saying that you want to talk to your HCP? d) i'm concerned with the way you've dismissed me. i know what i am doing

c) so you're saying that you want to talk to your HCP rationale in the this option, the nurse uses the therapeutic communication technique of reflection to redirect the client's feelings back for validation. the first option is nontherapeutic and addresses the legal issue of performing a procedure when in fact the client is refusing. although the second option may seem appropriate, it does not reflect the client's feelings to express feelings. the last option is clearly nontherapeutic because it focuses on the nurse's feelings rather than the client's feelings

a client is admitted to the hospital with possible rheumatic endocarditis. the nurse should check for a history of which type of infection? a) viral infection b) yeast infection c) streptococcal infection d) staphylococcal infection

c) streptococcal infection rationale rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A B-hemolytic streptococcal infections. it is frequently triggered by streptococcal pharyngitis. the other options are incorrect.

the nurse working in an LTAC is collecting data from a client experiencing chest pain. the nurse should interpret that the pain is likely a result of an MI if which observation is made by the nurse? a) the client is not experiencing nausea of vomiting b) the pain is described as substernal and radiating to the left arm c) the pain has not been unrelieved by rest and nitroglycerin tablets d) the client says the pain began while trying to open a stuck dresser drawer

c) the pain has not been unrelieved by rest and nitroglycerin tablets rationale the pain of angina may radiate to the left shoulder, arm, neck or jaw. it is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. the pain of MI may also radiate to the left arm, shoulder, jaw and neck. it typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea , diaphoresis, anxiety). the pain of MI is not relieved by rest and nitroglycerin tablets and requires opioid analgesics such as morphine sulfate, for relief

a client, who is 36 hours post-MI, has ambulated for the first time. the nurse determines that the client best tolerated the activity if which observation is made? a) the skin is cool by slightly diaphoretic b) dyspnea is noted only at the end of the exercise c) the preactivity pulse rate is 86 bpm; the postactivity pulse rate is 94 bpm d) the preactivity BP is 140/84 mmHg and the postactivity BP is 110/72 mmHg

c) the preactivity pulse rate is 86 bpm the postactivity pulse rate is 94 bpm rationale the nurse checks vital signs and the level of fatigue with each activity. the client is not tolerating the activity if systolic BP drops more than 20 mmHg, pulse rate increases more than 20 bpm, or if the client experiences dyspnea or chest pain. in addition, a significant drop in BP can indicate orthostatic hypotension, which is an abnormal condition. cool, diaphoretic skin is a sign of some degree of cardiovascular compromise.

a client with heart failure is scheduled to be discharged to home with digoxin (lanoxin) and furosemide (lasix) as ongoing prescribed medications. the nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? a) decrease in pedal edema b) high urine output during the day c) weight gain of 2 to 3 pounds in a few days d) cough accompanied by other signs of respiratory infection

c) weight gain of 2 to 3 pounds in a few days rationale clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. an increase in daytime voiding is expected while on diuretic therapy (lasix). a cough as a result of respiratory infection does not necessarily indicate that heart failure is exacerbating

a client has just returned from the cardiac catheterization laboratory. the left femoral vessel was used as the access site. after returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the HCP to write a prescription for the client to remain on bed rest. in which position should the bed be positioned? a) in the high-fowler's position b) with the head of bed elevated at least 60 degrees c) with the head of bed elevated no more than 30 degrees d) with the foot of bed elevated as much as tolerated by the client

c) with the head of bed elevated no more than 30 degrees rationale following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. if the femoral artery was used, strict bed rest is enforced for 6 to 12 hours or per agency procedure. the client may turn from side to side. the affected leg is kept straight and the head is elevated no more than 30 degrees until hemostasis is adequately achieved.

the nurse finds a client while lying in bed staring at the cardiac monitor. which is the nurse's best response when the client states, "there sure are a lot of wires around there. i suer hope we don't get hit by lightening!"? a) would you like a mild sedative to help you relax? b) oh, don't worry, the weather is supposed to be sunny and clear today. c) yes, this equipment is a little scary. can we talk about how the cardiac monitor works? d) i can appreciate your concerns. your family can stay with you tonight if you want them to.

c) yes, this equipment is a little scary. can we talk about how the cardiac monitor works? rationale the nurse should initially respond to validate the clients concern and then should determine the clients knowledge level of the cardiac monitor. this gives the nurse an opportunity to do client education if necessary. bringing in the family, friends or chaplain as an alternative resource may provide the client with additional psychological support. pharmacological interventions should be considered only if necessary. minimizing the client's concern is a communication block.

the nurse carries out a standard prescription for a stat ECG on a client who has an episode of chest pain. the nurse should take which action next? a) do a repeat 12-lead ECG b) wait to see whether the pain resolves c) report the episode of chest pain to the HCP d) give sublingual nitroglycerin (Nitrostat) per the HCP's orders

d) give sublingual nitroglycerin (Nitrostat) per the HCP's prescriptions rationale after completing the stat ECG, the nurse should administer a nitroglycerin tablet to dilate the coronary arteries and relieve ischemic pain. the nurse should not wait to see whether pain resolves on its own but should determine whether the pain is relieved with nitroglycerin. the nurse should do a repeat ECG if it is prescribed. the nurse should report the episode of pain to the HCP but should administer the nitroglycerin before doing so.

the nurse is assigned to assist with caring for a client after cardiac catheterization. the nurse should plan to maintain bed rest for this client in which position? a) high-Fowler's position b) lateral (side-lying) position c) head elevation of 45 degrees d) head elevation of no more than 30 degrees

d) head elevated of no more than 30 degrees rationale after cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period. the client may turn from side to side. the client is placed in the supine position and the head of the bed is not elevated to more than 30 degrees to keep the affected leg straight at the grain and prevent arterial occlusion. bathroom privileges are not allowed during the immediate postcatheterization period. for the high-fowler's position, the head of the bed is elevated 90 degrees.

a client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. the nurse reinforces instructions to the client regarding the procedure and home care measures. which statement by the client indicates an understanding of the instructions? a) i am considering cutting my workload b) i need to cut down on cigarette smoking c) i am so relieved that my heart is repaired d) i need to adhere to my dietary restrictions

d) i need to adhere to my dietary restrictions rationale following the angioplasty, the client needs to be instructed about specific dietary restrictions that must be followed. following the recommended dietary and lifestyle changes helps prevent further atherosclerosis. abrupt closure of the artery can occur if the recommended dietary and lifestyle changes are not followed. cigarette smoking needs to be stopped. an angioplasty does not repair the heart.

the nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). which statement should the nurse make to the client to try to motivate the client to quit smoking? a) since the damage has already been done, it will be all right to cut down a little at a time b) none of the cardiovascular effects are reversible, but quitting might prevent lung cancer c) if you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year d) if you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years

d) if you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years rationale the risks to the cardiovascular system from smoking are noncumulative and are non permanent. 3 to 4 years after cessation, a client's cardiovascular risk is comparable to that of a person who never smoked. therefore the other options are incorrect.

a client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. the client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. which factor would precipitate these episodes? a) exposure to heat b) being in a relaxed environment c) prolonged episodes of inactivity d) ingestion of coffee or chocolate

d) ingestion of coffee or chocolate rationale Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress

the nurse is preparing to ambulate a postoperative client after cardiac surgery. the nurse plans to do which to enable the client to best tolerate the ambulation? a) provide the client with a walker b) remove the telemetry equipment c) encourage the client to cough and deep breathe d) premedicate the client with an analgesic before ambulating

d) premedicate the client with an analgesic before ambulating rationale the nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing and ambulation.

a client is scheduled for a cardiac catheterization using a radiopaque dye. the nurse checks which most critical item before the procedure? a) intake and output b) height and weight c) peripheral pulse rates d) prior reaction to contrast media

d) prior reaction to contrast media rationale this procedure requires a signed informed consent because it involves injection of a radiopaque dye into the blood vessel. the risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. although intake and output, height and weight, and presence of peripheral pulses may be components of data collection, they are not the most critical items.

when preparing a client for a pericardiocentesis, which position does the nurse place the client in? a) supine with slight lowering of the head b) lying on the right side with a pillow under the head c) lying on the left side with a pillow under the chest wall d) supine with the head of bed elevated at a 45 to 60 degree angle

d) supine with the head of bed elevated at 45 to 60 degree angle rationale the client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60- degree angle. this places the heart in proximity to the chest wall for easier insertion of the needle into the pericardial sac. the remaining options are incorrect positions for this procedure.

a client with CAD has selected guided imagery to help cope with psychological stress. which statement by the client indicates understanding of this stress reduction measure? a) this will help only i play music at the same time b) this will work for me only if i am alone in a quiet area c) i need to do this only when i lie down in case i fall asleep d) the best thing about this is that i can use it anywhere, anytime

d) the best thing about this is that i can use it anywhere, anytime. rationale guided imagery involves the client's creation of an image in the mind, concentrating on the image, and gradually become less aware of the offending stimulus. it does not require any adjuncts and does not need to be done in a quiet area, although some clients may use other relaxation techniques or play music with it.

a client has an Unna boot applied for treatment of a venous stasis leg ulcer. the nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. which interpretation should the nurse make of these findings? a) the boot has not yet dried b) the boot is controlling leg edema c) the boot is impairing venous return d) the boot has been applied too tightly

d) the boot has been applied too tightly rationale an Unna boot that is applied too tightly can cause signs of arterial occlusion. the nurse assesses the circulation in the foot and teaches the client to do the same. the other options are incorrect interpretations.

a client is seen in the HCP's office for a physical examination after experiencing unusual fatigue over the last several weeks. height is 5 feet, 8 inches, with a weight of 220 pounds. vital signs are temperature 98.6 F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184 / 96 mm Hg.. random blood glucose is 110 mg / dl. in order to best collect relevant data, which question should the nurse ask the client first? a) do you exercise regularly b) would you consider losing weight c) is there a history of diabetes mellitus in your family d) when was the last time you had your blood pressure checked

d) when was the last time you had your blood pressure checked? rationale the client is hypertensive, which is a known major modifiable risk factor for CAD. the other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. the client is overweight, which is also a contributing factor. the client's nonmodifiable risk factors are age and gender. because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.

for a client diagnose with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. which client activities will contribute to achieving this goal? a) elevating the legs when in bed b) sleeping in the supine position c) using a bedside commode for stools d) seasoning beef with a meat tenderizer

c) using a bedside commode for stools rationale using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. elevating the client's legs would increase venous return and result in an increase in cardiac workload. the supine position can increase respiratory effort and decrease oxygenation, which increases cardiac workload. meat tenderizers are high in sodium. sodium contributes to hypertension, which increases cardiac workload.

a client has an inoperable abdominal aortic aneurysm (AAA). which measure should the nurse anticipate reinforcing when teaching the client? a) bed rest b) restricting fluids c) antihypertensives d) maintaining a low-fiber diet

c) antihypertensives rationale the medical treatment for AAA is controlling blood pressure. Hypertension creates the likelihood of rupture. there is no need for the client to restrict fluids to be on bed rest. a low-fiber diet is not helpful and will cause constipation.

the nurse in a medical unit is caring for a client with heart failure. the client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. the nurse immediately notifies the RN and expects which interventions to be prescribed? select all that apply administering oxygen inserting a Foley catheter administering forosemide (lasix) administering morphine sulfate intravenously transporting the client to the CCU placing the client in a low-Fowler's side-lying position

administering oxygen // inserting a Foley catheter // administering furosemide (Lasix) // administering morphine sulfate intravenously rationale pulmonary edema is a life-threatening event that can result from severe heart failure. in pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. oxygen is always prescribed, and the client is placed in a high-fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. a foley catheter is inserted to accurately measure output. intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. transporting the client to the CCU is not a priority intervention. in fact, this may not be necessary at all if the client's response to treatment is successful.

the nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. the nurse should include which items on a list of suggestions to be given to the client? select all that apply. wear elastic stockings be careful not to injure the legs or feet use a heating pad on the legs to aid vasodilation walk each day to increase circulation to the legs cut down on the amount of fats consumed in the diet

be careful not to injure the legs or feet // walk each day to increase circulation to the legs // cut down on the amount of fats consumed in the diet rationale long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). elastic stockings will not increase circulation. they are worn with peripheral vascular disease, but not peripheral arterial disease. application of heat directly to the extremity is contraindicated. the affected extremity may have decreased sensitivity and is at risk for burns. direct application of heat raises oxygen and nutritional requirements of the tissue even further.

a client is at risk for developing disseminated intravascular coagulopathy (DIC) the nurse should become concerned with which fibrinogen level? a) 90 mg/ dl b) 190 mg/dl c) 290 mg/dl d) 390 mg/dl

a) 90 mg/dl rationale the normal fibrinogen level is 180 to 340 mg/dl for men and 190 to 420 mg/dl for women. a critical value is less than 100 mg/dl. with DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. for these reasons, the nurse should become most concerned with the level of 90 mg/dl

a client complaining of chest pain has a PRN prescription for sublingual nitroglycerin (Nitrostat). before administering the medication to the client, the nurse should first check which? a) blood pressure b) cardiac rhythm c) respiratory rate d) peripheral pulse

a) blood pressure rationale assessing the blood pressure is a priority before administering nitroglycerin to determine the vasodilating effect of the medication and to monitor for a drop in blood pressure. cardiac rhythm and respiratory rate are also important to assess after checking the blood pressure. peripheral pulses do not need to be checked before administering this medication

a client diagnosed with thrombophelbitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. the nurse understands that a life-threatening complication of this condition is which? a) pneumonia b) pulmonary edema c) pulmonary embolism d) myocardial infarction

c) pulmonary embolism rationale pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension

the nurse is collecting data from a client with varicose veins. which finding would the nurse identify as an indication of a potential complication associated with this disorder? a) legs are unsightly in appearance and distress the client b) the client complains of aching and feelings of heaviness in the legs c) the client complains of leg edema, and skin breakdown has started d) the HCP finds that the legs become distended when the tourniquet is released during the Trendelenburg's test.

c) the client complains of leg edema, and skin breakdown has started rationale complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. the client with varicose veins may be distressed about the unsightly appearance of the varicosities. complaints of heaviness and aching in the legs are common. the last option describes the trendelenburg's test findings, which are indicative of varicose veins. in the test, the HCP has the client lie down and elevate the legs to empty the veins. a tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. if the veins are incompetent, they will quickly become distended due to backflow.

the clinic nurse is obtaining cardiovascular data on the client. the nurse prepares to check the client's apical pulse and places the stethoscope in which position? a) midsternum equal with the nipple line b) at the midaxillary line on the left side of the chest c) at the midline of the chest just below the xiphoid process d) at the midclavicular line at the fifth intercostal space

d) at the midclavicular line at the fifth left intercostal space rationale the heart is located in the mediastinum. its apex or distal end points to the left and lies at the level of the fifth intercostal space. a stethoscope should be placed in this area to pick up heart sounds most clearly. the other options are incorrect because they do not represent the anatomical positioning of the heart's apex.

a client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. the nurse sees no electrocardiographic complexes on the screen. the nurse should do which first? a) call a code blue b) call the HCP c) check the client status and lead placement d) press the recorder button the ECG console

c) check the client status and lead placement rationale sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. checking of the client and equipment is the first action by the nurse.

the nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. which beverage does the nurse instruct the client to select from the menu? a) tea b) cola c) coffee d) lemonade

d) lemonade rationale a client with a diagnosis of MI should not consume caffeinated beverages. caffeinated products produce a vasoconstrictive effect, leading to further ischemia. coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

a client is scheduled for a dipridamole thallium scan. the nurse should check to make sure that the client has not consumed which substance before the procedure? a) caffeine b) fatty meal c) excess sugar d) milk products

a) caffeine rationale this test is an alternative to the exercise stress test. dipyridamole (persantine) dilates the coronary arteries as exercise would. before the procedure, any form of caffeine should be withheld, as well as aminophylline or theophylline forms of medication. aminophylline is the antagonist to dipridamole.

the nurse is reinforcing dietary instructions to a client with heart failure (HF) the nurse determines that the client understands the instructions if the client states that which food item will be avoided? a) catsup b) sherbet c) cooked cereal d) leafy green vegetables

a) catsup rationale catsup is high in sodium. leaf green vegetables, cooked cereal, and sherbet all are low in sodium. clients with heart failure should monitor sodium intake.

the nurse is planning adaptations needed for ADLS for a client with cardiac disease. the nurse should incorporate which instruction in discussion with the client? a) increase fluids to 3000 mL per day to promote renal perfusion b) consume 1 to 2 oz of liquor each night to promote vasodilation c) try to engage in vigorous activity to strengthen cardiac reserve d) take in adequate daily fiber to prevent straining during a bowel movement

d) take in adequate daily fiber to prevent straining during a bowel movement rationale standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands of the heart, instituting a bowel regimen program to prevent straining and constipation, and maintaining fluid and electrolyte balance. increasing fluids to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease

the nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. the nurse understands further teaching is needed if a family member makes which statement? a) recuperation after cardiac surgery is generally slower for older people b) it's important to get out of bed every day, even if tired or weak at first c) fatigue, discomfort, and lack of appetite occur more commonly with older people and may last for 2 to 5 weeks d) a daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control

d) a daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control rationale clients generally increase activity by beginning a simple walking program, starting with distances of 400 feet twice daily and gradually increasing the distance until able to walk 1 1/4 mile (usually at the end of the second week). exercise has physiological and psychological benefits. the statements made in the other options are correct.

the nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. the nurse plans to reinforce which information about this type of angina when teaching the client? a) prinzmetal's angina is effectively managed by beta-blocking agents b) prinzmetal's angina improves with a low-sodium, high-potassium diet c) prinzmetal's angina has the same risk factors as stable and unstable angina d) prinzmetal's angina is generally treated with calcium channel blocking agents

prinzmetal's angina is generally treated with calcium channel blocking agents rationale prinzmetal's angina results from spasm of the coronary arteries and is generally treated with calcium channel blocking agents. the risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. beta-blockers are contraindicated because they may actually worsen the spasm. diet therapy is not specifically indicated although a healthy diet consuming foods low in fat and sodium is advocated in cardiac disease.

a client brings the following medications to the clinic for a yearly physical. the nurse realizes which medication has been prescribed to treat heart failure? a) digoxin (lanoxin) b) warfarin (coumadin) c) amiodarone (cordarone) d) potassium chloride (k-dur)

a) digoxin (lanoxin) rationale digoxin strengthens the heartbeat and decreases the heart rate. it is used in the treatment of heart failure. potassium chloride increases the potassium level. although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. warfarin and amiodarone do not treat heart failure.

the nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. the nurse understands that the client is most likely taking which? a) bilberry b) ginseng c) feverfew d) evening primrose

a) bilberry is an herbal supplement that has been used to treat varicose veins. this supplement has also been used to treat cataracts, retinopathy, diabetes mellitus, and peripheral vascular disease. ginseng has been used to improve memory performance and decreased blood glucose levels in type 2 diabetes mellitus. feverfew is used to prevent migraine headaches and to treat rheumatoid arthritis. evening primrose is used to treat eczema and skin irritation.

a 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. the nurse also notes superficial thrombophlebitis of the lower leg. the nurse should check the client for which next? a) smoking history b) recent exposure to allergens c) history of recent insect bites d) familial tendency toward peripheral vascular disease

a) smoking history rationale the mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). this is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. this disorder is typically found in young men who smoke. the cause is unknown but is suspected to have an autoimmune component.

a client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. the nurse interprets that the client is experiencing which type of angina? a) stable b) variant c) unstable d) intractable

a) stable rationale stable angina, also known as exertional angina, is triggered by a predictable amount of effort or emotion. unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. variant angina is triggered by coronary artery spasm; the attacks are of longer duration than classic angina and tend to occur early in the day and at rest. intractable angina is chronic and incapacitating and is refractory to medical therapy

acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA) when the nurse takes the aspirin to the client, the client asks the nurse about its purpose. what is the purpose of the aspirin? a) to prevent the formation of clots b) to relieve pain at the injection site c) to prevent a fever after the procedure d) to prevent inflammation of the injection site

a) to prevent the formation of clots rationale before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure. the other options are unrelated to the purpose of administering aspirin to this client.

the nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? a) tall, peaked T waves b) ST-segment depression c) prolonged P-R interval d) widening of the QRS complex

b) ST-segment depression rationale in the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. the client may also exhibit a flat T wave. the other options are cardiac findings noted in the client with hyperkalemia.

the nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. during the admission, the client reports chest pain. the nurse immediately asks the client which question? a) are you having any nausea b) where is the pain located c) are you allergic to any medications d) do you have your nitroglycerin with you

b) where is your pain located rationale if a client complains of chest pain, the initial assessment question is to ask the client about eh pain intensity, precipitating factors, location, radiation, and quality. although the other options may be components of the assessment, these would not be the initial assessment questions in this situation.

a client is diagnosed with thrombophlebitis. the nurse should tell the client that which prescription is indicated? a) bed rest, bathroom privileges only b) bed rest, keeping the affected extremity flat c) bed rest, with elevation of the affected extremity d) bed rest, with the affected extremity in a dependent position

c) bed rest, with elevation of the affected extremity rationale elevation of the affected leg facilitates blood flow by the flow of gravity and decreases venous pressure, which in turn relieves edema and pain. the foot of the bed is elevated and bed rest is indicated to prevent emboli and pressure fluctuations in the venous systems that occur with walking. the positions in the remaining options are incorrect.

the nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. why is acetaminophen (Tylenol) usually prescribed to be taken before the administration of the topical nitrate? a) headache is a common side effect of nitrates b) fever usually accompanies coronary artery disease c) acetaminophen potentiates the therapeutic effects of nitrates d) acetaminophen does not interfere with platelet action as aspirin does

a) headache is a common side effect of nitrates rationale headache occurs as a side effect of nitrates. acetaminophen may be given before nitrates to prevent headache or to minimize the discomfort from the headaches. the second option is incorrect and the other options are unrelated to the data in the questions

the nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. the nurse should tell the client to do which? a) bend the leg at the hip b) keep the ankles uncrossed c) place two pillows under the knees d) use the knee gatch on the bed controls

b) keep the ankles uncrossed rationale a graft can become clotted from any form of pressure, which results in impaired blood flow through the graft. positions and movements to be avoided include bending at the hip or knee, crossing the knees or ankles, or the use of a knee gatch or pillows under the knees

a client is admitted to the hospital with possible rheumatic heart disease. the nurse collects data from the client and checks the client for which signs/symptoms? a) skin scratches b) vaginal itching c) fever and sore throat d) burning on urination

c) fever and sore throat rationale rheumatic heart disease can occur as a result of infection with group A beta-hemolytic streptococcal infections. it is frequently triggered by streptococcal pharyngitis of sore throat and fever. the other options are unrelated to this problem and indicate possible yeast infection, skin lesions, and urinary tract infection, respectively

the nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. the nurse determines that the client is best tolerating ambulation if which parameter is noted? a) mild dyspnea after walking 10 feet b) minimal chest pain rated 1 on a 1-to-10 pain scale c) pulse rate that increases from 68 to 94 beats per minute d) blood pressure that increases from 114 / 82 to 118 / 86 mmHg

d) blood pressure that increases from 114/82 to 118/86 mmHg rationale general indicators that a client is tolerating exercise include an absence of chest pain or dyspnea, a pulse rate increase of less than 20 beats per minute, and a blood pressure change of less than 10 mmHg.

a client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. the nurse takes which important action in delivering holistic nursing care to this client? a) reports the client to the police for illegal drug use b) explains to the client the damage that cocaine does to the heart c) tells the client it is imperative to stop before myocardial infarction occurs d) teaches about the effects of cocaine on the heart and offers referral for further help

d) teaches about the effects of cocaine on the heart and offers referral for further help rationale to provide the most holistic care, the nurse should meet the information needs of the client about the effects of cocaine on the heart and offer referral for further help with this possible addiction. the first option is partially correct but does not meet the holistic needs of the client. the second option is not indicated and breaches the client's right to confidentiality. the third option is incorrect because it "preaches" to the client.