Nursing 203 chapter81 Pass point Angela_Hussey9
How do baroreceptors respond in a client with cardiogenic shock who experiences low blood pressure
Stimulate the sympathetic nervous system
A client reports recent onset of sporadic chest pain with exertion and mild ankle swelling at the end of the day. The nurse suspects a cardiovascular disorder. Which of the following assessments would provide additional data if a cardiovascular disorder is suspected? Select all that apply.
Shortness of breath Substernal chest pain Fatigue
The physician has ordered digoxin for a client with pulmonary edema. The nurse knows that digoxin has a direct and beneficial effect on myocardial contraction in the failing heart. This effect
slows the conduction of impulses through the atrioventricular (AV) node
A child with tetralogy of Fallot may assume which position of comfort during exercise?
squat
Which statement by the client best indicates an understanding on how to self-monitor while taking warfarin?
"I should use a soft toothbrush."
Which instruction by the nurse would be most appropriate for a child with symptomatic aortic stenosis?
Restrict exercise
The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant?
Rheumatic fever
The nurse is obtaining data from a new client in the cardiovascular clinic. When asking about childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant?
Rheumatic fever
A nurse is obtaining data from a child with left-sided heart failure. Which symptoms does the nurse correlate with the diagnosis?
Tachypnea and dyspnea
A child has undergone a repair of total anomalous pulmonary venous return and develops pulmonary hypertension postoperatively. Which finding would the nurse be most likely to observe in a child with this condition?
Tachypnea-rapid breathing Explanation: Pulmonary hypertension may result as a postoperative complication of this procedure, which can cause hypoxia. Symptoms of hypoxia include tachy pnea, cyanosis, chest retractions, and fatigue.
The nurse is evaluating an electrocardiogram (ECG) tracing. Which graphic shows the QT interval?
The QT interval extends from the beginning of the QRS complex to the end of the T wave. It measures the time needed for ventricular depolarization and repolarization
A child returns to the unit after a cardiac catheterization. The nurse should reinforce education for the child and parents on which point regarding mobility?
The child will be maintained on bed rest with the affected extremity immobilized.
A nurse is aware that the kidneys play an important role in regulating blood pressure. When hypertension occurs, which responses by the kidneys help normalize blood pressure?
The kidneys excrete sodium and excrete water
A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?
The severity of discomfort isn't related to the size of varicosities.
A client has just had a myocardial infarction (MI) and the nurse is preparing to administer morphine. What is the primary reason for administering morphine to this client?
To decrease the client's pain
The nurse suspects that a 68-year-old client has digoxin toxicity. The nurse should assess for:
Vision changes
A client with a deep vein thrombosis (DVT) is admitted to the hospital for treatment. Which medication will the nurse administer orally to prevent further thrombus formation?
Warfarin prevents vitamin K from synthesizing certain clotting factors. This oral anticoagulant can be given long-term.
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as:
a third heart sound (S3)
An agitated client with left-sided heart failure reports increasing shortness of breath and coughs up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of which disorder?
acute pulmonary edema
A client with left-sided heart failure reports of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
acute pulmonary edema.
A male client has been reporting chest pain and shortness of breath for the past 2 hours. He has a temperature of 99° F (37.2° C), a pulse of 96 beats/minute, respirations that are irregular and 16 breaths/minute, and a blood pressure of 140/96 mm Hg. He's placed on continuous cardiac monitoring to:
assess for potentially dangerous arrhythmias.
Echocardiography reveals vegetation on a client's heart valves. The nurse knows that this finding indicates:
bacterial invasion.
The nurse cares for an older adult client with a history of left-sided heart failure. Which finding indicates to the nurse that the client is experiencing an exacerbation of heart failure?
bibasilar fine crackles
A client is in hemorrhagic shock. What data best reflects the effectiveness of fluid replacement therapy?
blood pressure
The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first
establish unresponsiveness.
The nurse is assessing a client with heart failure. Which heart valve sound will the nurse hear best at the fifth left intercostal space at the midclavicular line?
mitral
A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time?
Decreased cardiac output related to depressed myocardial function, deficient fluid volume or impaired electrical conduction.
A nurse is monitoring a client with asthma taking atenolol. Which finding would indicate a potential complication associated with atenolol?
Development of audible expiratory wheezes
A client is admitted to the hospital displaying sinus bradycardia, nausea, anorexia and blurred vision. What should the nurse suspect this client to be experiencing?
Digoxin toxicity
A nurse is caring for a client diagnosed with myocardial infarction (MI) who is prescribed a nitrate. What does the nurse identify as the purpose of giving a nitrate to this client?
Dilate coronary arteries
When caring for a child diagnosed with a ventricular septal defect, which description would the nurse incorporate when talking with the parents about this condition?
Failure of a septum to develop completely between the ventricles
Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?
Frequent respiratory infections
Which finding would a nurse expect to observe in a child with truncus arteriosus?
Harsh systolic ejection murmur
A client with a history of atrial arrhythmia is receiving propranolol, 10 mg by mouth three times per day. The nurse knows that propranolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located?
Heart
A nurse obtaining data from a client observes jugular vein distention (JVD). Which condition does the nurse suspect this client to have?
Heart failure
The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. Which condition should the nurse suspect?
Heart failure
A client is placed on a medication to stimulate the sympathetic nervous system. Which response should the nurse expect from this medication?
Heart rate increased from 60 to 88 beats/minute
Which characteristic should a nurse expect to see on a normal cardiac rhythm strip obtained from an adult client?
Heart rate of 88 beats/minute
A patent ductus arteriosus (PDA) is suspected in a newborn. When reviewing the assessment data, which findings are supportive of this potential diagnosis? Select all that apply.
Heart rate pounding at 150 beats per minute Tachypnea
Which of the following complications is most common after an abdominal aortic aneurysm resection?
Hemorrhage and shock
The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium
A white male, age 43, is admitted to an acute care facility with a tentative diagnosis of infective endocarditis. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis?
History of aortic valve replacement
Within hours after suffering a massive myocardial infarction, a client experiences cardiogenic shock. All vital functions are being monitored closely; an intra-arterial catheter has been inserted to detect changes in arterial blood pressure. Which statement comparing intra-arterial and cuff blood pressure readings is accurate?
Intra-arterial readings should be at least 10 mm Hg higher than cuff readings.
A nurse is caring for a child with acute rheumatic fever. Which symptom would indicate Sydenham chorea, a major manifestation of acute rheumatic fever?
Involuntary muscle movements
Atropine is being administered to a child with sinus bradycardia. Which statement is most accurate about the administration of this medication?
It increases heart rate.
A client who suffered blunt chest trauma in a car accident reports chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position?
Leaning forward while sitting
A 9-year-old child had cardiac surgery 2 days ago. The child tells the nurse he is sore and doesn't want to move much today. Which action by the nurse is most appropriate?
Medicate the child for discomfort and then begin activities related to ambulation.
A nurse is reinforcing education for a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, what should the nurse encourage the client to do?
Increase activity level.
Which of the following signs and symptoms suggest that a client's abdominal aortic aneurysm is extending?
Increased abdominal and back pain
The nurse is caring for a client with a ventricular septal repair receiving dopamine postoperatively. Which response indicates a therapeutic response of the medication?
Increased cardiac output.
What would be the most common adverse reaction a nurse might observe after administering enteric-coated erythromycin?
Nausea and vomiting
A nurse is caring for a client who has been administered digoxin 0.125 mg by mouth daily. The client develops sinus bradycardia with a heart rate of 50 beats/minute. His vital signs are stable. Which of the following actions should the nurse take first?
Notify the physician
While receiving a heparin infusion to treat deep vein thrombosis, a client reports that the gums bleed when brushing the teeth. What should the nurse do first?
Notify the physician.
A client reported chest pain and received sublingual nitroglycerin. Which statement by the client indicates that this drug is producing its therapeutic effect?
"Mt chest pain is decreasing.
Which statement by a client who has had a fasting lipoprotein profile indicates that further education is needed?
"My total cholesterol level is optimal! It used to be 350 and now it is 250 mg/dl." 240 mg/dl or more as high, levels of 200 to 239 mg/dl as borderline high, and levels less than 200 mg/dl as desirable. LDL cholesterol levels of 100 mg/dl or less and HDL cholesterol levels 60 mg/dl or more are optimal.
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
Apply warm soaks and elevate the client's legs higher than the level of the heart.
A child hospitalized with right-sided heart failure is tearful and states "My parents do not want me to have any activity and I always needs to rest." Which action by the nurse is most appropriate
Ask the child if he would like to have assistance sharing concerns with the parents
A client with chest pain doesn't respond to nitroglycerin. On admission to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?
3 to 6 hours
A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member, the monitor exhibits the following. Which intervention should the nurse do first?
Assess the client's airway, breathing, and circulation.
A nurse receives a report on a client who has been diagnosed with an abdominal aortic aneurysm (AAA). The nurse would expect the client to have which underlying disease
Atherosclerosis is linked to 75% of all AAAs. Plaque damages the wall of the artery and weakens it, causing an aneurysm.
The licensed practical nurse discovers a client with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he reports dizziness. Which medication would the registered nurse use to treat the client's bradycardia?
Atropine I.V. push atropine is used to treat symptomatic bradycardia.
A client who comes to the hospital reporting severe substernal chest pain that is radiating down the left arm is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which nursing action is a priority on admission to coronary care?
Begin electrocardiogram (ECG) monitoring.
A nurse is monitoring a client following an initial administration of sotalol. Which of the following would be of greatest concern to the nurse?
Bilateral inspiratory wheezing upon auscultation
When measuring the radial pulse of a client with known aortic insufficiency, the nurse detects a "water-hammer" or Corrigan's pulse. What are the characteristics of this pulse?
Bounding, with a rapid rise and fall
A child diagnosed with tetralogy of Fallot has been ordered to undergo testing. Which test would the nurse prepare the child for that will indicate the direction and amount of shunting in this child
Cardiac catheterization
A client is experiencing cardiac tamponade after a chest trauma. Which type of shock will the nurse monitor for?
Cardiogenic
A 58-year-old male with heart failure is experiencing tachycardia, decreased blood pressure, and decreased peripheral pulses. The nurse interprets these symptoms as indicating which condition?
Cardiogenic shock is related to ineffective pumping of the heart and is an acute and serious complication of heart failure.
The telemetry monitor technician notifies the nurse that her client has sinus bradycardia with a heart rate of 42 beats/minute. What should the nurse do first?
Check the client's level of consciousness (LOC), obtain vital signs, and assess the client for symptoms.
Which of the following signs and symptoms should the nurse expect to find in a client with angina? Select all that apply.
Chest tightness Chest pressure Jaw pain
A child with tetralogy of Fallot has clubbing of the fingers and toes. The nurse understands that this finding is related to which condition?
Chronic hypoxia
A client diagnosed with acute arterial occlusive disease is scheduled to undergo an atherectomy. What is the priority nursing intervention for this client immediately after the procedure?
Closely monitor catheter site for bleeding.
The nurse is reviewing orders from the primary health care provider for a child scheduled for cardiac surgery the following day. Which orders will likely be included? Select all that apply
Complete blood count Electrolyte levels Urinalysis Partial prothrombin time (PTT)
A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply.
Creatine kinase (CK) Troponin T and troponin I Myoglobin
A client is evaluated for hypertension. The physician prescribes atenolol, 50 mg by mouth daily. Atenolol should have which therapeutic effect on the client?
Decreased cardiac output and systolic and diastolic blood pressure.
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's plan of care, the nurse should include which expected outcome?
"Client will verbalize the intention to stop smoking."
Before discharge, which instruction should the nurse give to a client receiving digoxin?
"Call the physician if your heart rate goes above 120 beats/minute."
The nurse is talking with the parent of a 3-year-old child who has congenital heart disease. The parent reports feeling concerns that the child does not seem to be maturing emotionally in a manner that is at the same rate as the two older children in the family. Which response by the nurse is most appropriate?
"Children who have chronic health issues may experience developmental delays."
A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the prescribed cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction?
"Client walks 4 miles (6.4 km) in 1 hour every day."
The nurse is caring for an adolescent diagnosed with Wolff-Parkinson-White syndrome. When asking the teen how he is feeling which response would be most consistent with this condition?
"I have had periods of time today in which my heart seemed to beat very fast."
A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates an understanding of discharge instructions?
"I should only have approximately 2,400 mg of sodium per day."
A client has arteriosclerosis with intermittent claudication. The nurse has worked with the client to develop a walking program. Which client statement indicates an understanding of the program? Select all that apply.
"I should stop walking and elevate my legs when pain occurs."
A nurse is attempting to administer lisinopril to a client. The client refuses to take the pill, stating that in the past he developed a rash as an allergic reaction to the medication. Which of the following is the best response by the nurse?
"I will call the physician with this information."
A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply.
"I will take the digoxin with my antacids at night." "If I forget a dose, I will catch-up by doubling the next dose." "I understand that I will need annual blood work to check therapeutic levels."
When reinforcing education for the client about the importance of smoking cessation, which statements made by the client indicate understanding? Select all that apply.
"It causes the platelets in the blood to clump together and become sticky." "It causes spasms in the coronary arteries." "It lowers good cholesterol." "It reduces the amount of oxygen carried by the red blood cells."
The nurse is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize?
"Lie down for 5 to 10 minutes after taking the drug."
The parents of a 3-year-old with a congenital heart disease are being seen for a check-up. They report that they are concerned about giving a flu vaccine to their child. Which statement is appropriate for inclusion in the nurse's response?
"The flu vaccine is both safe and recommended to children who have chronic illness such as heart disease."
When collecting data from a client who reports recent chest pain, the nurse obtains a thorough history. Which statement by the client most strongly suggests angina pectoris?
"The pain occurred while I was mowing the lawn."
The nurse instructs the client with acute pulmonary edema that high Fowler's position is best to aid breathing. Which statement made by the client would indicate an understanding of this?
"This position reduces venous return and thus will help my breathing."
The parents of a 14-year-old child who underwent an atrial septal repair 5 days ago have asked if a few family members can visit. Which response by the nurse is appropriate?
"While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery."
Which assessment data for a patient with a myocardial infarction requires further assessment and notification of a health care provider? Select all that apply.
+1 pitting edema to right lower extremity Bluish tinge to nail beds
Treatment for a child with sinus bradycardia includes atropine 0.02 mg/kg. If the child weighs 20 kg, how much is given per dose?
0.4 mg Explanation: 4. The child should receive 0.4 mg. Use the following equation: 0.02 mg/kg × 20 kg = 0.4 mg.
The nurse is reviewing a listing of assigned clients. Which client should be seen first?
A 14 year old child who had cardiac surgery 2 days ago and who had urinary output of 200 mL over the past 8 hours
During a local wellness fair, a nurse takes some clients' blood pressures. Which client is at the highest risk for the diagnosis of essential (primary) hypertension?
A 72-year-old female with a blood pressure of 142/88 mm Hg
Untreated hypertension
A client comes to the emergency department reporting visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension?
A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. He also reports nausea, diaphoresis, and shortness of breath. What should the nurse do?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
What should be the nurse's first intervention for a client experiencing a myocardial infarction (MI
Administering oxygen
Which precaution should a nurse take when caring for a client with a myocardial infarction (MI) who has received a thrombolytic agent?
Avoid puncture wounds Thrombolytic agents are declotting agents that place the client at risk for hemorrhage from puncture wounds. All unnecessary needlesticks and invasive procedures should be avoided.
A client is admitted to the emergency department with chest discomfort, diaphoresis, and nausea. Suspecting possible myocardial infarction (MI), the nurse would anticipate the health care provider to prescribe which diagnostic test to quickly determine myocardial damage?
Electrocardiogram (ECG)
The nurse is caring for a child who has recently been diagnosed with a cardiovascular disorder. The child's parents do not seem to be accepting of the diagnosis and the changes the diagnosis will make in their lives. What initial action by the nurse will be most therapeutic?
Encourage the parents to discuss their feelings about the loss of their child's health.
Which action by the nurse is the priority care for a client exhibiting signs and symptoms of coronary artery disease?
Enhance myocardial oxygenation.
A client with chronic heart failure is receiving digoxin, 0.25 mg by mouth daily, and furosemide, 20mg by mouth twice daily. Which statements by the client indicate that further teaching is needed regarding digoxin toxicity?
I should report if I am unable to completely empty my bladder to my physician. I should report a metallic taste in my mouth to my physician. I should report if I am unable to completely empty my bladder to my physician. I should report any sleep disturbances to my physician.
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
Leg edema
A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take?
Look at the chart for his last potassium level and contact the physician.
The nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
Low serum potassium level
Which home care instruction is most appropriate for a child after cardiac surgery?
Maintain the prescribed medication regimen until the health care provider makes a change.
The nurse is caring for a child with heart failure. What should the nurse recognize when monitoring administration of oxygen to avoid complications?
Oxygen decreases the work of breathing.
A client has been hospitalized with a diagnosis of acute arterial occlusive disease. After surgery the health care provider orders heparin IV therapy for the client. What test does the nurse need to monitor for this client while on heparin?
PTT Partial Thromboplastin Time is used to monitor response to heparin therapy and is used to evaluate all the clotting factors of the intrinsic pathway.
A nurse is caring for a child with transposition of the great arteries. Which associated defect should the nurse expect to see in this client?
Patent foramen ovale
The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.
Pepperoni pizza Bacon Cheese Soft drinks
The nurse is caring for a client with cardiac tamponade. Which treatment would the nurse anticipate for this client?
Pericardiocentesis Explanation: Pericardiocentesis, or needle aspiration of the pericardial cavity, is done to relieve tamponade. An opening is created surgically if the client continues to have recurrent episodes of tamponade.
A client is receiving captopril for heart failure. Which finding indicates that the medication isn't producing the desired treatment outcome and requires the nurse to notify the health care provider?
Peripheral edema
A client is receiving captopril for heart failure. Which finding indicates that the medication isn't producing the desired treatment outcome and requires the nurse to notify the physician?
Peripheral edema
The nurse is reviewing the telemetry for a group of assigned clients. In which client would sinus bradycardia be considered a normal finding?
Physically conditioned adolescent
A client has recently been diagnosed with hypertension. The client has an elevated blood pressure with no symptoms and the cause is uncertain. Which term best describes this?
Primary hypertension
A 3-year-old child has a high red blood cell count and polycythemia. When assisting with the planning of care which action will be of greatest impact in preventing complications?
Promote adequate fluid intake.
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for adverse effects of heparin, especially bleeding. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that's specific to heparin. Which agent fits this description?
Protamine sulfate
A nurse is obtaining data from a client who's at risk for cardiac tamponade due to chest trauma sustained in a motorcycle accident. What's the client's pulse pressure if the blood pressure is 108/82 mm Hg? Record your answer using a whole number.
Pulse pressure is the difference between systolic and diastolic pressures. 108 - 82 = 26.
When obtaining data from a child with suspected Kawasaki disease, which symptom is common?
Strawberry tongue
The nurse is performing an electrocardiogram (ECG) for a client with chest pain. Which position will the nurse place the client in that will provide the best results?
Supine
When assisting with an electrocardiogram (ECG), the nurse would expect to place the client in which position?
Supine
A child receives prednisone after undergoing a heart transplant. What is the desired outcome of this medication?
Suppress immune response
A client comes to the emergency department diagnosed with a ruptured aortic aneurysm. What is the priority action for this client?
Surgical intervention
A client comes to the emergency department reporting visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension?
Untreated hypertension
A client sustained a stroke and has impaired verbal communication. What interventions can the nurse provide that will maintain the client's dignity? Select all that apply.
Use a normal tone of voice when communicating. Allow adequate time for the client to respond. Be honest when unable to decipher the client's speech.
A client has sudden cardiac death. Which arrhythmia commonly associated with sudden cardiac death does the nurse suspect this client may have experienced?
Ventricular fibrillation
A client is admitted for treatment of Prinzmetal's angina. When developing the plan of care, the nurse keeps in mind that this type of angina is triggered by:
coronary artery spasm.
The nurse cares for a client on the first postoperative day after repair of an abdominal aortic aneurysm. Which finding requires additional collaboration with the RN?
decreased urine output
