Total Cardiac

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?

The client has an apical pulse of 56.

CK-MB indicate MI not heart failure

A positive D-dimer indicate pulmonary embolism

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?

An elevated B-type natriuretic peptide (BNP). specific test, higher the number worse the condition

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?

"Are you sexually active?" - sexual activity is a risk factor for angina from coronary disease BUT client's being elderly should not affect teaching about sexual activity

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse?

"Chest pain is caused by decreased oxygen to the heart muscle." - this stated in layman's terms - do not use medical terms - explain the correct procedure!

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching?

"If my chest pain is not gone with one tablet, I will go to the ER." - keep in the dark - the tabs should burn on sting when put under the tongue - client should take 1 pill every 5 minutes and after the third pill still chest pain then call 911

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response?

"Your heart is damaged and needs about four (4) to six (6) weeks to heal."

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.

- Administer an aspirin orally. - Apply oxygen via a nasal cannula. PAY ATTENTION THE ROUTES! - MORPHINE ONLY IV - NITROGLYCERIN ONLY SUBLINGUAL IN THIS SITUATION

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.

2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table.

The nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to an unlicensed nursing assistant? 2. Assist feeding the client diagnosed with congestive heart failure.

2. The nursing assistant can feed a client.

The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hour if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL per hour. At what rate should the nurse set the pump?

20 mL per hour

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.

1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. WRONG! restricted in hypertension 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply. 1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for paresthesia.

1. The nurse should determine if the client has any numbness or tingling. 2. The nurse should determine if the client has pulses, the presence of which indicates there is no circulatory compromise. 3. The nurse should determine if the client can move the feet and legs. 4. The nurse should determine if the client's feet are pink or pale. 5. The nurse should assess the feet to determine if they are cold or warm.

The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1480 mL. What is the total intake for this client?_______

1520 mL

The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every shift and PRN.

2. Clients should be on bed rest for five (5) to seven (7) days after diagnosis to allow time for the clot to adhere to the vein wall, thereby preventing embolization. 3. Bed rest and limited activity predispose the client to constipation. Fluids and diets high in fiber will help prevent constipation. Fluids will also help provide adequate fluid volume in the vasculature. 4. The client will be administered a heparin IV drip, which should be monitored.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?

3. The client is complaining of numbness in the right foot. - indicate decreased blood supply to the right foot - do neurovascular assessment after PTCA - keep legs straight for 6-8 hours

The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first? 1. Complete a neurovascular assessment.

An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease, but the nurse must ensure that the feet can be moved and are warm, which indicates adequate blood supply to the feet.

Which interventions should the nurse discuss with the client diagnosed with atherosclerosis?Select all that apply. 1. Include significant other in the discussion. 2. Stop smoking or using any type of tobacco products

Adherence to lifestyle modifications is enhanced when the client receives support from significant others. 2. Tobacco use is the most significant modifi- able risk factor that contributes to the development of atherosclerosis.

The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client who is four (4) day post-operative abdominal surgery and is complaining of left calf pain when ambulating.

A complication of immobility after surgery is developing a DVT. This client with left calf pain should be assessed for a DVT.

The nurse is teaching a class on coronary artery disease. Which modifiable risk factors should the nurse discuss when teaching about atherosclerosis? 1. Stress.

A modifiable risk factor is a risk factor that can possibly be altered by modifying or changing behavior, such as developing new ways to deal with stress.

The nurse is discussing the pathophysiology of atherosclerosis with a client who has a normal high-density lipoprotein (HDL) level. Which information should the nurse discuss with the client concerning HDL? A normal HDL is good because it has a protective action in the body.

A normal HDL level is good because HDL transports cholesterol away from the tissues and cells of the arterial wall to the liver for excretion. This helps decrease the development of atherosclerosis.

Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration.

A potentially life-threatening complication of DVT is a pulmonary embolus, which causes chest pain. The nurse should determine if the client has "thrown" a pulmonary embolus.

Which assessment data would support the diagnosis of abdominal aortic aneurysm (AAA)? 2. Abdominal bruit.

A systolic bruit over the abdomen is a diagnostic indication of an AAA.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?

Assist the client to a sitting position THEN vital and check pulse ox then sponge the client's forehead

. The nurse and an unlicensed nursing assistant are caring for a 64-year-old client who is four (4) hours post-operative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the unlicensed nursing assistant? Elevate the foot of the client's bed.

After the surgery, the client's legs will be elevated to help decrease edema. The surgery has corrected the decreased blood supply to the lower legs.

The health-care provider prescribes an ACE inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication? 3. ACE inhibitors prevent vasoconstriction and sodium and water retention.

Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II, and this, in turn, prevents vasoconstriction and sodium and water retention.

Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease? 3. An antiplatelet medication

Anti-platelet medications inhibit platelet aggregations in the arterial blood, such as aspirin or clopidogrel (Plavix).

Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair? 1. Absent bilateral pedal pulses.

Any neurovascular abnormality in the client's lower extremities indicates the graft is occluded or possibly bleeding and requires immediate intervention by the nurse.

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?

Apical pulse rate of 110 and 4+ pitting edema of feet.

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?

Assess the client's chest dressing and vital signs. - if the chest pain is expected postop or if it is a complication

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?

Assess the client's neurovascular status. - assess for pulses, paresthesia, paralysis, coldness and pallor - HOB elevated no more than 10 degrees, client kept in bedrest

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?

Assess the client's serum potassium level. - assess apical pulse not radial pulse

The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first? 1. Assess the client's bowel sounds.

Assessment is the first part of the nursing process and is the first intervention the nurse should implement.

The nurse knows the client understands the teaching concerning a low-fat, lowcholesterol diet when the client selects which meal? 3. Baked chicken, baked potato, and skim milk.

Baked, broiled, or grilled meats are recommended; a plain baked potato is appropriate; and skim milk is low in fat—so this meal is appropriate for a low-fat, lowcholesterol diet.

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?

CARDIAC REHABILITATION

Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency? Brown discolored skin

Chronic venous insufficiency leads to chronic edema that, in turn, causes a brownish pigmentation to the skin.

The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply. 1. Wash legs and feet daily in warm water. 2. Apply moisturizing cream to feet. 4. Do not wear any type of knee stocking. 5. Wear clean white cotton socks.

Cold water causes vasoconstriction and hot water may burn the client's feet; therefore, warm tepid water should be recommended. 2. Moisturizing prevents drying of the feet. 4. This will further decrease circulation to the legs. 5. Colored socks have dye and dirty socks may cause foot irritation that may lead to breaks in the skin.

The nurse is discussing the importance of exercising with a client who is diagnosed with CAD. Which statement best describes the scientific rationale for encouraging 30 minutes of walking daily to help prevent complications of atherosclerosis? 1. Exercise promotes the development of collateral circulation.

Collateral circulation is the development of blood supply around narrowed arteries; it helps prevent complications of atherosclerosis, including myocardial infarction, cerebrovascular accidents, and peripheral vascular disease. Exercise promotes the development of collateral circulation.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?

Diaphoresis and cool clammy skin. - these are systemic reaction

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?

Do not walk outside if it is less than 40˚F. - when it is cold outside, it causes vasoconstriction and lower oxygen to heart muscles - perform isotonic exercises not isometric - walk at least 30 minutes not 15 minutes for 3-4 times - wear supportive shoes not sandals!

The nurse is caring for the client with chronic venous insufficiency. Which statement indicates that the client understands the discharge teaching? 2. "I need to elevate the foot of my bed while sleeping."

Elevating the foot of the bed while sleeping helps the venous blood return to the heart and decreases pressure in the lower extremity.

The client diagnosed with essential hypertension asks the nurse, "I don't know why the doctor is worried about my blood pressure. I feel just great." Which statement by the nurse would be the most appropriate response? 1. "Damage can be occurring to your heart and kidneys even if you feel great."

Even if the client feels great, the blood pressure can be elevated, causing damage to the heart, kidney, and blood vessels.

Which actions should the surgical scrub nurse take to prevent from personally developing a DVT? 2. Flex the leg muscles and change the leg positions frequently.

Flexing the leg muscles and changing positions assist the blood to return to the heart and move out of the peripheral vessels.

The health-care provider ordered a femoral angiogram for the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement? 4. Inform the client that fluids will be increased after the procedure.

Fluids will help flush the contrast dye out of the body and help prevent kidney damage.

The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins? 4. Wear graduated compression hose.

Graduated compression hose help decrease edema and increase the circulation back to the heart; this helps prevent varicose veins.

The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client? 3. Avoid green leafy vegetables and notify the HCP of red or brown urine.

Green leafy vegetables contain vitamin K, which is the antidote for warfarin. These foods will interfere with the action of warfarin. Red or brown urine may indicate bleeding.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will:

Have an audible S1 and S2 with no S3 heard by end of shift.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

Have the client sit down immediately. - decreases the need for oxygen, may help decrease the chest pain

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

Help position the client who is having a portable x-ray done. - unstable patient from ICU is not delegated - teaching is not delegated

Which assessment data would cause the nurse to suspect the client has atherosclerosis? 3. Intermittent claudication.

Intermittent claudication is a sign of generalized atherosclerosis and is a marker of atherosclerosis.

The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm. Which sign/symptom would make the nurse suspect the client has an expanding AAA? 1. Complaints of low back pain.

Low back pain is present because of the pressure of the aneurysm on the lumbar nerves; this is a serious symptom, usually indicating that the aneurysm is expanding rapidly and about to rupture.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?

Monitor the client's potassium level and assess the client's intake of bananas and orange juice. - most probable cause of the pain is hypokalemia - peripheral edema may cause calf tightness not cramping

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

Notify the health-care provider immediately. - means left ventricular failure, should be reported ASAP

Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease? 3. The client has numbness and tingling.

Numbness and tingling are paresthesia, which is a sign of a severely decreased blood supply to the lower extremities.

The male client is diagnosed with Guillain Barré syndrome (GB) and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range of motion (ROM) exercises? 4. They help to prevent DVTs by movement of the blood through the veins.

One reason for performing range of motion exercises is to assist the blood vessels in the return of blood to the heart, preventing DVT.

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment? 2. "I don't have any abdominal pain or any type of problems."

Only about two-fifths of clients with AAA have symptoms; the remainder are asymptomatic.

The male client diagnosed with essential hypertension has been prescribed an alphaadrenergic blocker. Which intervention should the nurse discuss with the client? Change position slowly when going from lying to sitting position.

Orthostatic hypotension may occur when the blood pressure is decreasing and may lead to dizziness and light-headedness so the client should change position slowly.

The client is being admitted with Coumadin (warfarin), an anticoagulant, toxicity. Which laboratory data should the nurse monitor?. 3. International Normalized Ratio (INR).

PT/INR is a test to monitor warfarin (Coumadin) action in the body.

The client with varicose veins is six (6) hours post-operative vein ligation. Which nursing intervention should the nurse implement first? 2. Assess and maintain pressure bandages on the affected leg.

Pressure bandages are applied for up to six (6) weeks after vein ligation to help prevent bleeding and to help venous return from the lower extremities when in the standing or sitting position.

The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse? 2. The client has a weight gain of 2 kg within 1-2 days.

Rapid weight gain—for example, 2 kg in 1-2 days—indicates that the loop diuretic is not working effectively; 2 kg equals 4.4 lbs; 1 L of fluid weighs l kg.

The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client? 1. Notify HCP of any redness or irritation of incision.

Redness or irritation of the incision indicates infection and should be reported immediately to the HCP.

The unlicensed nursing assistant is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. Applying compression stockings before going to bed.

Research shows that removing the compression stockings while the client is in bed promotes perfusion of the subcutaneous tissue. The foot of the bed should be elevated.

The wife of a client with arterial occlusive disease tells the nurse, "My husband says he is having rest pain. What does that mean?" Which statement by the nurse would be most appropriate? 2. "His legs are deprived of oxygen during periods of inactivity."

Rest pain indicates a worsening of the arterial occlusive disease; the muscles of the legs are not getting enough oxygen when the client is resting to prevent muscle ischemia.

The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation? 2. Discuss sedentary lifestyle and smoking cessation.

Sedentary lifestyle is discouraged in clients with hypertension, and daily isotonic exercises are recommended. Smoking increases the atherosclerotic process in vessels; causes vasoconstriction of vessels; and adheres to hemoglobin, decreasing oxygen levels.

The HCP prescribes an HMG-COA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication? 2. This medication should be taken in the evening.

Statin medications should be taken in the evening for best results because the enzyme that destroys cholesterol works best in the evening and the medication enhances this process.

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?

Teach the client how to prevent orthostatic hypotension. - if cough stop the medication - may cause hyperkalemia - take 1 hour before meals or 2 hours after meals

The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands the client teaching concerning the DASH diet? 1. "I should eat at least four (4) to five (5) servings of vegetables a day."

The DASH diet has proved beneficial in lowering blood pressure. It recommends eating a diet high in vegetables and fruits.

The nurse and an unlicensed nursing assistant are bathing a bedfast client. Which action by the assistant warrants immediate intervention? 2. The assistant begins to massage and rub lotion into the client's calf.

The assistant could dislodge a blood clot in the leg when massaging the calf. The assistant can apply lotion gently, being sure not to massage the leg.

The nurse just received the A.M. shift report. Which client should the nurse assess first? The client diagnosed with deep vein thrombosis who is complaining of chest pain.

The chest pain could be a pulmonary embolus secondary to deep vein thrombosis and requires immediate intervention by the nurse.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?

The client diagnosed with myocardial infarction who has an audible S3 heart sounds. - S3 is ventricular failure it is an emergency

Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer? 1. Impaired skin integrity.

The client has a foot ulcer, therefore the protective lining of the body—the skin— has been impaired.

The client is one (1) day post-operative abdominal aortic aneurysm repair. Which information from the unlicensed nursing assistant would require immediate intervention from the nurse? 2. The client's urinary output is 90 mL in six (6) hours.

The client must have 30 mL urinary output every hour. Clients who are post-operative AAA are at high risk for renal failure because of the anatomical location of the AAA near the renal arteries.

The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement? 2. Explain that the client needs to lower the cholesterol level.

The client needs to be taught ways to lower the cholesterol level.

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?

The client refuses to keep the leg straight.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication?

The client's blood pressure is 90/62. - apical pulse between 60-100 can give - serum calcium is not monitored for Ca channel blockers - if BP lower than 90 do not give

The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis? 1. Hairless skin on the legs.

The decreased oxygen over time causes the loss of hair on top of feet and ascends both legs.

1. The 66-year-old male client has his blood pressure (BP) checked at a health fair. The B/P is 168/98. Which action should the nurse implement first? Instruct the client to see his health-care provider as soon as possible.

The diastolic blood pressure should be less than 85 according to the American Heart Association; therefore, this client should see the health-care provider.

The nurse has just received the A.M. shift report. Which client would the nurse assess first? 3. The client with arterial occlusive disease who cannot move the foot.

The inability to move the foot means that a severe neurovascular compromise has occurred, and the nurse should assess this client first.

The client diagnosed with arterial occlusive disease is one (1) day post-operative right femoral popliteal bypass. Which intervention should the nurse implement? 4. Assess the client's leg dressing every four (4) hours.

The leg dressing needs to be assessed for hemorrhaging or signs of infection.

Which assessment data would support that the client has a venous stasis ulcer? 1. Superficial pink open area on the medial part of the ankle.

The medial part of the ankle usually ulcerates because of edema that leads to stasis, which, in turn, causes the skin to break down.

Which client would be most likely to develop an abdominal aortic aneurysm? 3. A 69-year-old male with peripheral vascular disease.

The most common cause of AAA is atherosclerosis (which is the cause of peripheral vascular disease); it occurs in men four (4) times more often than women and primarily in Caucasians.

The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply. 1. Tell the client to exercise three (3) times a week for 30 minutes. 2. Encourage the client to eat a low-fat, low-cholesterol diet. 4. Discuss with the client the importance of losing weight.

The most common cause of AAA is atherosclerosis, so teaching should address this area. 2. A low-fat, low-cholesterol diet will help decrease development of atherosclerosis. 4. Losing weight will help decrease the pressure on the AAA and will help address decreasing the cholesterol level.

The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? Venous ulcerations.

Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcerations to heal, and often clients must be seen in wound care clinics for treatment.

The client diagnosed with a DVT is on a heparin (an anticoagulant) drip at 1400 units per hour, and Coumadin (warfarin sodium; also an anticoagulant) 5 mg twice a day. Which intervention should the nurse implement first? 1. Check the PTT and PT/INR.

The nurse should check the laboratory values pertaining to the medications before administering the medications.

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement? 2. Question administering the medication if the blood pressure is 90/60 mmHg.

The nurse should question administering the beta blocker if the B/P is low because this medication will cause the blood pressure to drop even lower, leading to hypotension.

The 80-year-old client is being discharged home after having surgery to debride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client? Social worker.

The social worker would assess the client to determine if home health care services or financial interventions were appropriate for the client. The client is elderly, immobility is a concern, and wound care must be a concern when the client is discharged home.

The client diagnosed with essential hypertension asks the nurse, "Why do I have high blood pressure?" Which response by the nurse would be most appropriate? "There is no specific cause for hypertension, but there are many known risk factors."

There is no known cause for essential hypertension, but many factors, both modi- fiable (obesity, smoking, diet) and nonmodifiable (family history, age, gender) are risk factors for essential hypertension.

The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhaged areas on the upper abdomen. Which action should the nurse implement? 3. Explain that this results from the medication.

This is not hemorrhaging, and the client should be reassured that this is a side effect of the medication.

The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record? 2. Intermittent claudication.

This is the classic symptom of arterial occlusive disease.

The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis? 3. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels.

This is the scientific rationale why diabetes mellitus is a modifiable risk factor for atherosclerosis.

The client asks the nurse, "My doctor just told me that atherosclerosis is why my legs hurt when I walk. What does that mean?" Which response by the nurse would be the best response? 4. "You have a hardening of your arteries that decreases the oxygen to your legs."

This response explains in plain terms why the client's legs hurt from atherosclerosis.

The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions? 4. Smoking cigarettes.

Tobacco use is the strongest factor in the development of atherosclerotic lesions. Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure. It also increases the risk of clot formation by increasing the aggregation of platelets.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction?

Troponin. - elvated within 1-2 hours - CK-MB within 12-24 - LDH within 24-36

The client with varicose veins asks the nurse, "What caused me to have these?" Which statement by the nurse would be most appropriate? 1. "You have incompetent valves in your legs."

Varicose veins are irregular, tortuous veins with incompetent valves that do not allow the venous blood to ascend the saphenous vein.

Which client would be most at risk for developing varicose veins? 1. A Caucasian female who is a nurse.

Varicose veins are more common in white females in occupations that involve prolonged standing.

The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? 3. The client takes vitamin E over-the-counter medications.

Vitamin E can affect the action of warfarin. The nurse should explain to the client that these and other medications could potentiate the action of warfarin.

2. The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing exercise? Walk at least 30 minutes a day on flat surfaces.

Walking 30 to 45 minutes a day will help in reducing blood pressure, weight, and stress and will increase a feeling of overall wellbeing.

Which instruction should be included when a client diagnosed with peripheral arterial disease is being discharged? 3. Instruct the client to walk daily for at least 30 minutes.

Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis.

Which medical treatment would be prescribed for the client with an AAA less than 3 cm? 1. Ultrasound every six (6) months.

When the aneurysm is small (5-6 cm) an abdominal sonogram will be done every six (6) months until the aneurysm reaches a size at which surgery to prevent rupture is of more benefit than possible complications of an abdominal aortic aneurysm repair.