UWorld Cardiovascular

The most concerning findings of PAD:

- Cool skin temperature: Skin temperature that is cool to touch is associated with impaired perfusion. This is especially concerning when it occurs in a localized area (eg, lower left extremity) along with other findings associated with impaired perfusion (eg, decreased leg hair). - Decreased palpable pulses: Decreased palpable pulses indicate impaired perfusion to the affected area. This finding is concerning for peripheral artery disease. - Delayed capillary refill time (ie, >3 sec): Delayed reperfusion to distal extremities is concerning for impaired perfusion (eg, peripheral artery disease) or fluid volume deficit. Hypertension and elevated BMI are risk factors for peripheral artery disease. These findings should be addressed, BUT signs of impaired perfusion are the priority to prevent further disease progression. This client has a history of chronic obstructive pulmonary disease, and the lung examination findings (ie, decreased breath sounds throughout and prolonged expiration) are EXPECTED. The client is not in respiratory distress and saturating oxygen well with normal respiratory rate

Client teaching regarding prevention of vasospasms for Raynaud phenomenon includes:

- Wear gloves when handling cold objects (Option 5) = Dress in warm layers, particularly in cold weather. - Avoid extremes and abrupt changes in temperature. - Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). - Avoid excessive caffeine intake (Option 1). - Refrain from use of tobacco products (Option 4). - Implement stress management strategies (eg, yoga, tai chi) (Option 3). - If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes. Cold water will cause vasoconstriction and worsen the condition.

The client received a prescription for varenicline for smoking cessation. Which of the following statements indicate a correct understanding of the teaching? Select all that apply.

1. "I can start this medication now while planning to stop smoking cigarettes soon." 2."I may experience a disturbance in my sleep and have unusual dreams." ."4."I should call my health care provider if I notice a significant change in my mood." Smoking = risk factor of PAD. Varenicline is a partial nicotine agonist that aids in smoking cessation. - Smoking cigarettes is permissible while on the medication because varenicline inhibits nicotine receptor stimulation, which decreases the pleasurable effects and nicotine cravings (Option 1). - Sleep disturbances and unusual dreams are common adverse effects (Option 2) Significant changes in behavior or mood are warning signs of suicidal behavior that should be reported to the provider (Option 4) Weight GAIN is a common effect of smoking cessation; Varenicline CAN be combined with a nicotine replacement (eg, gum, lozenge) if cravings cannot be controlled.

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.

1. "I will apply moisturizing lotion on my legs every day." "3."I will keep my legs below heart level when sitting. "4."I will start walking outside with my neighbor." - Lower the extremities below the heart when sitting and lying down - improves arterial blood flow - Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion - Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin - Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation - Stop smoking - prevents vessel spasm and constriction - Avoid tight clothing and stress - prevents vasoconstriction - Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development elevating legs promotes venous return NOT arterial circulation heating pads should not be used with altered perfusion or sensation d/t increased risk for burns

Which of the following prescriptions should the nurse anticipate? Select all that apply.

1. 12-lead ECG - 12-lead ECG to assess for abnormal electrical cardiac conduction. ECG changes vary based on the location and extent of myocardial damage. MIs may be classified as either ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI), 3. Blood specimen for troponin level - Troponin is a highly specific cardiac marker for the detection of MI. Cardiac enzymes are released into the bloodstream as ischemic myocardial cells become necrotic and lyse (ie, rupture). Serum troponin levels rise approximately 4 hours after the onset of MI and peak near 24 hours post-MI Orthostatic vital signs assess for orthostatic hypotension, a significant drop in blood pressure with position changes often caused by medications and dehydration. Blood specimen for culture and sensitivity is indicated when clinical manifestations concerning for sepsis are present (eg, infection, tachycardia, fever, hypotension A urine specimen for urinalysis aids in diagnosing urinary tract infections or other renal abnormalities a

Which of the following conditions should the nurse suspect as the cause of back pain

1. Abdominal aortic aneurysm - client reporting new-onset back pain and abdominal pulsation. 3.Intervertebral disc herniation (bulging of an intervertebral disc) -which places pressure on nearby spinal nerve roots that results in back pain; usually the pain is burning or shock-like and often radiates down the legs (below the knees to the foot); 4.Kidney stone -can obstruct the urinary tract, resulting in abdominal, flank, or back pain that ranges from dull to sudden and severe; pain may radiate to the groin, and hematuria may be present 5.Peptic ulcer perforation - may cause burning and epigastric pain; however, if the ulcer is perforating through the posterior walls, pain radiating to the back may be present as well Appendicitis typically causes persistent periumbilical pain that migrates to the right lower abdominal quadrant (RLQ), followed by onset of nausea. It typically doesn't cause back pain

The nurse should prioritize interventions for ________ due to the risk of __________ .

1. Abdominal aortic aneurysm 2. Intraabdominal hemorrhage When an abdominal aortic aneurysm (AAA) is left untreated, the continuous force of blood pumping through the aorta (ie, hydrostatic pressure) can increase the dilated diameter of the aneurysm over time and eventually overcome the weakened arterial wall, causing it to rupture. A ruptured aorta can temporarily develop a hematoma but often causes massive hemorrhage and death without immediate intervention. The nurse should prioritize interventions to prevent, detect, and emergently manage AAA rupture due to the risk of life-threatening intraabdominal hemorrhage. Kidney stones can cause urinary obstruction and urine stasis. Without treatment these conditions can lead to renal infection, hydronephrosis (ie, kidney distension), and kidney injury. Peptic ulcer disease can lead to gastrointestinal perforation and peritonitis if ulcers are left untreated Disc herniation typically causes corresponding nerve root spinal cord compression resulting in radicular pain to the legs because most herniations occur on the lateral side.

The nurse observes the rhythm shown in the exhibit on a client's cardiac monitor. The client reports palpitations and lightheadedness. Which intervention does the nurse anticipate? Click on the exhibit button for additional information.

1. Adenosine IVP This client is experiencing paroxysmal supraventricular tachycardia (PSVT). In PSVT, the heart rate can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced cardiac output such as hypotension, palpitations, dyspnea, and angina. Treatment includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of choice for PSVT treatment. Due to its very short half-life, adenosine is administered rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be given twice if previous administration is ineffective Atropine: increases HR in clients with sympotomatic bradycardia (less that 60/min) and external pacing is used for symptomatic bradycardia too Defibrillation - ventricular filbrilation

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.

1. Avoid excessive caffeine 3. Practice yoga or tai chi 4. Refrain from using tobacco products 5. Wear gloves when handling cold objects Raynaud phenomenon is a vasospastic disorder triggered by exposure to cold or stress. When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis --> numbness and coldness. When blood flow is restored --> area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water Key elements of client teaching include management of acute attacks, avoidance of vasoconstrictive substances (eg, tobacco, cocaine, caffeine), stress reduction, and appropriate clothing (eg, gloves, warm layers).

Which clinical finding is the priority for the nurse to investigate further?

1. Back pain Abdominal aortic aneurysm (AAA) is a bulging or outpouching of the aorta caused by weakening of the arterial wall.Symptoms may include abdominal and back pain, leg pain (due to ischemia of lower limbs), and abdominal pulsation (ie, throbbing). These findings are the priority for further investigation to determine if AAA is present or rupturing

The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension?

1. Black race 2.Frequent stress at work 4.Smoking one pack of cigarettes daily 5.Type 2 diabetes mellitus Your HDL ("good" cholesterol) is the one number you want to be high (ideally above 60). Your LDL ("bad" cholesterol) should be below 100.

A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted into the left femoral artery. What signs of potential complications should the nurse report immediately to the health care provider (HCP)? Select all that apply.

1. Bleeding at the catheterization site - Bleeding at the puncture site indicates that a clot has not formed at the insertion site. This is an arterial bleed as catheterization was done via the femoral artery. Arterial bleeds can lead to hypovolemic shock and death if not treated immediately. 4. Left foot remarkably cooler than right foot -Reduced warmth in the lower extremity of the insertion site is a sign of decreased perfusion (lack of oxygenated blood flow) to the extremity and can result in tissue necrosis of the affected area.

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? Select all that apply. Loop diuretics (furosemide, torsemide, bumetanide) are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis.

1. Blood pressure - Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. 2. Blood urea nitrogen (BNP) - Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. 4. Potassium - When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, a medical emergency that can result in other life-threatening complications such as heart arrythmias, as well as muscle cramps and weakness monitor: vital signs, serum electrolytes, kidney function tests (blood urea nitrogen/creatinine) --> prevent hypokalemia, hypotension, and kidney injury

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?

1. Head of the bed elevated to a 45-degree angle Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a 30- to 45-degree angle. The nurse will observe for distension and prominent pulsation of the neck veins. The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overlo

The nurse is caring for the client after coronary artery bypass grafting. Complete the following sentence by choosing from the lists of options. The nurse should be most concerned if the client develops ____________ that may indicate ____________

1. Hypotension 2. Cardiac tamponade Coronary artery bypass grafting (CABG) is a surgical intervention that involves harvesting healthy blood vessels (ie, grafts) from a different part of the body (eg, great saphenous vein) to reroute myocardial blood flow around the blocked coronary arteries. Following CABG, clients are at risk for bleeding and fluid accumulation within the pericardial sac (ie, pericardial effusion). Hypotension may indicate progression to life-threatening hemorrhage or cardiac tamponade. Cardiac tamponade impairs contractility of the heart and requires immediate intervention (eg, pericardiocentesis, emergency sternotomy) to restore function. Left untreated, hypotension can also cause the graft to collapse.

The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)?

1. Pain or pallor in one foot In IE, the vegetations over the valves can break off and embolize to various organs, resulting in life-threatening complications. These include the following: - Stroke - paralysis on one side - Spinal cord ischemia: paralysis of both legs - Ischemia to the extremities - pain, pallor, and cold foot or arm - Intestinal infarction: abdominal pain - Splenic infarction: left upper-quadrant pain (LUQ) IE commonly/expected s/s: fever, arthralgias (multiple joints pains - pain in both knees), weakness, and fatigue. IE clients typically require intravenous antibiotics for 4-6 weeks. Splinter hemorrhages can occur with infection of the heart valves (endocarditis). Not as critical as macroemboli causing stroke or painful cold leg

The nurse should prioritize interventions for _______ to prevent _______

1. Peripheral artery disease 2. Tissue necrosis The nurse should prioritize interventions for peripheral artery disease (PAD) to prevent tissue necrosis. PAD is characterized by impaired perfusion, particularly to the lower extremities. Without intervention (eg, lifestyle changes, surgical revascularization), PAD progressively worsens, and clients can develop ischemic pain at rest, nonhealing ulcers, gangrene, and tissue necrosis. DVT --> pulmonary emboli Chronic venous insufficiency (inadequate venous blood return to the heart) --> venous stasis ulcers (side of the ankle)

Click to highlight the prescription that the nurse should perform first.

1. Request transport to an emergency medical care facility - The clinic setting may have limitations regarding diagnostic testing (eg, ultrasound) and necessary treatment options for abdominal aortic aneurysm (AAA). Treatment for a small, asymptomatic AAA includes close monitoring, medication (eg, beta blocker), and possible elective surgical intervention. However, if imaging reveals a ruptured or impending rupture of AAA, the client requires immediate surgical repair. Therefore, the priority is to arrange transport to an emergency medical care facility.

The nurse identifies which of the following risk factors as contributing to the development of peripheral artery disease? Select all that apply.

1. cigarette smoking 2. diabetes mellitus 3. hyperlipidemia Factors that cause chronic vascular changes and increase risk for PAD include: - Smoking: Chronic vasoconstriction from nicotine inhalation (Option 1) - Hypertension: Vessel damage from chronically elevated vascular resistance - Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option 2) - Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option 3) Elevated estrogen levels (eg, oral contraceptive use, pregnancy, hormone replacement therapy) make blood hypercoagulable. However, elevated estrogen levels are more likely to form thrombi in veins

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first?

2. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension The client with pericardial effusion should be seen first. This client is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distension) of developing cardiac tamponade, a life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart. The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Emergency pericardiocentesis is needed. Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable; this client is not a priority over the client with possible tamponade. Atrial fibrillation is often a chronic arrhythmia and is managed with ventricular rate control and anticoagulation. Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic.

A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

2. Administer furosemide 40 mg IV push S/s of pulmonary edema: - A history of orthopnea and/or paroxysmal nocturnal dyspnea - Anxiety and restlessness - Tachypnea (often >30/min), dyspnea, and use of accessory muscles - Frothy, blood-tinged sputum - Crackles on auscultation This client is exhibiting signs of pulmonary edema, a life-threatening condition. The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema Management of acute decompensated heart failure (ADHF) may also include oxygen therapy, vasodilators (eg, nitroglycerin, nesiritide), and positive inotropes (eg, dopamine, dobutamine). digoxin - improves contractility -- long term treatment of HF dopamine - short-term treatment of ADHF, does not resolve fluid overload

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively?

2. Assess character and quality of peripheral pulses The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Graft occlusion may require reoperation. Peripheral artery disease = absence of hair growth on lower extremities

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up?

2. Blood pressure is 96/66 mm Hg and apical pulse is 112/min The client must be monitored postoperatively for graft leakage and hemodynamic stability. Adequate blood pressure is necessary to maintain graft patency, and prolonged hypotension can lead to the formation of graft thrombosis. Signs of graft leakage include a decreasing blood pressure and increasing pulse rate.

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP?

2. Difficulty swallowing Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment. low back pain - abdominal aortic aneurysm

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse?

2. Distant heart tones and jugular venous distension When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (life threatening complication of PE) (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest. Expected findings in PE: pericardial friction rub --> =high-pitched, leathery, and grating sound, ST-segment elevation in almost all ECG leads, pain that worsens with deep breathing or when in supine position (sit thek in Fowler *45-60 position with support)

The nurse is teaching the client about home management of peripheral artery disease. Which of the following statements should the nurse include in the teaching? Select all that apply.

2. Incorporate more fruits and vegetables into your diet." 3. "Inspect your feet daily for any wounds." 5. "Walk each day until you have leg pain, rest for 10 minutes, and then continue walking." Home management of peripheral artery disease (PAD) focuses on symptom management and lifestyle modifications to prevent worsening PAD, such as: - Incorporating more fruits and vegetables into the diet and consuming low-cholesterol, low-fat foods to reduce formation of additional arterial plaques (Option 2) - Inspecting the feet daily for wounds because decreased perfusion can lead to small foot ulcerations or gangrene (Option 3) - Exercising regularly with light physical activity, stopping if ischemic pain develops, and gradually increasing the intensity to promote development of collateral arteries, improve perfusion, and decrease exertional pain (Option 5) Elevating the legs would further impair arterial blood flow and distal perfusion, and worsen symptoms in clients with PAD. - Elevated legs = chronic venous insufficiency to promote venous return Clients with PAD have decreased sensations from nerve ischemia and should never apply direct heat (eg, heating blanket) to the extremity due to the increased risk for a burn injury.

The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?

2. Keep a diary of activities and any symptoms experienced A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities. Client instructions include the following: - Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances -Do not bathe or shower during the test period (Option 4) - Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record (Option 3) - Results/data not over the phone, take the monitor back to provider's office

The nurse is performing an initial assessment on a client in hypertensive crisis. What is the nurse's priority assessment? Click on the exhibit button for additional information.

2. Level of consciousness The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention (Option 2). Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting.

The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding?

2. Murmur heard at the aortic area Murmurs are produced by turbulent blood flow across diseased or malformed cardiac valves. They can be characterized as musical, blowing, swooshing, or rasping sounds heard between normal heart sounds. The aortic area is located at the second intercostal space, right sternal border. - Arterial bruit = turbulent blood flow sound heard in peripheral artery -Pericardial friction rub (inflamed surfaces of the heart rub against each other) = high-pitched, scratchy sound during S1 or S2 at the apex of the heart. It is best heard with the client sitting and leaning forward and at the end of expiration. - S3 gallop = extra heart sound that occurs closely after S2, low-pitched sound heard in early diastole that is similar to the sound of a horse's gallop.

The nurse is caring for a client who had an anterior wall myocardial infarction 24 hours ago. Which finding is most concerning at this time?

2. New S3 heart tone Myocardial infarction (MI) can affect the pumping ability of the left ventricle, putting the client at risk for heart failure and cardiogenic shock. The development of pulmonary congestion, auscultation of a new S3 heart tone, crackles on lung auscultation, or jugular venous distension can signal heart failure and should be immediately reported to the health care provider ( An increase in temperature following an MI is usually due to a systemic inflammatory process caused by myocardial cell death. During MI, clients may experience nausea and vomiting resulting from stimulation of the vomiting center by severe pain or from vasovagal reflexes initiated from the area of the infarction. T Dysrhythmias are a common complication after MI due to ventricular irritability. Premature ventricular contractions are not significant if they occur infrequently.

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply.

2. Notify health care provider (HCP) of redness, swelling, or drainage at the incision site 3.Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP 4.Take a shower daily without soaking chest and leg incisions - Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). - Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. - Clarify no driving for 4-6 weeks or until the HCP approves. - If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). - Notify the HCP if the following symptoms occur:Chest pain or shortness of breath that does not subside with restFever >101 F (38.3 C)Redness, drainage, or swelling at the incision sites (Option 2).

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN?

2. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry The carotid arteries should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a syncopal episode. Pulse symmetry for other key arteries (eg, temporal, brachial, radial, posterior tibial) is assessed by bilaterally palpating each pair simultaneously. Erbs point - third left ICS --> auscultate heart murmurs JVD = semi-fowler's position (30-45 degrees) To assess the point of maximal impulse (PMI) the client is positioned supine or with the head of the bed elevated to 45 degree

The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.

3 Ventricular fibrillation (VF) = chaotic QRS complex es--> SHOCK VF is characterized on the ECG by irregular waveforms of varying shapes and amplitudes. This represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as heart failure and cardiac myopathy. Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine, vasopressin, amiodarone).

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?

3. 500 mg naproxen twice daily Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) are common medications used for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. The nurse should investigate the reason a client with cardiovascular disease is taking an NSAID and alert the health care provider of the medication usage Isosorbide dinitrate (Isordil) is a long-acting nitrate medication prescribed to prevent angina in clients with CAD. Atorvastatin (Lipitor) is a statin drug prescribed to lower cholesterol, which can reduce the risk of atherosclerosis and coronary artery disease. Fish oil is an over-the-counter nutritional supplement often taken by clients with heart disease or individuals at risk.

The nurse is caring for a client who, 30 minutes ago, underwent an ablation procedure for supraventricular tachycardia in the cardiac catheterization laboratory. The client has a dressing over the femoral insertion site with a small amount of oozing blood. Which action by the nurse causes the charge nurse to intervene?

3. Assists client to sit on the side of the bed to use the urinal After cardiac catheterization, clients must remain SUPINE with the HOB at ≤30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site. The charge nurse should intervene if the nurse is assisting the client to sit on the side of the bed to use the urinal (Option 3). - Small amount of bleeding is expected after the catheter is removed --> appropriate to apply pressure above the insertion site to control bleeding - Appropriate to verify adequate perfusion to the affected limb by palpating the pedal pulses bilaterally. -Chest pain after ablation may be due to cardiac muscle damage but could also be caused by cardiac ischemia. This should be reported immediately to the health care provider.

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform?

3. Check for presence and quality of posterior tibial and dorsalis pedis pulses This client is exhibiting symptoms of intermittent claudication or ischemic muscle pain that can be due to peripheral artery disease (PAD). PAD impairs circulation to the client's extremities. The nurse should first check for the adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality. Poor circulation to the extremities can place the client at increased risk for development of arterial ulcers and infection. Dry, scaly skin can be present in PAD - its a chronic condition of PAD and not a priority. When circulation to the extremities is impaired, the skin on the lower legs becomes thin, shiny, and taut; hair loss also occurs on the lower legs. This develops over time and would indicate that PAD has been present for a period of time and is not the priority assessment.

The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department. All ICU beds are currently full. Which client should the charge nurse consider as most appropriate for transfer out of the ICU?

3. Client extubated yesterday who has oxygen saturation of 95% on 2 L by nasal cannula Occasional premature ventricular contractions (PVCs) are common dysrhythmias that may be precipitated by several factors, including electrolyte imbalances (eg, potassium), stimulants (eg, caffeine, nicotine), and stress. Occasional PVCs typically do not cause hemodynamic instability. The client who is stable one day post extubation can be safely transferred to a telemetry or medical-surgical unit, where the occasional PVCs may be further investigated and treated (Option 3). Clients with atrial fibrillation and rapid ventricular response, complete heart block, or other threats to cardiovascular stability require continuous observation in the intensive care uni

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

3. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour Cardiac tamponade is a possible complication of acute pericarditis that impairs cardiac output and is life-threatening without immediate intervention. Clinical features of cardiac tamponade include hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) (Option 3). In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, and tachycardia may be present. Palpitations, tachycardia, and irregular pulse are expected findings in atrial fibrillation. Atrial fibrillation is usually a chronic arrhythmia. The heart rate must be controlled, but this is not a priority over tamponade. Increased white blood cell count in a client with infection may indicate ineffective treatment and/or progression to sepsis, both of which require follow-up. However, this finding is not immediately life-threatening. Liver cirrhosis causes portal hypertension and splenomegaly. An enlarged spleen sequestrates platelets, causing thrombocytopenia. Spontaneous bleeding requires further investigation after addressing a client with possible cardiac tamponade.

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?

3. Diffuse bilateral crackles at lung bases Acute-onset dyspnea and cough productive of pink, frothy sputum indicate severe pulmonary edema, likely a complication from myocardial infarction. Pink sputum results from ruptured bronchial veins due to high back pressure. The mix of blood and airway fluids creates the pink tinge. On assessment, crackles can be heard at the lung bases. Bronchial breath sounds at lung periphery = pneumonia Stridor = laryngospasm or edema of the upper airway.

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider

3. Leg. swelling Estrogen places clients at an increased risk for developing blood clots, due to hypercoagulability, and therefore adverse thrombotic events (eg, stroke, myocardial infarction, venous thromboembolism). Signs and symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider (HCP) immediately (Option 3). Transgender women clients are often prescribed antiandrogen medications (eg, spironolactone) to reduce androgen levels (eg, testosterone) and estrogen therapies to induce feminizing traits (eg, breast enlargement, reduction in body hair, decrease in testicular size and erectile function). Breast tenderness and enlargement are common = expected side effects weight gain = mild, caused by fluid retention

The nurse is caring for a client who experienced an anterior wall myocardial infarction 24 hours ago. The nurse recognizes the rhythm on the cardiac monitor as which rhythm? Click on the exhibit button for additional information.

3. Ventricular tachycardia Ventricular tachycardia (VT) is a potentially life-threatening dysrhythmia characterized by a ventricular rate of 100-250/min. The rhythm is often regular, but it can be irregular. QRS complexes are wider than 0.12 seconds and the P wave is usually buried in the QRS complex, making a PR interval unmeasurable. Pulseless VT is treated with cardiopulmonary resuscitation (CPR) and defibrillation.

The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis?

4. "When I sit down to rest and elevate my legs, the pain increases. The pain of peripheral artery is made WORSE with leg elevation. Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation. CHRONIC VENOUS INSUFFICIENCY: stasis ulcers on the medial side of the ankle; By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation.

A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Click on the exhibit button for additional information. Laboratory results Sodium: 134 mEq/L (134 mmol/L) Potassium: 3.4 mEq/L (3.4 mmol/L) Chloride: 108 mEq/L (108 mmol/L) Magnesium: 0.9 mEq/L (0.45 mmol/L)

4. Torsades de pointes Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate. Atrial fibrillation = clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening. Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers).

Hypertensive crisis

>180 and/or >120 Hypertensive crisis is a life-threatening medical emergency characterized by severely elevated blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure. Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema).

The nurse understands that the client has impaired perfusion of myocardial tissue. Urgent intervention is needed to reduce the client's risk of developing

Acute myocardial infarction affects ventricular function and requires urgent intervention to reduce the client's risk of developing heart failure, dysrhythmias, and cardiogenic shock. Clinical manifestations of HF include crackles with auscultation, a new S3 heart sound, pitting peripheral edema, and jugular venous distension Lethal arrhythmias such as ventricular tachycardia and ventricular fibrillation are a common cause of death from MI. In a client with an MI, signs of hypoperfusion such as altered mental status, decreased urine output, and cold/clammy skin are suggestive of cardiogenic shock. Infective endocarditis = inflammation of the innermost layer of heart --> associated with a history of congenital heart defects, valve replacement, and IV substance use Acute coronary syndrome (ACS) can lead to mechanical complications (ie, acute mitral regurgitation, ventricular septal rupture)

The home health nurse is visiting a client discharged 2 days ago after a coronary artery bypass graft. The client reports fatigue and palpitations, and the nurse connects the client to a portable heart monitor. The nurse recognizes the displayed rhythm as which type? Click on the exhibit button for additional information.

Atrial fibrillation (AF) is a common dysrhythmia after cardiac surgery. It is characterized by a total disorganization of atrial electrical activity that results in the loss of effective atrial contraction. P waves are not visible; they are replaced by fibrillatory waves. The ventricular rate varies, but the rhythm is typically irregular --> increased risk for stroke. Treatment includes rate control calcium channel blockers (eg, diltiazem, verapamil), beta blockers (eg, metoprolol), and digoxin to decrease rate to <100/min and anticoagulation to convert and maintain sinus rhythm (amiodarone, flecainide, and sotalol)

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action? Always ASSESS the client first, then report to the HCP

Auscultate the client's breath sounds Urine output of less than 30 mL/hr may indicate low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Given this client's heart failure, low urine output is likely due to decreased cardiac function and buildup of fluid in the lungs. The nurse should assess the lung sounds for crackles and report to the HCP, who can prescribe loop diuretics.

For each potential finding below, click to specify if the finding is consistent with the disease process of chronic venous insufficiency or peripheral artery disease. Each finding may support more than one disease process.

CHRONIC VENOUS INSUFFICIENCY: peripheral edema, pain improves with leg elevation D/T increased venous return PERIPHERAL ARTERY DISEASE: decreased leg hair, decreased peripheral pulses, skin temperature cool to touch The hallmark clinical manifestation of PAD is ischemic lower extremity pain during periods of exertion (due to increased oxygen demand) that is relieved with REST (ie, intermittent claudication). PAD --> ischemic ulcers between the toes, which can be painful and lead to infection (eg, gangrene).

The nurse calls for help, initiates chest compressions, and instructs the unlicensed assistive personnel (UAP) to obtain an automatic external defibrillator. For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client.

Expected: Instruct the UAP to contact emergency services, , open the client's airway using the jaw-thrust maneuver, place the defibrillator pads o the the right upper chest and left sternal rib cage, perform chest compressions with a ratio of 3 compressions to 2 breaths Unexpected: alternate compressions with the UAP every 5 minutes Cardiac arrest is a sudden cessation of heart function (ie, absence of a palpable pulse) and cardiac output that requires immediate CPR to restore perfusion to the brain and vital organs. Appropriate interventions for an adult in cardiac arrest include initiating chest compressions at a ratio of 30 compressions to 2 rescue breaths, contacting emergency services, obtaining a defibrillator, and applying defibrillator pads while continuing chest compressions. (The UAP should apply the pads while the nurse continues to provide chest compressions, minimizing interruptions between compressions) . The jaw-thrust maneuver should be used instead of the head tilt-chin lift maneuver to open the airway in clients who may have a head/spinal injury (forehead hematoma) - Fatigue can lead to ineffective compression depth or speed. To avoid fatigue, health care providers and unlicensed assistive personnel should alternate the role of compressor every 2 minutes (ie, every 5 cycles of CPR).

The client is diagnosed with peripheral artery disease. For each potential prescription, click to specify if the prescription is expected or unexpected for the care of the client.

Expected: antiplatelet medication, lipid-lowering medication, antihypertensive medication, blood testing for hemoglobin A1c, referral for supervised exercise therapy. unexpected: graduated compression stockings to the left lower extremity - Expected prescriptions include: - Antiplatelet medication (eg, aspirin, clopidogrel) to prevent further thrombus development. - Lipid-lowering medication (eg, HMG-CoA reductase inhibitor [statin]) to decrease atherosclerosis and improve blood flow. - Antihypertensive medication (eg, ACE inhibitor) to lower blood pressure and promote vasodilation, which improves blood flow. - Hemoglobin A1c level to check average blood glucose levels over the past 3 months; hyperglycemia causes inflammatory vascular changes that may contribute to PAD. If the client's hemoglobin A1c is high, blood glucose control is necessary. - Referral for supervised exercise therapy to promote collateral circulation and distal tissue perfusion with a gradual increase in exercise. Graduated compression stockings to the left lower extremity would be UNEXPETCED because compression would further impede arterial blood flow and perfusion to the feet. Compression stockings = chronic venous insufficiency to improve venous stasis.

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply.

RIGHT SIDED HEART FAILURE = SYSTEMIC/VENOUS CONGESTION 2. increased abdominal girth (ascites, hepatomegaly, splenomegaly) 3. jugular venous distention 4. lower extremity edema - Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option 4). - Jugular venous distension (Option 3). - Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option 2). - Hepatomegaly due to hepatic venous congestion Orthopnea (dyspnea with recumbency/lying flat), paroxysmal nocturnal dyspnea (PND), and crackles in lung bases are clinical manifestations of left-sided heart failure Orthopnea is the sensation of breathlessness in the recumbent position, relieved by sitting or standing. Paroxysmal nocturnal dyspnea (PND) is a sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information.

The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes d/t failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Atropine = symptomatic bradycardia Dopamine (inotrope) = hypotension d/t bradycardia. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. THE CLIENT SYMPTOMS OF BRADYCARDIA AND HYPOTENSION ARE CAUSED BY/DUE TO FAILURE TO CAPTURE

The nurse has just admitted a client with a history of aortic abdominal aneurysm who is experiencing back pain. The nurse needs to assess for a bruit. Where would the nurse place the stethoscope to auscultate for a bruit?

The nurse should listen for a bruit with the bell of the stethoscope over the periumbilical or epigastric area. An aneurysm is an outpouching or dilation of a vessel wall. An abdominal aneurysm occurs on the aorta. A bruit, a swishing or buzzing sound that indicates turbulent blood flow in the aneurysm, is best heard with the bell of the stethoscope. It may be auscultated over the aortic aneurysm in the periumbilical or epigastric area slightly left of the midline.

A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?

"Avoid strenuous activity before the surgery. Aortic stenosis is the narrowing of the orifice between the left ventricle and aorta. Many clients with aortic stenosis are asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot pump enough blood to meet the body's demands due to aortic obstruction (stenosis). These include dyspnea, angina, and, in severe cases, syncope (reduced blood flow to the brain). Clients usually do not experience symptoms at rest.

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply.

1. "I need to eat less red meat and more fresh vegetables. "2."I'll limit drinking soda to only one at a time as an occasional treat." 3."I'm going to replace potato chips with fruit during meals and snacking." The Dietary Approaches to Stop Hypertension (DASH) diet is often recommended to reduce blood pressure in clients with hypertension. The client is taught to limit intake of sugar, sodium, cholesterol, and trans or saturated fats, and instead choose healthier options (eg, fresh fruit and vegetables, whole grains, low-fat dairy products).

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

2. Attach the cardiac monitor to the client Dysrhythmias (ex: ventricular fibrillation, ventricular tachycardia, or PVCs) are the most common complication following myocardial infarction. The nurse should immediately attach the cardiac monitor when the client is admitted before taking vital signs and performing other assessments.

A client comes to the emergency department with crushing, substernal chest pain. The nurse obtains baseline vital signs. What action should the nurse perform next? Click the exhibit button for additional information.

2. Obtain a 12-lead ECG - Chest pain (angina) is a symptom of acute coronary syndrome (ACS), which is caused by a reduction of blood flow to the heart (ie, myocardial ischemia). ACS can present as unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), or STEMI. - Obtaining a 12-lead ECG is the priority so that the origin of angina can be detected and targeted interventions can be initiated to avoid cardiac tissue death (Option 2). Additional interventions in the emergency management of chest pain include: - Performing a cardiopulmonary assessment - Applying oxygen, as needed - Inserting 2 large-bore IV catheters - Administering antianginal medication (eg, nitroglycerin) - Obtaining baseline blood work (eg, cardiac markers, serum electrolytes) - Obtaining a portable chest x-ray - Assessing for contraindications to antiplatelet and anticoagulant therapy - Administering aspirin unless contraindicated - Defibrillator = lethal or shockable rhythm = pulseless ventricular tachycardia, ventricular fibrillation - Emergency cardiac catheterization = STEMI

The nurse is preparing to perform cardioversion in a client in supraventricular tachycardia shown in the exhibit that has been unresponsive to drug therapy. The client has become hemodynamically unstable. Which step is most important in performing cardioversion?

2. Push the synchronize button To perform safe cardioversion, the synchronizer button must be activated prior to discharging the unit. The synchronizer function allows the unit to sense the client's rhythm and not deliver a shock during a vulnerable time that could cause the client to go into a more lethal rhythm.

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure. The nurse will need to notify the HCP about which client?

4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg Mean arterial pressure (MAP) refers to the average pressure within the arterial system felt by the vital organs. A normal MAP is at least 70 mm Hg. If the MAP falls below 60 mm Hg, vital organs may be underperfused and can become ischemic. A MAP >110 mm Hg indicates that too much pressure is being placed on the arteries and can lead to cardiac muscle damage. MAP can be calculated using these formulas: MAP= systolic blood pressure+(diastolic blood pressure×2)/3 = 106 + (42X2) /3 = 63

The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse?

4. Troponin 0.7 ng/mL (0.7 mcg/L) Troponin is a highly specific cardiac marker for the detection of MI. It has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. Serum levels of troponin increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline after 10-14 days. A troponin value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority and immediate focus of the nurse. Normal values: troponin I <0.5 ng/mL (<0.5 mcg/L); troponin T <0.1 ng/mL (<0.1 mcg/L).

First-Degree Atrioventricular Block

A dysrhythmia in which there is a delay in conduction, usually at the level of the atrioventricular node. Every impulse is conducted to the ventricles, but the time of atrioventricular conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted.

Liver Biopsy positioning Sims position Lumbar puncture position

After a liver biopsy, clients should be placed in the right side-lying position for ≥2 hours to promote direct internal pressure to the liver, which minimizes bleeding. Sims position (ie, left side-lying position with the right hip and knee flexed) is optimal for enema administration. Before lumbar puncture, clients should be placed in the side-lying fetal position or hunched seated position to separate the vertebrae. After the procedure, clients should remain supine to minimize the risk for postprocedure headache from loss of cerebrospinal fluid.

The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip?

Atrial paced rhythm = spikes BEFORE P Waves The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks).

The nurse is assessing a client with severe mitral valve stenosis for the presence of a murmur. Select the best site to auscultate a murmur in this client.

Mitral valve stenosis often produces a diastolic murmur heard best at the apex of the heart (5th intercostal space, midclavicular line) with a stethoscope.

Radiofrequency catheter ablation

Radiofrequency catheter ablation is an invasive procedure that may be used to treat clients with recurrent episodes of supraventricular tachycardia. A catheter is inserted through a large artery or vein (eg, femoral) and threaded to the heart. Radiofrequency waves are delivered to inactivate tissue in the area of the heart causing the dysrhythmia.

1st-degree AV block

every impulse is conducted to the ventricles, but the time of AV conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second.

Myocardial Ischemia/infarction symptoms

MI s/s: dizziness, sweating or cold, clammy skin, shortness of breath, ischemic chest pain, nausea & vomiting, pain radiation: neck, jaw, left shoulder, arms, & epigastrium Findings concerning for acute coronary syndrome include chest pain/pressure radiating to the back, left arm, or jaw; diaphoresis; and dysrhythmias (ie, bradycardia). History of smoking and hyperlipidemia increase the client's risk for coronary artery disease, which can lead to ACS. Alcohol use can be a risk factor for gastritis, esophagitis, and pancreatitis.

Percutaneous coronary intervention (PCI)

Percutaneous coronary intervention (PCI) is performed to restore coronary artery perfusion and prevent or treat myocardial infarction (MI). During cardiac catheterization, a catheter is inserted into a large artery (eg, femoral, radial) and threaded into the coronary vessels. A balloon and stent on the catheter are positioned near the plaque and expanded, which holds the vessel open and improves blood flow. The stent remains permanently to maintain patency

Atrial Fibrillation (A-Fib) Chaotic = Atrial fibrillation with P-wave - " Chaotic" = used to describe fibrillation

an irregular and often very fast heart rate originating from abnormal conduction in the atria In atrial fibrillation, P waves are not present, but the rhythm is usually irregularly irregular.

Click to highlight below the 1 finding the nurse should be most concerned about at this time

Recurrent episodes of epigastric pain that occur during strenuous tasks and are relieved with rest The nurse should be most concerned about the client's cardiovascular findings. Recurrent episodes of epigastric pain that occur during strenuous activity and are relieved with rest are concerning for myocardial ischemia. Although ischemic chest pain most often occurs in the substernal area, pain in the epigastric region may develop due to inferior wall ischemia. Myocardial ischemia - lack of blood flow creates an ischemic region of myocardium (penumbra) and leads to tissue death Benign prostatic hyperplasia (BPH) refers to an enlarged prostate gland, which may cause urinary hesitancy, nocturia, and increased urinary frequency. BPH is a chronic condition that does not take priority over potential myocardial ischemia.

Ventricular bigeminy

every other heart beat is a premature ventricular contraction (PVC)

sinus rhythm

normal heartbeat triggered by the SA node has a rate of 60-100/min.

Complete heart block

or 3rd-degree atrioventicular (AV) block, is a form of AV dissociation in which no impulses from the atria are conducted to the ventricles. The atria are stimulated and contract independently of the ventricles. The ventricular rhythm is an escape rhythm

The nurse is teaching a client who had a permanent pacemaker inserted 4 hours ago. Which of the following pieces of information should the nurse include? Select all that apply.

"Avoid placing your cell phone directly over the pacemaker." 2."Discuss the pacemaker with health care providers before receiving an MRI." 3."Inform airport security of the pacemaker when traveling." Discharge teaching for the client with a permanent pacemaker should include: - Report fever or signs of redness, swelling, or drainage at the incision site. - Always carry a pacemaker identification card and wear emergency medical identification. - Take the pulse daily and report it to the health care provider if it is below the predetermined rate. - Avoid carrying a cell phone in a pocket directly over the pacemaker and, when talking on a cell phone, hold it to the ear on the opposite side of the pacemaker (Option 1). - Discuss the pacemaker with health care providers before receiving an MRI; not all pacemakers are MRI safe (Option 2). - Notify airport security of the pacemaker; a handheld screening wand should not be held directly over the device (Option 3). - Avoid standing near antitheft detectors in store entryways; walk through at a normal pace and do not linger near the device. The client should AVOID lifting the arm above the shoulder on the side of the pacemaker until approved by the health care provider because this can dislodge the pacemaker lead wires.

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm? Select all that apply.

2. Check for bleeding at groin puncture sites 4. Monitor fluid intake and urine output 5. Palpate and monitor peripheral pulses Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a sutureless aortic graft inside the aortic aneurysm via the femoral artery. It does NOT require an abdominal incision. The nurse will need to monitor the puncture sites in the groin area for bleeding or hematoma formation (Option 2). Peripheral pulses should be palpated and monitored frequently in the early post-op period and routinely afterward (Option 5). Renal artery occlusion can occur due to graft migration or thrombosis so careful monitoring of urine output and kidney function should be part of nursing care (Option 4). No abdominal incision or chest tubes required in an endovascular repair.

The nurse is talking with a client who is scheduled for a diagnostic left-sided cardiac catheterization. Which of the following statements by the client would require follow-up?

1. "I may experience numbness and tingling in my affected leg after the procedure." Left-sided cardiac catheterization is performed to diagnose and/or treat conditions such as coronary artery disease and heart failure. Complications of cardiac catheterization associated with the catheter insertion site include arterial thrombosis or embolism. The nurse should frequently assess the affected extremity and report any neurovascular changes (eg, numbness, tingling, decreased pulses, or coolness of the extremity) to the health care provider immediately as blood flow to the extremity may be compromised It is COMMON and EXPECTED for the client to feel warm or flushed while the contrast dye is injected. - GO HOME THE SAME DAY. Hospitalization for angioplasty or stent placement. Sedatives are used for comfort, not general anestheisa (midazolam, fentanyl)

The nurse is providing teaching to the client following femoral-approach cardiac catheterization with coronary artery stent placement. Which of the following client statements indicate correct understanding of the teaching

1. "I will increase my fluid intake for the next 24 hours." 2. "I will keep my leg straight for 4 hours." 3. "My health care provider will prescribe a medication to prevent blood clots." Nursing care after cardiac catheterization with percutaneous coronary intervention includes: - Increasing fluid intake or IV fluids to promote clearance of IV contrast (Option 2). - Keeping the affected leg straight for 2-6 hours as prescribed after femoral-approach cardiac catheterization; the head of the bed should remain at ≤30 degrees to prevent hip flexion that could disrupt clots at the insertion site and cause bleeding (Option 3). - Providing antiplatelet therapy to reduce risk of blood clots because the stent is a foreign body that can cause platelet aggregation until a smooth surface is created. Aspirin is taken for life, and a P2Y12 receptor blocker (eg, clopidogrel) is taken for several months post-MI (Option 5). Bleeding and swelling at the insertion site may indicate hematoma formation. The nurse should monitor for impaired neurovascular status (eg, pulse, skin color, sensation) distal to the insertion site Chest pain should be relieved promptly after the procedure due to restored myocardial perfusion.

A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision of the client's aortic dissection?

1. Administer IV labetalol to maintain blood pressure within prescribed parameters Aortic dissection is a tear in the inner lining of the aorta that allows blood to surge between the layers of the arterial wall, separating and weakening the aortic wall. Perfusion to vital organs may become impaired, and the dissection can rapidly progress to life-threatening cardiac tamponade or aortic rupture. Aortic dissection is characterized by acute onset of excruciating, sharp or "ripping" chest pain that radiates to the back. Emergency surgical repair is usually required. Before surgical repair, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the aorta. Administering IV beta blocker medication (eg, labetalol, metoprolol, propranolol) helps achieve this by lowering the heart rate and blood pressure, which are often elevated with aortic dissection (Option 1).

A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.

1. Administer oxygen via non-rebreather mask - Administer 100% oxygen via non-rebreather mask to improve oxygenation 2.Apply an occlusive dressing over the insertion site - Apply an occlusive dressing to the insertion site to prevent entry of additional air into the bloodstream (Option 2) 4.Monitor vital signs and respiratory effort - Continuously monitor vital signs and client respiratory effort to identify changes in client status (Option 4) 5.Notify the health care provider - Notify the health care provider immediately (Option 5) Position the client in left lateral Trendelenburg position to promote venous air pooling in the heart apex rather than the lung capillary beds. High Fowler position may worsen respiratory distress caused by air embolism by promoting displacement of venous air emboli into pulmonary circulation. Air embolism is a rare but life-threatening complication of central venous catheter (CVC) placement in which air enters the bloodstream. This air displaces blood in the pulmonary vessels, which prevents oxygenation of blood by the lungs. Air embolism may occur after CVC removal, as air can enter the bloodstream via the open, large-bore insertion site. Clients with air embolism can rapidly develop respiratory distress leading to cardiopulmonary collapse. Nurses caring for clients with symptoms of air embolism (eg, hypoxemia, dyspnea, sense of impending doom) after CVC removal or dislodgement should perform these actions:

The nurse is preparing to administer medications after assessing a client with a myocardial infarction. Based on the collected data, which of the following prescribed medications are appropriate for the nurse to administer? Click on the exhibit button for additional information. Select all that apply.

1. Aspirin - Aspirin, an antiplatelet agent, inhibits platelet aggregation, prevents thrombus formation, and reduces heart inflammation. Clients without signs of bleeding or low platelet levels may safely receive aspirin 2. Atorvastatin -Atorvastatin is a lipid-lowering medication given to clients to lower cholesterol levels (ie, LDL cholesterol), which reduces plaque and reinfarction risk (Option 2). However, statins may cause rhabdomyolysis and require monitoring for muscle weakness and pain. 3. Docusate sodium - Docusate sodium is a stool softener that reduces straining during bowel movements, thereby decreasing the workload on the heart. Straining can also cause bradycardia due to vagal response 4. Lisinopril - Lisinopril is an ACE inhibitor often prescribed to clients after an MI to prevent ventricular remodeling and progression of heart failure. Lisinopril may cause hyperkalemia and hypotension, and should be administered only to clients with normokalemia and normotension Metoprolol is a beta blocker prescribed to clients after MI to reduce the risk of reinfarction and heart failure. Metoprolol lowers blood pressure and heart rate; therefore, the nurse should hold the medication and notify the health care provider of hypotension or a heart rate <50/min.

Which of the following prescriptions should the nurse anticipate?

1. Aspirin PO now 2.Continuous cardiac monitoring 3.Nitroglycerin sublingual 4.Prepare client for percutaneous coronary intervention 5.Supplemental oxygen as needed to maintain SpO2 ≥95% For a client diagnosed with STEMI, the nurse should anticipate: - Maintaining airway patency and preparing for CPR if necessary - Aspirin PO now to decrease platelet aggregation and vasoconstriction (Option 1) - Continuous cardiac monitoring to watch for life-threatening dysrhythmias (Option 2) - Nitroglycerin sublingual to promote coronary artery vasodilation, increasing myocardial perfusion (Option 3) - Preparing the client for percutaneous coronary intervention (PCI) to restore coronary artery perfusion (Option 4) - Administering supplemental oxygen to maintain SpO2 ≥95% for clients with hypoxemia, respiratory distress, and heart failure; supplemental oxygen in clients with normal oxygen saturation may cause further vasoconstriction of the coronary arteries (Option 5) - Giving an antiplatelet medication (eg, prasugrel, ticagrelor, clopidogrel) to prevent platelet aggregation prior to PCI - Considering atropine and transcutaneous pacing for severe, symptomatic bradycardia

The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first?

1. Asses the client's breath sounds The client being admitted for heart failure-related fluid overload is likely to have dyspnea (difficulty breathing), orthopnea (labored breathing in a supine position), and paroxysmal nocturnal dyspnea (waking suddenly with difficulty breathing). The assessment phase of the nursing process must come before intervention and should be prioritized using the ABCs: airway, breathing, and circulation. Therefore, the nurse should first assess the client's breath sounds (Option 2). Rales or "crackles" may be auscultated in the lungs as a result of pulmonary congestion It is appropriate for this client to have continuous cardiac monitoring that can alert staff to life-threatening rhythms (eg, ventricular tachycardia) if they occur. However, the client's respiratory status should be assessed first.

The nurse is caring for a client with end-stage heart failure. The rhythm shown in the exhibit is seen on the cardiac monitor, and the nurse finds the client unresponsive with no palpable pulse. What is the correct interpretation of this rhythm? Click on the exhibit button for additional information.

1. Asystole Asystole is characterized by no electrical activity or obvious wave. Clients will have no pulse or respirations, and will be unresponsive (Option 1). Cardiopulmonary resuscitation (CPR) should be initiated, followed by advanced cardiac life support measures, including administration of epinephrine, placement of an advanced airway, and treatment of any reversible causes.

The nurse should document the client's cardiac rhythm as ____________ and should anticipate _____________ at this time.

1. Atrial fibrillation 2. Administering a beta blocker Atrial fibrillation (AF) is a COMMON cardiac dysrhythmia that occurs following coronary artery bypass grafting (CABG). AF is characterized by the absence of P waves, presence of fibrillatory waves, and an irregularly irregular rhythm. Ineffective atrial contractions result in incomplete atrial emptying, decreased cardiac output, and increased risk for atrial thrombi formation due to blood stasis. Clients with AF require antiarrhythmic medications (eg, beta blockers, digoxin) to control the ventricular rate and/or electrical cardioversion to convert the rhythm.

A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?

1. Auscultate breath sounds The nurse should start assessment based on the ABCs (Airway, Breathing, Circulation). This client is at risk for acute decompensated heart failure and pulmonary edema. Pulmonary edema is an acute, life-threatening situation in which the lung alveoli become filled with serosanguineous fluid. Auscultation may include crackles, wheezes, and rhonchi if fluid has moved into the lungs. The next priority is for the nurse to measure vital signs (Option 3). This would identify if the client's heart rate or respiratory rate is elevated and if the oxygen saturation is compromised.

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply.

1. Blood pressure of 90/70 mm Hg 4.Distant heart tones 5.Jugular venous distension Clinical features of cardiac tamponade (s/s): narrowed pulse pressure, muffled heart sounds, distended neck veins (Beck's triad) Signs and symptoms of cardiac tamponade include: - Hypotension with narrowed pulse pressure (Option 1) - Muffled or distant heart tones (Option 4) - Jugular venous distension (Option 5) - Pulsus paradoxus (when your blood pressure decreases with inhalation (breathing in). - Dyspnea (SOB), tachypnea (rapid shallow breathing) - Tachycardia Bounding pulses = fluid overload or hypertension, anxiety or fever Decreased breath sounds = atelectasis, pleural effusion (water on or around the lungs), or pneumothorax.

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? Select all that apply.

1. Calf pain 3. Lower leg warmth and redness 5. Unilateral leg edema Although clients with a DVT may have no symptoms, typical clinical manifestations include unilateral edema, localized pain (eg, calf pain) or tenderness to touch, warmth, erythema, and occasionally low-grade fever (Options 2, 4, and 5). blue, cyanotic toes = impaired arterial blood perfusion to the extremity = acute arterial occulusion (arterial embolism) or reduced blood flow (vasopressor, atheroscelerosis) dry, shiny, hairless skin = chronic peripheral arterial disease

The nurse receives hand-off report on assigned clients. Which client should the nurse assess first?

1. Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately. - Chronic venous insufficiency is the inability of the leg veins to efficiently pump blood back to the heart. Expected findings = edema and thick skin with brown pigmentation Gangrene of the foot is a complication of peripheral arterial disease (PAD) associated with decreased blood flow to the extremity. Coolness of the skin and shiny, hairless legs, feet, and toes are expected manifestations of PAD, Intermittent claudication = expected finding of PAD

A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? Select all that apply.c

1. Crackles on auscultation (indicate pulmonary edema or fluid in the alveoli due to heart failure, pulmonary fibrosis, or acute respiratory distress syndrome). 2. Increased jugular venous distention 6. 3+ pitting edema on lower extremities Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure. Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) in this client. Although dependent pitting edema of the extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is related to sodium and fluid retention (right-sided failure) in this client. dry mucous membranes and poor skin turgor/tenting = dehydration rhonchi = continuous lung sounds heard on expiration --> secretions in larger airways

The nurse is preparing to discharge a client who developed heart failure after a myocardial infarction. Based on the discharge data, the nurse plans to include which topics during teaching? Select all that apply. Click on the exhibit button for additional information.

1. Daily weighing 2. How to take own pulse 5. Reduction of sodium in diet (& restrict fluid intake) - Client is NOT taking warfarin, so monthly INR is not indicated "The I in INR looks like a 1 so <1.2" PT: < 1.2 unless taking warfarin Increase food rich in potassium if taking potassium-losing diuretics; restrict potassium if taking potassium-sparing diuretics ( (Amiloride (Midamor) Eplerenone (Inspra) Spironolactone (Aldactone, Carospir) Triamterene (Dyrenium) Spironolactone is a potassium-sparing diuretic, and so increasing dietary potassium is not necessary. Angiotensin-converting enzyme inhibitors (ACE inhibitors) such as captopril can cause HYPERKALEMIA.

The nurse should expect to first _______ and then _________

1. Elevate the head of the bed to 45 degrees 2. Assess for bladder distention Clients with spinal cord injuries above T6 are at risk for autonomic dysreflexia, an acute, life-threatening, response to noxious stimuli (eg, bladder distension) that causes severe hypertension, bradycardia, headache, and diaphoresis. The nurse should immediately elevate the head of the bed to at least 45 degrees to reduce blood pressure and assess for and remove noxious stimuli (eg, bladder distension) to determine the underlying cause. If bladder distension is suspected, the nurse should insert a urinary catheter to drain the bladder and relieve distension. If a urinary catheter is already in place, the nurse should assess for kinks that obstruct drainage from the tubing.

The nurse is positioning clients before and after scheduled procedures. Follow-up would be required if the nurse places a client in which position?

1. Fowler position after a cardiac catheterization via femoral entry Immediately following cardiac catheterization, the head of the bed should remain ≤30 degrees to prevent hip flexion which could disrupt clot formation at the insertion site and initiate bleeding. Fowler position (45-60 degrees) places the client's head >30 degrees which is contraindicated (Option 1). If bleeding occurs, apply direct pressure over the arterial puncture site. Semi-fowlers (30-45 degrees) Insertion of the sheath involves a large incision and dilation of the femoral vessel, which greatly increases the risk for rapid, life-threatening hemorrhage after device removal.

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time?

1. Immunosuppressive therapy as a lifelong commitment Immunosuppressive therapy (eg, mycophenolate, tacrolimus, corticosteroids) is required after organ transplantation to prevent acute and chronic rejection of the organ. This is a lifelong drug regimen for the transplant client, and it has adverse side effects (eg, nephrotoxicity, hepatotoxicity, infection susceptibility). Prior to surgery, the client needs to fully understand the physical, psychological, and financial commitment required. It is important for the nurse at every opportunity to emphasize strict immunosuppressive therapy compliance to prevent acute transplanted organ rejection.

A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.

2. Capillary refill time - dicates adequacy of blood flow to the peripheral tissues. It is measured by the time taken for color (pink) to return to an external capillary bed (nail bed) after pressure is applied to cause blanching 5. Skin color and temperature -Normal skin color and temperature are indicators of the adequacy of peripheral blood flow; these are usually within normal limits during the initial and compensatory stages of shock ( Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by the level of consciousness, urine output, capillary refill time, peripheral sensation, skin color, extremity temperature, and peripheral pulses. Apical pulse = central pulse and does not indicate adequacy of tissue perfusion lung sounds - ventilation and gas exchange pupillary response - cerebral function

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first?

2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival. A decreased ejection fraction (normal 55%-70%) results in decreased cardiac output and inability to meet oxygen demand, leading to shortness of breath and activity intolerance. The nurse should assess lung sounds. However, this is an expected finding, so the nurse does not need to assess this client first. (Option 4) Subcutaneous emphysema is air in the tissue surrounding the chest tube insertion site and can occur in a client with a pneumothorax. The nurse should assess lung sounds and palpate to determine the degree of emphysema. However, this is an expected finding, so the nurse does not need to assess this client first.

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply.

2. "Drink plenty of fluids every day and limit caffeine and alcohol intake." 3."Elevate legs on a footstool when sitting and dorsiflex the feet often." 4."Resume your walking program as soon as possible after getting home. Risk factors for DVT include venous stasis, blood hypercoagulability, and endothelial damage. Therefore, discharge teaching for a client with resolved DVT emphasizes interventions to promote blood flow and venous return (eg, exercise, smoking cessation) to prevent reoccurrence. Clients do NOT need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour). Obtain adequate fluid intake and limit caffeine and alcohol intake to avoid dehydration because dehydration increases the risk for blood hypercoagulability (Option 2). Elevate the legs when sitting and dorsiflex the feet often to reduce edema and promote venous return (Option 3). Resume an exercise program (eg, walking, swimming) and change positions frequently to promote venous return (Option 4). Stop smoking to prevent endothelial damage and vasoconstriction. Avoid restrictive clothing (eg, tight jeans), which interferes with circulation and promotes clotting. Consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels.

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine. The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days. Which question is most important for the nurse to ask next?

2. "How are you currently taking your blood pressure medications?" BLOOD PRESSURE MEDICATIONS & HYPERTENSION = POOR ADHERENCE to prescribed medications is the #1 cause of uncontrolled hypertension. A major problem in the long-term management of hypertension is poor adherence to the treatment plan, often due to unpleasant side effects (eg, fatigue, dizziness, reduced libido, erectile dysfunction) and medication cost. This problem can worsen if a client must take multiple medications. Determining whether a client is taking medications as prescribed is a priority, as sudden or abrupt discontinuation of antihypertensive medications can cause rebound hypertension and possibly hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath ) The nurse should assess for peripheral edema, which may indicate heart failure. However, this can be done after assessing medication adherence.

A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching?

2. "I prop my legs up in the recliner and use a heating pad when my feet are cold." Clients with peripheral arterial disease (PAD) have decreased sensations from nerve ischemia or coexisting diabetes mellitus. They should never apply direct heat to the extremity due to the risk for a burn wound. Wound healing is impaired in these clients. However, clients with PAD usually do not have swelling, but rather have decreased blood supply. The extremities should not be elevated above the level of the heart because extreme elevation further impedes arterial blood flow to the feet. Additional teaching for the client with PAD includes the following: Smoking cessation Regular exercise Achieving or maintaining ideal body weight Low-sodium diet Tight glucose control in diabetics Tight blood pressure control Use of lipid management medications Use of antiplatelet medications Proper limb and foot care Lack of hair, brittle nails, dry skin, and skin atrophy are due to decreased blood supply to these structures and are common, expected findings in PAD. Statins (eg, simvastatin, atorvastatin) are typically taken in the evening as they are more effective during that period.

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?

2. Bradycardia in a client with a demand pacemaker set at 70/min A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify the health care provider immediately. Clients with atrial fibrillation are usually prescribed an anticoagulant, such as rivaroxaban (Xarelto), due to increased risk for blood clots that can lead to stroke. This client's ventricular rate is controlled, so there is no urgency. First-degree atrioventricular (AV) block can be associated with beta-adrenergic blocker drugs, such as atenolol (Tenormin), as they delay conduction at the AV node. This is reflected as prolonged PR interval on ECG -- delayed with adverse effect. Only second or third degree heart block should be a priority Dehydration can cause hypotension. Tachycardia is a normal compensatory mechanism to increase the cardiac output associated with hypotension.

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply. A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease

2. Do not consume caffeine for 24 hours before the test 3.Do not smoke on the day of the test 4.Do not take beta blockers on the day of the test Pre-procedure client instructions include the following: - Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications (Option 3). - Avoid caffeine products 24 hours before the test (Option 2). - Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option 1). - Do not take theophylline 24-48 hours prior to the test (if tolerated). - If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 5). Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: Nitrates (nitroglycerine orisosorbide), Dipyridamole (antiplatelet medication that prevents blood cells/platelets from sticking together and forming clots), Beta blockers (Option 4)

The client is scheduled to have a cardiac catheterization. Which of the following findings would cause the nurse to question the safety of the test proceeding? Select all that apply.

2. History of previous allergic reaction to IV contrast 4.Received metformin today for type 2 diabetes mellitus 5.Serum creatinine of 2.5 mg/dL (221 µmol/L) - Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast medium (Option 2). -Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore, health care providers may discontinue metformin 24-48 hours before administration of contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option 4). - Contrast-induced nephropathy: - Iodinated contrast can cause acute kidney injury in clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]). Therefore, clients with renal impairment should not receive iodinated contrast unless absolutely necessary. - Creatinine: 0.5-1.5 C-reactive protein, produced during acute inflammation = elevated risk for coronary artery disease

The nurse is caring for clients with central venous access devices. At highest risk for developing a central line-associated bloodstream infection is the client who has a central venous access device in the

2. femoral vein, inserted in the emergency department 48 hours ago Appropriate site selection for a CVAD (eg, avoidance of the femoral vein, when possible) reduces the risk for CLABSIs. Femoral CVADs bring a high risk for infection due to their strong susceptibility to contamination by urine or feces; in addition, they are difficult to cover with an occlusive dressing (Option 2). basilic vein is a preferred site for a peripherally inserted central catheter (PICC). The internal jugular and subclavian veins are preferred sites for CVADs

The nurse is caring for assigned clients. Which client should the nurse assess first?

3. Client who has a peripherally inserted central venous catheter and is reporting swelling of the right arm and shortness of breath Clinical manifestations of DVT include unilateral extremity swelling, redness, tenderness, and warmth. Clients who develop DVT are at increased risk for pulmonary embolism (PE), which is life-threatening and may occur if the thrombus becomes dislodged. Clients with a peripherally inserted central venous catheter (PICC) have an increased risk for developing DVT and PE because PICC insertion damages the vessel wall and alters blood flow around the catheter lumen. The nurse should immediately assess a client with a PICC demonstrating signs of DVT (eg, unilateral extremity swelling) and PE (eg, shortness of breath) Diminished breath sounds and an elevated temperature in a postoperative client may indicate the development of pneumonia from atelectasis but is not immediately life-threatening. Clients with atrial fibrillation are often prescribed warfarin to prevent clot formation and embolus. An INR of 1.2 is subtherapeutic (goal: 2-3) but is not immediately life-threatening. The international normalised ratio (INR) is a measure of how long it takes your blood to clot. The longer it takes your blood to clot, the higher your INR.

The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures?

3. Client with a mechanical aortic valve replacement Clients with any form of prosthetic material in their heart valves, prosthetic heart valve, or who have unrepaired cyanotic congenital heart defect or prior history of IE should take prophylactic antibiotics prior to dental procedures to prevent development of IE.

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first?

3. Initiate continuous cardiac monitoring When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker. If the atrioventricular (dual-chambered) pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes (electrical capture). If the pacemaker is not working properly (eg, failure to capture, failure to sense), the health care provider should be contacted immediately (Option 3). nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure. Postoperative lung sounds are auscultated to assess for atelectasis, but lung assessments do not take priority over ensuring pacemaker functionality.

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of sodium nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being light-headed. What is the priority nursing action?

3. Measure the client's blood pressure Sodium nitroprusside (a highly potent venous and arterial vasodilator) is commonly used in hypertensive emergencies and for conditions in which blood pressure (BP) control is essential (eg, aortic dissection, acute decompensated heart failure). Sodium nitroprusside begins to exert its effects within 1 minute and can produce a sudden and drastic drop in BP (symptomatic hypotension [eg, light-headedness; cold, clammy skin]). Therefore, the client's BP should be monitored closely (ie, every 2-5 min) (Option 3).

The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? Click on the exhibit button for additional information

3. Potassium chloride IVPB once Prompt potassium replacement is the priority action for hypokalemic clients with myocardial infarction because they are at increased risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) and cardiac arrest. Hypokalemia hyperpolarizes cardiac electrical conduction pathways, increasing the risk for dysrhythmias. ACE inhibitors (eg, captopril, enalapril, lisinopril) help reduce the risk of future MIs by reducing blood pressure and cardiac workload and inhibiting ventricular remodeling. ACE inhibitors should be administered after MI; however, life-threatening dysrhythmias pose a higher risk to the client. Strict glycemic control in the resolution phase of an acute MI is associated with better long-term outcomes (eg, reduced morbidity/mortality), but it does not take priority.

A client is admitted to the emergency department after a fall with dizziness and light-headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the exhibit. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.

3. Sinus bradycardia Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate of <60/min. SB is classified as symptomatic if, in addition to a heart rate <60/min, the client experiences such symptoms as dizziness, syncope, chest pain, hypotension, and light-headedness The client with symptomatic SB is first treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine is considered. A permanent pacemaker may be needed. If SB is the result of a medication (eg, beta blocker, digoxin), the drug may need to be held, discontinued, or given in a reduced dosage.

A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? Click on the exhibit button for additional information.

3. Sinus rhythm with premature ventricular contractions (PVCs) Periodic wide bizarre ORS complexes = PVCS PVCs can be associated with stimulants (eg, caffeine), medications (eg, digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress. PVCs are usually not harmful in the client with a healthy heart. In the client with myocardial ischemia/infarction, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation).

A client comes to the emergency department with a "pounding heart beat." The client is diaphoretic and pale and admits to using cocaine approximately one hour ago. The client is connected to a cardiac monitor that shows the rhythm displayed in the exhibit. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.

3. Supraventricular tachycardia Supraventricular tachycardia (SVT) is a dysrhythmia that originates from an ectopic focus above the bifurcation of the bundle of His. The heart rate can be 150-220/min. The rhythm is usually regular. P waves are often hidden. If visible, they may have an abnormal shape and the PR interval may be shortened. The QRS complex is usually narrow (<0.12 second). Stimulants (eg, nicotine, caffeine, cocaine) and organic heart disease can cause SVT. Clinical significance depends on the client's symptoms. A prolonged episode of SVT with a heart rate >180/min will cause decreased cardiac output and hypotension. The client may also experience palpitations, dyspnea, and angina. Treatment includes vagal stimulation and drug therapy. Common vagal maneuvers include Valsalva, coughing, and carotid massage. IV adenosine is the drug of choice to convert SVT to a sinus rhythm. If vagal stimulation and drug therapy are ineffective and the client becomes hemodynamically unstable, synchronized cardioversion is used.

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention?

3. The client has new dependent edema of the feet New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain d/t fluid retention, lung crackles) and treatment. Further intervention required but not lifethreatening: loss of short-term memory = signs of dementia, painful red area on the buttocks = pressure injury, strong foul smelling urine = UTI

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern?

3. Urinary output of 90 mL in the past 4 hours Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair. Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to decreased renal perfusion and potential kidney injury. The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine output. Urine output should be at least 30 mL/hr. This client should have an output of at least 120 mL of urine in a 4-hour period. ) Diminished breath sounds in the lung bases are a common occurrence after surgery, especially in a client who has an abdominal incision that is painful with deep inspiration. Hypoactive bowel sounds are typical after abdominal surgery as the bowel has been handled and manipulated. NG tube until bowel sounds return. A decreased or absent pulse, together with cool, pale, or mottled extremities, would be cause for concern. This client has WARM extremitieS

A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock?

3. Urine output <0.5 mL/kg/hr (58%) Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume --> results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: Change in mental status Tachycardia with thready pulse Cool, clammy skin Oliguria Tachypnea Decreased urine output (<0.5 mL/kg/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function JVD = increased central venous pressure and intravascular volume. Shock is decreased. A mean arterial blood pressure of 70-105 mm Hg is considered normal, and >60 mm Hg is needed for adequate tissue perfusion to vital organs - Warm flushed skin = neurogenic shock

The telemetry nurse is reviewing the cardiac monitors of 4 clients. Which cardiac rhythm is the priority for intervention by the nurse?

3. Ventricular Fibrillation Ventricular fibrillation (VF) is a lethal arrhythmia characterized by disorganized electrical activity in the heart ventricles. Because of this erratic electrical activity, the heart's muscles lose the ability to contract, resulting in loss of blood flow and pulse (eg, cardiac arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation (Option 3).

A nurse in the intensive care unit is interpreting a client's cardiac rhythm. Which rhythm should the nurse document? Click on the exhibit button for more information.

3. Ventricular paced rhythm Ventricular paced rhythms are seen in clients with ventricular pacemakers. Ventricular pacemakers typically have one lead placed in the right ventricle. The pacer spike just before the QRS complex signals electrical stimulation of the ventricle by the pacemaker lead (Option 3). Implanted permanent pacemakers are often placed in clients with symptomatic bradycardia or heart block.

The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?

4. "I will shave with an electric razor from now on." Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding. Teaching topics for clients on anticoagulants: - Take medication at the same time daily - Depending on medication, report for periodic blood tests to assess therapeutic effect - Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a razor blade) (Option 4) - Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) - Limit alcohol consumption - Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale, spinach, broccoli, greens) (Option 2) and do not take vitamin K supplements - Consult with health care provider before beginning or discontinuing any medication or dietary/herbal supplement (eg, Ginkgo biloba and ginseng affect blood clotting and may increase bleeding risk) (Option 1) - Wear a medical alert bracelet indicating what anticoagulant is being taken - Early in the recovery period, care of the incision site typically includes washing with soap and water and patting it dry. Ointments and Vitamin E after it has healed.

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required?

4. "Potato chips are an acceptable snack in moderation." The client is likely dealing with some level of denial regarding his diagnosis of congestive heart failure. Glossing over the importance of salt avoidance is missing an important opportunity to help them avoid further hospitalizations for the same condition Adding potassium to a diet, especially when substituting it for sodium, can decrease blood pressure and fluid retention. Some diuretics, such as furosemide (Lasix), may also cause low levels of potassium. Hypokalemia is common in heart failure (HF) and is associated with increased mortality. Potassium supplements are commonly used to treat hypokalemia and maintain normokalemia

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up?

4. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds Clients with pulmonary embolism or deep venous thrombosis are treated with anticoagulant therapy. Unfractionated heparin is one such agent, and its efficacy is measured through partial thromboplastin time (PTT) levels. The goal during anticoagulation therapy is a PTT 1.5-2.5 times the normal reference range of 30-40 seconds (ie, therapeutic PTT 46-70 seconds). A PTT of 127 seconds is much too prolonged, and spontaneous bleeding could occur Clients with chronic obstructive pulmonary disease typically have elevated PaCO2 levels secondary to air trapping. Clients with heart failure are expected to have elevated brain natriuretic peptide (BNP) levels (>100 pg/mL [100 ng/L]). The nurse should compare BNP levels with those from the previous day. The client is likely receiving th. A normal white blood cell count is 5,000-10,000/mm3 (5.0-10.0 × 109/L). A WBC count of 13,000/mm3 (13.0 × 109/L) is elevated but would be expected in a client with an infection.erapy for heart failure

The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?

4. Massages the affected leg to reduce pain and swelling. -Clients with DVT are at risk for developing a life-threatening pulmonary embolism (PE). The clot may become dislodged by massage or use of sequential compression devices on the affected extremity. The nurse would intervene immediately if a client was observed massaging the site because this may trigger an embolism Interventions for deep venous thrombosis (DVT) include anticoagulants, warm compresses, limb elevation while in bed, and early ambulation.

The nurse is reviewing the telemetry strips of assigned clients. The rhythm strip displayed in the exhibit is given to the nurse by the telemetry technician. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.

4. Normal Sinus Rhythm After determining the rate, the nurse should analyze the P waves, QRS complexes, and T waves (if present) and determine the rhythm. A regular heart rate of 60-100/min with normal PR intervals, QRS complexes, and QT intervals indicates that the client is in normal sinus rhythm (Option 4).

The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time? Click on the exhibit button for additional information

4. Notify the cardiologist and prepare for temporary pacing Ablation performed near the atrioventricular (AV) node can damage conduction, causing varying degrees of AV block. Third-degree AV block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). On ECG, third-degree AV block presents as a regular rate and rhythm with disassociated P waves and QRS complexes. This type of AV block requires temporary or permanent pacing to restore electrical conduction and hemodynamic stability. cardioversion is performed for ventricular or supraventricular tachydysrhythmias but is not indicated in heart block.

A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first?

4. Obtain a 12-lead electrocardiogram Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction (MI), such as diaphoresis, nausea, fatigue, or dyspnea, but may not always experience chest discomfort. Pain may be absent or atypical or may radiate to unusual locations (eg, jaw, back). Some clients may report pain as "indigestion" (epigastric burning or gas). The nurse should obtain a 12-lead electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or infarction (Option 4). ST-segment elevation MI is life-threatening and requires rapid coronary intervention. In clients with diabetes, diaphoresis may indicate hypoglycemia, but other symptoms, such as epigastric pain, in this client make MI more likely.

The nurse is caring for a 65-year-old client who had an acute myocardial infarction 3 days ago and is reporting tenderness and warmth of the left calf. Which of the following actions would be a priority for the nurse to take?

4. Perform a neurovascular assessment of the lower extremities - involves both vascular (eg, skin color, edema, temperature, peripheral pulses, capillary refill) and neurologic (eg, pain, sensation) assessments of each leg for comparison. Typically, a neurologic assessment also includes motor function. The nurse also measures the circumference of both calves and thighs because unilateral edema is an important indicator of DVT. Venous thromboembolism (eg, deep venous thrombosis [DVT]) occurs when a blood clot becomes lodged in a vein, most often in the deep veins of the lower extremities. DVT is an urgent condition because a clot may dislodge, travel, and cause life-threatening complications (eg, pulmonary embolism). Manifestations of DVT include unilateral edema, pain, redness, and warmth. Risk for DVT increases with age ≥65, immobility, obesity, oral contraceptive use, and history of stroke. It is a priority for the nurse to perform a complete neurovascular assessment (Option 4).

A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?

4. Prepare for synchronized cardioversion with the external defibrillator Occasionally, an ICD may be unable to convert the arrythmia to a hemodynamically stable rhythm and will repeatedly shock the client. If the client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should promptly obtain a manual external defibrillator and initiate measures to prevent hemodynamic instability and cardiac arrest - vagal response = coughing --> supraventricular tachycardia Deactivating the ICD and obtaining an ECG are NOT appropriate at this time because they delay lifesaving interventions.

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?

4. Right calf is 4 cm larger than left calf Deep venous thrombosis (DVT) is a major concern in clients with unilateral leg pain after prolonged immobilization (eg, air travel, surgery) or those with obesity, pregnancy, or other hypercoagulable states (eg, cancer). Eighty percent of DVTs start in the veins of the calf and move into the popliteal and femoral veins. Classic symptoms include unilateral leg edema, local warmth, erythema, and low-grade fever. Therefore, the swelling in one leg is highly concerning.

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following?

4. Sitting up and leaning forward The most common cause of acute pericarditis is a recent viral infection. It is an inflammation of the visceral and/or parietal pericardium. Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. This position reduces pressure on the inflamed parietal pericardium, especially during lung inflation. The pain is different than that experienced during myocardial infarction. Assessment shows a pericardial friction rub (scratchy or squeaking sound). Treatment includes a combination of nonsteroidal anti-inflammatory drugs (NSAIDS) or aspirin plus colchicine. Pericarditis causes pain on inspiration, the supine or lying-down position worsens pericarditis pain. Pursed-lip breathing = COPD

The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client?

4. Taking blood pressure medications as prescribed The priority teaching topic for this client is taking blood pressure medications as prescribed. A major problem with long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant side effects, including fatigue, dizziness, and erectile dysfunction. Client may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. The nurse should determine whether the client has been taking the medications consistently.

A nurse in the intensive care unit is caring for a postoperative cardiac transplant client. What intervention is most important to include in the plan of care?

4. Use careful hand washing and aseptic technique to prevent infection Clients receiving transplanted organs are prescribed lifelong immunosuppressive medications (eg, cyclosporine, mycophenolate) to prevent rejection. Posttransplant infection is the most common cause of death. Signs of infection may include fever >100.4 F (38 C), productive or dry cough, and changes in secretions; however, common signs of infection (eg, redness, swelling) may be absent due to immunosuppression. Critical postoperative infection control measures incorporate vigilant hand washing, aseptic technique for line/dressing changes, and possibly reverse isolation.

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.

Amphetamine use, cigarette smoking, cold exposure, sexual intercourse Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: - Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) - Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload - Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency?

Brownish, hardened skin on lower extremities The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery (Option 1). Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with peripheral arterial disease due to hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues.

The nurse is providing discharge teaching. For each of the statements made by the client, click to specify whether the statement indicates correct understanding or incorrect understanding of the discharge teaching provided.

Correct understanding: "I will continue my cardiac rehabilitation at home", "I will abstain from sexual activity until approved by my health care provider." - Continuing a cardiac rehabilitation program at home to gradually strengthen the cardiac muscle under supervision - Abstaining from sexual activity until approved by the health care provider because strenuous activities increase cardiac demand - Modifying risk factors for cardiac disease (eg, smoking cessation, healthy diet) to minimize the risk for future cardiac events (eg, myocardial infarction) Incorrect Understanding: "I may take a bath as long as I pat the incision dry with a towel.", "I can lift my 2-year-old grandchild as long as it does not cause pain -Submerging the incisions or applying creams postoperatively can introduce microorganisms to the surgical sites and cause delayed healing. Wound care generally involves washing the incisions gently with mild soap and water and patting dry. -Lifting heavy items (eg, a 2-year-old child), even if it does not cause pain, indicates an incorrect understanding of discharge teaching. Lifting heavy objects and bending at the waist place strain on the sternum, increasing the risk for

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis --> severe organ damage?

Decrease mean arterial pressure (MAP) by no more than 25% Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3 A blood pressure of 120/80 mm Hg (MAP 93 mm Hg) is too low for an initial goal. This rapid drop from the client's initial pressure of 250/145 mm Hg (MAP 180 mm Hg) is a decrease of greater than 25% and could cause organ damage. However, it may be necessary to lower the SBP below 120 mm Hg if the client is experiencing an aortic dissection, as a higher BP can cause rupture.

For each finding below, click to specify if the finding is consistent with the disease process of gastroesophageal reflux disease or stable angina. Each finding may support more than one disease process.

GERD: epigastric pain, relieved by antacids, symptom duration often < 1 hour - sx: heartburn, indigestion, and epigastric pain. Stable angina (predictable, intermittent chest pain with most common cause atherosclerosis): epigastric pain, worsened by performing strenuous tasks - Manifestations include substernal chest pain that may radiate to the neck, arm, jaw, shoulder, or epigastric area; dyspnea; and nausea. Pain is often worsened by performing strenuous tasks (eg, exercise, stress) and is relieved with rest and/or nitroglycerin administration. Symptom duration is short (ie, <15 min).

The nurse has requested transport to an emergency care facility and is monitoring the client. For each finding, click to specify whether the finding indicates that the client's status has improved or declined.

Improved: Client states, "I would like some ice water. My nausea has finally subsided Declined: Blood pressure of 106/68 mm Hg, Pedal pulses are palpable with 1+ strength, Client states, "Let me close my eyes for a minute. I feel like the room is spinning."Client states, "That pain medicine really helped, but now my pain is suddenly a lot worse. - Blood pressure of 106/68 mm Hg when the baseline reading was 150/90 mm Hg. The client is experiencing hypotension (ie, a >40 mm Hg drop in systolic blood pressure from baseline) that is symptomatic (eg, dizziness). These findings should cause the nurse to suspect hypovolemia due to intraabdominal hemorrhage from abdominal aortic aneurysm (AAA) rupture.

The nurse is preparing the client for cardiac catheterization with percutaneous coronary intervention. For each intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

Indicated: Implement NPO Status, assess client for iodine allergy, review most recent creatinine level, verify informed consent has been obtained, Not indicated: administer beta blocker When preparing the client for cardiac catheterization with PCI, the following actions are indicated: - Assess client for iodine allergy because IV contrast used to visualize vessels contains iodine. - Implement NPO status prior to intraoperative procedures to help prevent aspiration. - Review most recent creatinine level if available to assess kidney function due to risk of renal damage from IV contrast. - Verify informed consent has been obtained prior to the procedure. The client should be able to correctly verbalize the indications and risks of the procedure. Beta-adrenergic blockers (eg, metoprolol, atenolol) are used to decrease myocardial oxygen demand during MI by lowering heart rate and blood pressure; however, administering a beta blocker is not indicated for this client due to bradycardia (eg, heart rate 48/min).

For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client

Indicated: cover the client with a warming blanket, monitor blood pressure via an arterial line, notify the provider if the chest tube drainage is > 100 ml/hr -iCovering the client with a warming blanket, increasing the room temperature, and using warmed IV fluids to treat postoperative hypothermia caused by cardiopulmonary bypass -an arterial line, which provides continuous readings and produces more accurate results than an external blood pressure cuff. Use of an arterial line can help acutely identify complications (eg, hypotension). -Notifying the health care provider (HCP) of chest tube drainage >100 mL/hr, which could indicate hemorrhage. Not indicated: palpate femoral pulses on graft site, removing the dressing to inspect the chest incision site - Palpating the femoral pulse is not indicated because it is located ABOVE the graft site (ie, great saphenous vein). The nurse should assess for perfusion in the affected extremity by palpating pulses BELOW the graft (eg, pedal pulses). - Removing the dressing to inspect the chest incision site is not indicated. The dressing is typically removed about 24 hours after surgery, depending on the client's condition and the HCP's prescription.

For each potential intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client

Indicated: frequently monitor peripheral pulses, instruct the client to report any changes in pain, prepare the client to transport to any emergency medical care facility - The client with symptoms of abdominal aortic aneurysm should be transferred promptly to an emergency medical care facility because surgical repair is likely required. While awaiting transport, the nurse should monitor for rupture by performing frequent neurovascular checks (pedal pulses, capillary refill) of the bilateral lower extremities --> impaired perfusion may be a sign of hypovolemia and assessing for a change in the quality of pain (sudden, severe abdominal, back, or flank pain may indicate ruptured aneurysm and hemorrhage) Contraindicated: perform deep palpation of the abdomen to assess for changes - can increase pressure on the aorta and contribute to rupture of the aneurysm.

pericaridal effusion

Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Cardiac tamponade: when the fluid sac around your heart (pericardium) fills with too much blood or other fluid and puts pressure on your heart.

The client reports chest pain of 5 on a scale of 0-10. The pain is sharp and occasionally radiates to the upper back; it makes it difficult for the client to take a deep breath and increases with movement. The client recently recovered from an upper respiratory infection 1 week ago but still has a persistent, dry cough. Lung sounds are clear, and no shortness of breath is noted. A high-pitched, grating sound is heard over the left lower sternal border. No peripheral edema or extremity pain is noted.

Pericarditisis, or inflammation of the membrane surrounding the heart, is most commonly caused by viral infections. Clinical manifestations include sharp, pleuritic chest pain that worsens with inspiration and coughing and a pericardial friction rub (ie, high-pitched grating sound) caused by the inflamed surfaces of the heart rubbing against one another. Interventions include: - Encouraging the client to sit up and lean forward, which relieves chest pain by reducing pressure on the inflamed parietal pericardium, especially during lung inflation - Administering nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen) with colchicine to decrease inflammation - Monitoring for signs of bleeding (eg, melena) due to NSAID use Monitoring for signs of cardiac tamponade (eg, muffled heart sounds), which occurs when fluid accumulates within the pericardial membrane (ie, pericardial effusion) and impairs the heart's ability to contract and eject blood

Sinus Tachycardia

Sinus tachycardia involves a heart rate of 101-200/min but also has a normal P wave preceding each QRS, with a normal shape and duration. The PR interval is normal (0.10-0.20 second) and the QRS is <0.12 second.

Ventricular tachycardia (V-tach) Bizarre QRS complex = v-tach "Bizarre" = used to describe tachycardia "SHOCK"

Ventricular tachycardia has a ventricular rate of 150-250/min and originates from foci firing repeatedly in the ventricle. P waves are usually not visible and are buried in the QRS, and the PR interval is not measurable. The QRS complex is typically wide (>0.12 second). Sharp peaks with a regular pattern

The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)?

Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: - Trauma (endothelial injury and venous stasis from immobility) - Major surgery (endothelial injury and venous stasis from immobility) - Prolonged immobilization (eg, stroke, long travel) causing venous stasis - Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) - Oral contraceptives (estrogen is thrombotic) - Underlying malignancy (cancer cells release procoagulants) - Smoking (produces endothelial damage by inflammation) - Old age - Obesity and varicose veins (venous stasis) - Myeloproliferative disorders (increase blood viscosity) The 80-year-old 4-day postoperative client has the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age, and is at greatest risk for developing a DVT. (Option 1) Smoking cigarettes and using oral contraceptives increase plasma fibrinogen and coagulation factors and cause hypercoagulability of blood, but the client is not at greatest risk. Hormonal contraceptives are not recommended if the client is age >35 and also smokes. (Option 2) Elevated hemoglobin/hematocrit level (erythrocytosis) causes increased blood viscosity and hypercoagulability of blood, which increases the risk for DVT. However, the client is not at greatest risk. (Option 3) Anticoagulants and antiplatelet agents are administered before and after coronary stent placement. This client is at increased risk due to endothelial damage and advanced age but is not at greatest risk.