420: Test 1
When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum? 0.5 in (1 cm) 1 in (2.5 cm) 1.5 in (4 cm) 2 in (5 cm)
2 in (5 cm) An adult's sternum must be depressed 2 inches (5 cm) with each compression to ensure adequate heart compression.
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? "The pain lasted about 45 minutes." "The pain resolved after I ate a sandwich." "The pain got worse when I took a deep breath." "The pain occurred while I was mowing the lawn."
"The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
Which instruction by the nurse is given to a patient who is about to undergo Holter monitoring is most appropriate? "You may remove the monitor only to shower or bathe." "You should connect the monitor whenever you feel symptoms." "You should refrain from exercising while wearing this monitor." "You will need to keep a diary of all your activities and symptoms.
"You will need to keep a diary of all your activities and symptoms. A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.
The nurse is performing a client's admission assessment. Which assessment finding would support the possibility that this client may have cardiovascular disease? Select all that apply. 1. fatigue 2. chest pain 3. weight loss 4. light-headedness 5. dependent edema
1. fatigue 2. chest pain 4. light-headedness 5. dependent edema Cardiovascular disease is any abnormal condition characterized by dysfunction of the heart and blood vessels. Common clinical manifestations of cardiovascular disease include chest pain, irregularities of the heart rhythm, cyanosis, fatigue, light-headedness, weight gain, dependent edema, and dyspnea. The client may report dyspnea when lying in a flat position, but not while upright.
A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). To determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask? 1. "What time did your chest pain start?" 2. "Did you take any nitroglycerine before coming to the emergency department?" 3. "Do you have any allergies?" 4. "Is this the first time you experienced this type of pain?"
1. "What time did your chest pain start?" Thrombolytic therapy must be started within 6 hours of the onset of the myocardial infarction (MI). The time the chest pain started is the priority. The nurse can assess for allergies once the time is determined. Nitroglycerine will not impact the administration of thrombolytic therapy.
A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is ordered. The nurse knows that morphine is given because it: 1. eliminates pain, reduces cardiac workload, and increases myocardial contractility. 2. lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. 3. raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain. 4. increases venous return, lowers resistance, and reduces cardiac workload.
2. lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand. When given to treat acute MI, morphine eliminates pain, reduces venous return to the heart, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine doesn't increase myocardial contractility, raise blood pressure, or increase venous return.
While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. What should the nurse do next? 1. Stop and assess the client further. 2. Obtain the client's blood pressure and heart rate. 3. Call for help and place the client in a wheelchair. 4. Administer nitroglycerin.
1. Stop and assess the client further. The nurse should stop and assess the client further. A chair should be available for the client to sit down. Obtaining the client's blood pressure and heart rate are important when exercising. These values can be used to predict when the oxygen demand becomes greater than the oxygen supply. Calling for help is not necessary for the midsternal burning. If the health care provider (HCP) has prescribed nitroglycerin, the nurse can administer it; however, stopping the activity may restore the oxygen balance.
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? 1. The client demonstrates ability to tolerate more activity without chest pain. 2. The client exhibits a heart rate within normal limits. 3. The client requests information regarding smoking cessation. 4. The client is able to verbalize the action of all prescribed medications.
1. The client demonstrates ability to tolerate more activity without chest pain. The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. A heart rate within the normal limits of 60-100 per minute does not necessarily indicate a favorable response to treatment. Smoking is a cardiovascular risk factor that the client would be wise to eliminate, but it does not indicate favorable response to treatment. Knowledge of prescribed meds is a good thing, but again does not impact response to treatment.
After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first? 1. the client with heart failure who is having some difficulty breathing 2. the anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today 3. the coronary bypass client asking for pain medication for "11 of 10" pain in the donor site 4. the client admitted during the previous shift with new-onset controlled atrial fibrillation, who has a call light on
1. the client with heart failure who is having some difficulty breathing The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs an analgesic, but that does not take priority over a client with difficulty breathing.
A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority? 1. A client's cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions. 2. A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. 3. A client's monitor shows frequent paced beats with capture. 4. A client's monitor shows sinus tachycardia with frequent premature atrial contractions (PACs).
2. A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. The client whose cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation takes priority. This cardiac rhythm change may cause clots to shower from the atria, placing the client at risk for a stroke. The client whose cardiac monitor reveals sinus tachycardia with isolated premature ventricular contractions is not experiencing a life-threatening situation; therefore, does not take priority. Frequent paced beats with capture is a normal finding for a client with a pacemaker. Sinus tachycardia with premature atrial contractions is not a priority situation.
A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention? 1. Reduce the nausea and vomiting and stabilize the blood glucose. 2. Control the pain and support breathing and oxygenation. 3. Decrease the anxiety and reduce the workload on the heart. 4. Monitor and manage potential complications.
2. Control the pain and support breathing and oxygenation. Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.
An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after insertion of a permanent pacemaker? 1. Maintain skin integrity. 2. Maintain cardiac conduction stability. 3. Decrease cardiac output. 4. Increase activity level.
2. Maintain cardiac conduction stability. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours.
A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? 1. the client with a history of cardioversion for sustained ventricular tachycardia 2 days ago 2. the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block 3. the client with a history of heart failure who has bibasilar crackles and pitting edema in both feet 4. the client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday
2. the client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client who underwent cardioversion 2 days ago has likely had the underlying reason for the sustained ventricular tachycardia corrected. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first is not necessary. The client who underwent PCI with stenting was at risk for reperfusion arrhythmias and/or bleeding from the arterial puncture site but could be considered to be stable 24 hours post-procedure.
A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? 1. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. 2. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician. 3. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. 4. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
4. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the physician before completing the initial assessment is premature.
A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? prolonged PR interval absent Q wave elevated ST segment widened QRS complex
elevated ST segment Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.
A nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first: establish unresponsiveness. call for help. open the airway. assess the client for a carotid pulse.
establish unresponsiveness. The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths, and check for a carotid pulse.
The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation. The nurse should anticipate which intervention? an I.V. push of digoxin an I.V. line for emergency medications immediate defibrillation synchronized cardioversion
immediate defibrillation When ventricular fibrillation is verified, the first intervention is defibrillation, which is the only intervention that will terminate this lethal dysrhythmia. Digoxin is not indicated for V-fib. An I.V. will be one of the priorities, but not first. The client would need to have a functional rhythm for synchronized cardioversion to be performed.
A client with severe angina pectoris and electrocardiogram changes is seen in the emergency department. What laboratory studies would the nurse most likely anticipate? creatine kinase lactate dehydrogenase myoglobin troponin
troponin This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin tests can show evidence of muscle injury, but they are less specific indicators of myocardial damage than troponin.
The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure? 1. Iron 2. Iodine 3. Aspirin 4. Penicillin
2. Iodine The physician will usually use an iodine-based contrast to perform this procedure. Therefore it is imperative to know whether or not the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.
A nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation. Why is this check so important? 1. The delivered shock must be synchronized with the client's QRS complex. 2. The defibrillator will not deliver a shock if the synchronizer switch is turned on. 3. The defibrillator will not deliver a shock if the shock delivery is set at 400. 4. The shock must be synchronized with the client's T wave.
2. The defibrillator will not deliver a shock if the synchronizer switch is turned on. The nurse needs to check the synchronizer switch to ensure the switch is turned off. The defibrillator will not deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on. The synchronizer switch should be turned on when attempting to terminate arrhythmias that contain QRS complexes, such as rapid atrial fibrillation that's resistant to pharmacologic measures. A synchronized shock should occur with the QRS complex, not the T wave, to avoid inducing ventricular fibrillation and allow for a lower shock dose.
A nurse is monitoring a client on the telemetry unit. The electrocardiogram tracing shows a PR interval of 0.22 seconds. What is the appropriate action of the nurse? Document the findings and continue to monitor the client. Contact the healthcare provider. Administer epinephrine. Administer oxygen via nasal cannula.
Document the findings and continue to monitor the client. The PR interval normally ranges from 0.12 to 0.20 seconds. A reading of 0.22 seconds is first-degree heart block. The nurse should monitor the client and document the findings. The other interventions are not necessary at this time.
A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority intervention at this time? calling the resuscitation team defibrillating the client delivering a precordial thump assessing the client
assessing the client The priority action of the nurse would be to assess the client to determine if the client is having a loss of consciousness with cessation of respiration or pulse. The electrodes may have lost connection with the client's skin. The other choices would be inappropriate actions until an assessment has been performed.
A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply. hemoglobin and hematocrit (HCT) serum glucose creatine kinase (CK) troponin T and troponin I myoglobin blood urea nitrogen (BUN)
creatine kinase (CK) troponin T and troponin I myoglobin With myocardial ischemia or infarction, levels of CK, troponin T, and troponin I typically rise because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage. Hemoglobin, HCT, serum glucose, and BUN levels do not provide information related to myocardial ischemia.
The rapid response team arrives in the room of a client who has had a cardiac arrest. The nurse should first apply which piece of monitoring equipment? electrocardiogram (ECG) electrodes pulse oximeter blood pressure cuff Doppler pulse detection unit
electrocardiogram (ECG) electrodes The nurse should first apply the ECG electrodes to the client's chest. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate the client. Pulse oximetry is not an immediate priority. The client's oxygenation is evaluated in a code situation using arterial blood gas analysis. The client's blood pressure is evaluated after the ECG rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of a pulse or to check the blood pressure in a code situation.
An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. Changes in which leads of a 12-lead ECG indicate damage to the left ventricular septal region? leads I, aVL, V5, and V6 leads II, III, and aVF leads V1 and V2 leads V3 and V4
leads V3 and V4 Leads V3 and V4 record electrical events in the septal region of the left ventricle. Leads I, aVL, V5, and V6 record electrical events on the lateral surface of the left ventricle. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle. Leads V1 and V2 record electrical events on the anterior surface of the right ventricle and the anterior surface of the left ventricle.
The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? 1. pulse rate 2. oxygen saturation 3. respiratory rate 4. blood pressure
4. blood pressure Nitroglycerin can cause hypotension. A priority nursing assessment after the administration of nitroglycerin is the client's blood pressure. Oxygen saturation, respiratory rate, and pulse rate are not priority nursing assessments after the administration of nitroglycerin.
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? Monitor daily weights and urine output. Limit visitation by family and friends. Provide client education on medications and diet. Reduce pain and myocardial oxygen demand.
Reduce pain and myocardial oxygen demand. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
Which condition most commonly results in coronary artery disease (CAD)? 1. atherosclerosis 2. diabetes mellitus 3. myocardial infarction 4. renal failure
1. atherosclerosis Atherosclerosis (plaque formation), is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related
A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, the nurse correctly identifies which ECG changes associated with an evolving MI? Select all that apply. 1. notched T-wave 2. presence of a U-wave 3. T-wave inversion 4. prolonged PR-interval 5. ST-segment elevation
3. T-wave inversion 5. ST-segment elevation T-wave inversion, ST-segment elevation, and a pathologic Q-wave are all signs of tissue hypoxia which occur during an MI. Ischemia results from inadequate blood supply to the myocardial tissue and is reflected by T-wave inversion. Injury results from prolonged ischemia and is reflected by ST-segment elevation. A notched T-wave may indicate pericarditis in an adult client. The presence of a U-wave may or may not be apparent on a normal ECG; it represents repolarization of the Purkinje fibers. A prolonged PR-interval is associated with first-degree atrioventricular block.
A client with third-degree atrioventricular heart block with a rate of 28 is admitted to the coronary care unit. Which intervention takes priority? 1. applying an apnea monitor 2. reviewing information regarding advanced directives 3. teaching the client to take the pulse 4. teaching the client about a temporary pacemaker
4. teaching the client about a temporary pacemaker Third degree A-V heart block is manifested by profound bradycardia and may be accompanied by confusion, dizziness, and syncope. This type of heart block will require pacemaker insertion. Applying an apnea monitor is not appropriate for this client. Reviewing advanced directives are not necessary at this time. Teaching the client to take the pulse is important but also not a priority.
A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take? Assess the client's airway, breathing, pulses, and level of conciseness. Defibrillate the client. Begin cardiopulmonary resuscitation (CPR). Apply the external pacemaker.
Assess the client's airway, breathing, pulses, and level of conciseness. If the client is experiencing ventricular tachycardia, the priority for the nurse is to assess the client's airway, breathing, and level of consciousness before any further action is taken.
A client in the emergency department has symptoms of anxiety, a "racing heart," and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse? Assess the client's vital signs and oxygen saturation. Administer a beta blocker to slow the heart rate. Administer diazepam 2.5 mg I.V. push for anxiety. Obtain a stat 12-lead electrocardiogram (EKG) and tropin level.
Assess the client's vital signs and oxygen saturation. Sinus tachycardia has multiple causes; further assessment is needed before determining the treatment. Administration of beta blockers or diazepam may not be indicated depending on the cause of the sinus tachycardia. A 12-lead EKG and tropin level might be appropriate following assessment of the client.
A nurse notes that the client's PR interval is .17 and the QRS complex is .10. What action should the nurse take next? Document the findings. Request a 12-lead electrocardiogram. Administer the ordered nitroglycerin paste. Give 2 liters of oxygen via nasal cannula.
Document the findings. These are normal findings. The nurse should document the findings. A 12-lead ECG would be ordered if the client needs further evaluation in the event of an abnormal finding. Administering nitroglycerin is a routine intervention and not related to the measured PR and QRS intervals. Oxygen administration is not indicated in the presence of normal findings.
The nurse connects a client to the electrocardiogram (EKG) monitor. The nurse would plan the need for transcutaneous pacing with observation of which heart rhythm? sinus bradycardia normal sinus rhythm with premature junctional contractions (PJCs) third-degree atrioventricular block ventricular asystole
third-degree atrioventricular block The nurse would retrieve the defibrillator, which has the capability of transcutaneous pacing, when observing a third-degree atrioventricular block. There is no communication between the atria and ventricles with this block, therefore the client would be bradycardiac with a reduced cardiac output. Sinus bradycardia may be a normal finding based on the client and would not be automatically treated with transcutaneous pacing. Having premature junctional contractions with a normal sinus rhythm will continue to produce a normal cardiac output due to the rate of 60-100 beats/minute. With ventricular asystole, cardiopulmonary resuscitation is needed instead.
A client with severe angina pectoris and ST-segment elevation on an electrocardiogram is being seen in the emergency department. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a: creatine kinase level hemoglobin (Hb) level. troponin level. liver panel.
troponin level. Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction (MI). It's the best serum indicator of MI and is more indicative of cardiac damage than creatine kinase. Hb values and liver panel components aren't as useful in the diagnosis of MI as a troponin level.
A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time? fear related to threat of death activity Intolerance related to decreased cardiac output social isolation related to restricted visiting hours in the ICU ineffective tissue perfusion (cardiopulmonary) related to arrhythmia
ineffective tissue perfusion (cardiopulmonary) related to arrhythmia The client suffered a lethal arrhythmia, requiring immediate resuscitation. This arrhythmia resulted from ineffective perfusion to the heart. Therefore, the appropriate nursing diagnosis is Ineffective tissue perfusion (cardiopulmonary). While all the other nursing diagnoses are appropriate for this client, they are not the priority. Fear related to threat of death is not a priority at this time because the client is likely fearful. Activity intolerance and social isolation are results of the client's critical condition; therefore, they are considered therapeutic, not problems warranting nursing diagnoses.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. What should the nurse do first? Assess for changes in vital signs. Draw an arterial blood gas. Evaluate heart sounds with the client leaning forward. Obtain a 12-lead electrocardiogram.
Assess for changes in vital signs. The nurse should first obtain vital signs as changes in the vital signs will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position, and can best be heard when the client is in these positions, not with the client learning forward. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.
A client's electrocardiogram (EKG) tracing shows normal sinus rhythm followed by three premature ventricular contractions (PVCs) and a return to normal sinus rhythm. What is the priority action of the nurse? Assess the client's apical-radial pulse rate. Assess the client's blood pressure. Administer oxygen. Administer amiodarone.
Assess the client's apical-radial pulse rate. Nonsustained ventricular tachycardia is several consecutive PVCs followed by the return to normal sinus rhythm. PVCs may reduce the CO and lead to angina and heart failure depending on frequency. Because PVCs in CAD or acute MI indicate ventricular irritability the nurse should first assess the client's physiologic response to PVCs by obtaining the client's apical-radial pulse rate, since PVCs often do not generate a sufficient ventricular contraction to result in a peripheral pulse. This can lead to a pulse deficit. Assessment of the client's hemodynamic status is important to determine if treatment with drug therapy is needed. Treatment relates to the cause of the PVCs such as oxygen therapy for hypoxia, electrolyte replacement, and drug therapy includes beta-adrenergic blockers, procainamide, or amiodarone.
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? Monitor the laboratory values. Observe neurologic function every 15 minutes. Observe the puncture site for swelling and bleeding. Monitor skin warmth and turgor.
Observe the puncture site for swelling and bleeding. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.
A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents: atrial repolarization. ventricular repolarization. atrial depolarization. ventricular depolarization.
Ventricular depolarization. The QRS complex on the ECG strip represents ventricular depolarization. Atrial repolarization usually occurs at the same time as ventricular depolarization and is impossible to distinguish on the ECG. The T wave represents ventricular repolarization. The P wave represents atrial depolarization.
Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's: electrocardiogram (ECG). lidocaine level. troponin level. blood pressure.
electrocardiogram (ECG). Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Lidocaine level will be monitored but it is not the primary focus; troponin level monitors myocardial damage. Blood pressure, which can drop on lidocaine, does need to be monitored but the focus should be the ECG to evaluate the effectiveness of the medication.
When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should asses the client for which changes? 1. cardiac arrhythmias 2. hypertension 3. seizure 4. hypothermia
1. cardiac arrhythmias Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.
The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used. Obtain a history of which drugs the client has used recently. Take vital signs. Position electrodes on the chest. Administer the prescribed dose of morphine.
Position electrodes on the chest. Take vital signs. Administer the prescribed dose of morphine. Obtain a history of which drugs the client has used recently. The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.
The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding? 1. Stenosis of the heart valves 2. Decreased adrenergic sensitivity Incorrect 3. Increased parasympathetic activity 4. Loss of elasticity in arterial vessels
4. Loss of elasticity in arterial vessels An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. Valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.
After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action? Call for help Obtain vital signs Ask the client to "lift up" Assess the groin site
Assess the groin site Assessment of the groin site is the priority. This establishes the source of the blood, and determines how much blood has been lost. The goal is to stop the bleeding. The nurse would call for help if needed after the assessment of the situation. After determining the extent of the bleeding, vital sign assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause re-bleeding.
A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client? 1. "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." 2. "PTCA involves cutting away blockages with a special catheter." 3 3. "PTCA involves passing a catheter through the coronary arteries to find blocked arteries." 4. "PTCA involves inserting grafts to divert blood from blocked coronary arteries."
1. "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. Cutting away blockages with a special catheter is an atherectomy. Passing a catheter through the coronary arteries to find blocked arteries is a cardiac catheterization. Inserting grafts to divert blood from blocked arteries describes coronary artery bypass graft surgery.
A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride, an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within: 1. 1 to 2 minutes after I.V. bolus administration. 2. 1 to 2 minutes after continuous I.V. infusion. 3. 10 to 15 minutes after I.V. bolus administration. 4. 10 to 15 minutes after continuous I.V. infusion.
1. 1 to 2 minutes after I.V. bolus administration. Lidocaine exerts its antiarrhythmic effect in 1 to 2 minutes after I.V. bolus administration. A continuous I.V. infusion will maintain lidocaine's antiarrhythmic effect for as long as the drip is used. Lidocaine provides antiarrhythmic effects for only 15 minutes after the I.V. infusion is stopped.
A nurse is preparing for elective cardioversion on a client experiencing uncontrolled atrial fibrillation. In which order will the nurse perform the following steps? All options must be used. 1. Obtain the consent. 2. Sedate the client. 3. Turn the defibrillator setting to synchronize. 4. Select the appropriate energy level. 5. Place the paddles on the client's chest. 6. Check the location of other staff and call out "all clear" and deliver the electrical charge.
1. Obtain the consent. 2. Sedate the client. 3. Turn the defibrillator setting to synchronize. 4. Select the appropriate energy level. 5. Place the paddles on the client's chest. 6. Check the location of other staff and call out "all clear" and deliver the electrical charge. The correct order is to obtain the consent before sedating the client, turn the defibrillator to synchronize, select the energy level, place the paddles on the chest, call all "clear," and then deliver the charge without endangering hospital staff.
A client with an acute myocardial infarction is receiving nitroglycerin by continuous infusion. Which client statement indicates that this drug is producing its therapeutic effect? 1. "I have a bad headache." 2. "My chest pain is decreasing." 3. "I feel a tingling sensation around my mouth." 4. "My vision is blurred, so my blood pressure must be up."
2. "My chest pain is decreasing." Nitroglycerin, a vasodilator, increases the arterial supply of oxygen-rich blood to the myocardium. This action produces the drug's intended effect: relief of chest pain. Headache is an adverse effect of nitroglycerin. The drug shouldn't cause a tingling sensation around the mouth and should lower, not raise, blood pressure.
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first? 1. Activate the rapid response team. 2. Assess the client's orientation and vital signs. 3. Call the health care provider (HCP). 4. Administer a bolus of lidocaine.
2. Assess the client's orientation and vital signs. The priority action is to assess the client and determine whether the rhythm is life threatening. More information, including vital signs, should be obtained and the nurse should notify the HCP. A bolus of lidocaine may be prescribed to treat this arrhythmia. This is not a code-type situation unless the client has been determined to be in a life-threatening situation.
A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priority action? 1. Obtain an order for furosemide 80 mg I.V. push. 2. Obtain an order for calcium gluconate 2 g I.V. push over 2-5 minutes. 3. Increase the rate of the client's I.V. fluid to 150 ml/hour. 4. Arrange for an emergency hemodialysis session.
2. Obtain an order for calcium gluconate 2 g I.V. push over 2-5 minutes. All the actions listed will reduce the serum magnesium concentration. The calcium gluconate will react the quickest to reduce the critical level.
The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation of the heart reveals the presence of a murmur. What is this assessment finding indicative of? 1. Increased viscosity of the patient's blood 2. Turbulent blood flow across a heart valve 3. Friction between the heart and the myocardium 4. A deficit in heart conductivity that impairs normal contractility
2. Turbulent blood flow across a heart valve Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.
A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? 1. monitoring the platelet count 2. assessing B-type natriuretic peptide levels 3. assessing troponin 1 levels 4. monitoring the white blood cell count
3. assessing troponin 1 levels Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority.
The nurse receives an order to administer morphine to a client with an acute myocardial infarction. What is the purpose of this medication? 1. to decrease cardiac output 2. to increase preload and afterload 3. to increase myocardial oxygen demand 4. to decrease myocardial oxygen demand
4. to decrease myocardial oxygen demand Morphine will calm and relax the client and decrease respiratory rate, anxiety, and stress, thus decreasing myocardial oxygen demand. It doesn't have any effect on cardiac output or preload or afterload.
When performing cardiopulmonary resuscitation (CPR), which finding indicates that external chest compressions are effective? 1. mottling of the skin 2. pupillary dilation 3. palpable pulse 4. cool, dry skin
3. palpable pulse With CPR, effectiveness of external chest compressions is indicated by palpable peripheral pulses, the disappearance of mottling and cyanosis, the return of pupils to normal size, and warm, dry skin. To determine whether the victim of cardiopulmonary arrest has resumed spontaneous breathing and circulation, chest compressions must be stopped for 5 seconds at the end of the first minute and every few minutes thereafter.
The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best action? 1. Document the finding in the medical record. 2. Determine whether the rhythm is irregular, coinciding with inspiration and expiration. 3. Teach the client about risks for coronary artery disease. 4. Notify the healthcare provider.
4. Notify the healthcare provider. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle; elevated ST sements indicate that the client is experiencing a myocardial infarction. The healthcare provider should be notified. Teaching should be delayed until the client is stable. An irregular heart rhythm that varies with respiration—sinus arrhythmia—is a normal variation of sinus rhythm; there is no intervention needed.
A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances? 1. early defibrillation in cases of atrial fibrillation 2. cardioversion in cases of atrial fibrillation 3. pacemaker placement 4. early defibrillation in cases of ventricular fibrillation
4. early defibrillation in cases of ventricular fibrillation AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates.
A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? The dobutamine may need to be decreased. The client is experiencing an allergic reaction to the dobutamine. The client is experiencing an exacerbation of the heart failure. The dobutamine needs to be increased.
The dobutamine may need to be decreased. Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client does not show symptoms of allergic reaction or heart failure.
A client with hypertrophic cardiomyopathy (HCM) is experiencing dyspnea, chest pain, syncope, fatigue, and palpitations and has an apical systolic thrill and heave, fourth heart sound (S4), and systolic murmur. Which nursing diagnosis should the nurse use to guide this client's care? decreased cardiac output risk for deficient fluid volume ineffective peripheral tissue perfusion risk for activity intolerance
decreased cardiac output Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of risk for deficient fluid volume is not applicable. Ineffective peripheral tissue perfusion would be applicable if the client is experiencing an alteration in peripheral pulses, capillary refill time greater than 3 seconds, or a change in skin characteristics. Although it might seem that the diagnosis of risk for activity intolerance would be applicable because of dyspnea and fatigue, addressing cardiac output will help reduce these symptoms.
The nurse is caring for a client following a myocardial infarction and is aware that complications can occur due to damage to the myocardium. Which interventions would be appropriate for this client? Select all that apply. 1. electrocardiogram with any chest pain 2. continuous cardiac monitoring via telemetry 3. ambulating length of hall in first 24 hours 4. maintaining bed rest for 72 hours 5. auscultating apical pulse every 2 hours
1. electrocardiogram with any chest pain 2. continuous cardiac monitoring via telemetry 5. auscultating apical pulse every 2 hours After a myocardial infarction, it is important to monitor the client carefully for complications. An EKG should be done with any chest pain to assess for any changes that would indicate additional damage to the heart muscle. Auscultating the apical pulse and continuous cardiac monitoring would identify a change in status. Bed rest would be maintained for 24 hours, and ambulation would be added gradually, not in the first 24 hours.
A client with angina shows the nurse the nitroglycerin tablets that the client carries in a plastic bag in a pocket. Where should the nurse teach the client to keep the nitroglycerin tablets? 1. in the refrigerator 2. in a cool, moist place 3. in a dark container to shield from light 4. in a plastic pill container where it is readily available
3. in a dark container to shield from light Nitroglycerin in all dosage forms (sublingual, transdermal, or intravenous) should be shielded from light to prevent deterioration. The client should be instructed to keep the nitroglycerin in the dark container that is supplied by the pharmacy, and it should not be removed or placed in another container.
