Adult Health- Cardiovascular
The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days post-abdominal aortic aneurysm repair with a pedal pulse decreased from baseline 2. 2 days post coronary bypass graft surgery with a white blood cell count of 18,000/mm^3 (18.0 x 10^9/L) 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion 4. Pneumothorax with a chest tube to negative suction and subcutan
1. 2 days post-abdominal aortic aneurysm repair with a pedal pulse decreased from baseline A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity in a client who is postoperative abdominal aortic aneurysm repair can indicate the presence of an arterial or graft occlusion and poses the greatest threat to survival.
The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker? 1. Auscultate the client's apical pulse rate 2. Measure the client's blood pressure 3. Obtain a 12-lead ECG 4. Palpate the client's radial pulse rate
1. Auscultate the client's apical pulse rate For clients with a newly implanted permanent pacemaker, the nurse should assess for electrical capture of heart rhythm (ex. ECG) and mechanical capture of heart rate (ex. pulse). A central pulse (ex. auscultation of apical, palpation of femoral) should be assessed to determine mechanical capture.
The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse if 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these supports the diagnosis of acute heart failure exacerbation? 1. B-type natriuretic peptide (BNP) 1382 pg/mL [1382 pmol/L] 2. Flat jugular veins when seated at a 45-degree angle 3. Sodium 150 mEq/L [150 mmol/L] 4. Urine output greater than 100 mL/hr
1. B-type natriuretic peptide (BNP) 1382 pg/mL [1382 pmol/L] The nurse should assess the BNP level in clients admitted with heart failure exacerbations. Elevated BNP levels indicate increased ventricular stretch and correlate with severity of heart failure and fluid volume overload. Heart failure clients may also present with jugular venous distention, low serum sodium, and decreased urine output.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? 1. "I'm not worried about the device firing now because I know it won't hurt" 2. " I will let my daughter fix my hair until my health care provider says I can do it" 3. "I will look into public transportation because I won't be able to drive again" 4. "I will notify my travel agent that I can no longer travel by plane"
2. " I will let my daughter fix my hair until my health care provider says I can do it" After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system
A nurse is making initial rounds at the beginning of the shift. Which client should the nurse see first? 1. 36 y/p client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur 2. 40 y/o client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distention 3. 67 y/o client admitted for pneumonia with new-onset atrial fibrillation, who has BP of 130/90 mm Hg and heart rate of 110/min 4. 70 y/o client with advanced heart failure who is receiving IV diuretics, has BP of 80/60 mm Hg, and is watching TV
2. 40 y/o client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distention Clients with pericardial effusion should be monitored and assessed closely for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular venous distension, and pulsus paradoxus.
A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply. 1. Apical pulse 2. Capillary refill 3. Lung sounds 4. Pupillary response 5. Skin color and temperature
2. Capillary refill 5. Skin color and temperature The adequacy of blood flow to peripheral tissues is determined by measuring cap refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock
A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the HCP. Which assessment data is most important for the nurse to report to the HCP? 1. Blood pressure (BP of 140/86 mm hG 2. Difficulty swallowing 3. Dry, hacking cough 4. Low back pain
2. Difficulty swallowing The nurse should report swallowing difficulty immediately in a client with a thoracic aortic aneurysm. This could indicate that the aneurysm has increased in size and may require treatment.
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 are important to review with the client? 1. How to transmit the readings over the phone 2. Keep a diary of activities and any symptoms experienced 3. Refrain from exercising while wearing the monitor 4. The monitor may be removed only when bathing
2. Keep a diary of activities and any symptoms experienced The nurse should instruct the client with a Holter monitor to keep a diary of activities and any symptoms that occur while wearing it. The client should also be taught not to bathe during the testing period but to continue all other normal activities
A nurse on the telemetry unit observes the following rhythm on the monitor of a client admitted with coronary artery disease. What action should the nurse take first? 1. Administer atropine 0.5 mg IV push 2. Measure the client's vital signs 3. Move the client back to bed from chair 4. Obtain a temporary pacemaker
2. Measure the client's vital sign Assess the client with second-degree atrioventricular block, type 1 for symptoms associated with the rhythm (ex. hypotension, dizziness, SOB). If no symptoms are present, closely monitor the client. If symptoms are present, anticipate using atropine or temporary pacing.
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? 1. Arterial bruit 2. Murmur heard at the aortic area 3. Pericardial friction rub 4. S3 gallop heard at the mitral area
2. Murmur heard at the aortic area Murmurs indicate turbulent blood flow across diseased or malformed cardiac valves. They are often described as musical, blowing, or swooshing sounds that occur between normal heart sounds. They may be auscultated at the aortic, pulmonic, tricuspid, or mitral areas
A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which lab value would indicate that the heparin infusion needs to be turned off? 1. Hematocrit of 30% (0.30) 2. Partial thromboplastin time of 110 seconds 3. Platelet count of 80,000/mm^3 4. Prothrombin time of 11 seconds
2. Partial thromboplastin time of 110 seconds
The nurse receives handoff of care report on four clients. Which client should the nurse see first? 1. Client with atrial fibrillation who reports feeling palpitations and has an irregular pulse of 122/min 2. Client with liver cirrhosis who reports bleeding from an IV insertion site and has a platelet count of 48,000 mm^3 (48 x 10^9/L) 3. Client with pericarditis who blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour 4. Client with pneumonia whose white blood cell count has increased from 14,000 mm^3 (14 x 10^9/L) 8 hours ago to 30,000 mm^3 (30 x 10^9/L)
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 with immediate intervention. Clinical features of cardiac tamponade include hypotension, muffled heart sounds, and neck vein distension (Beck triad).
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and cough with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? 1. Bronchial breath sounds at lung periphery 2. Clear vesicular breath sounds at lung bases 3. Diffuse bilateral crackles at lung bases 4. Stridor in upper airways
3. Diffuse bilateral crackles at lung bases Acute-onset dyspnea and cough with frothy, pink-tinged sputum indicate pulmonary edema. Auscultation reveals crackles at the lung bases.
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? 1. Assess incision for bleeding or hematoma formation 2. Auscultate bilateral anterior and posterior lung sounds 3. Initiate continuous cardiac monitoring 4. Reestablish IV fluids and postoperative antibiotics
3. Initiate continuous cardiac monitoring Assessing the function of a new permanent pacemaker is a priority after operative placement. The nurse should immediately attach the cardiac monitor before making other appropriate assessments
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 2. Check for peripheral edema 3. Measure the client's vital signs 4. Review the client's weight log over the past several days
3. Measure the client's vital signs The nurse should follow the ABCs of assessment with the heart failure client who is SOB and coughing. Airway, breathing, and circulation should be assessed including auscultation of breath sounds, measurement of respiratory rate, and oxygen saturation.
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? 1. Jugular venous distention 2. Mean arterial blood pressure 65 mm Hg 3. Urine output < 0.5 mL/kg/hr 4. Warm, flushed skin
3. Urine output < 0.5 mL/kg/hr S&S of hypovolemic shock are associated with inadequate tissue perfusion and include change in mental status; tachypnea; tachycardia with thready pulse; cool, clammy skin; and oliguria; decreased intravascular volume and central venous pressure
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 DVT? 1. An 25 y/o client with abdominal pain who smokes cigarettes and takes oral contraception 2. A 55 y/o ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% 3. A 72 y/o client with a fever who is 2 days post coronary stent placement 4. An 80 y/o client who is 4 days postoperative from repair of a fractured hip
4. An 80 y/o client who is 4 days postoperative from repair of a fractured hip DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma. surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.
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? 1. "I'm glad that I can continue taking my Ginkgo biloba." 2. "I will increase my intake of leafy green vegetables. "3. "I will start applying vitamin E to my chest incision after showering." 4. "I will shave with an electric razor from now on."
4. I will shave with an electric razor from now on. Clients who are on anticoagulants should avoid aspirin, NSAIDS, and other otc or herbal products (ex. Ginkgo biloba) that can increase bleeding risk. They should also avoid behaviors that increase the risk of clotting (ex. eating excess green leafy vegetables)
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask the client? 1. Diet recall for this current week 2. Fluid intake for the past 2 days 3. Medications and dosages taken over the past 2 days 4. Presence of shortness of breath, coughing, or edema
4. Presence of shortness of breath, coughing, or edema The client with chronic heart failure is at risk for exacerbation. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.
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? 1. Adenosine IVP 2. Atropine IVP 3. Defibrillation 4. External pacing
Adenosine IVP The drug of choice in clients with PSVT is adenosine. It is given rapidly via IVP over 1-2 seconds and followed by a 20-mL saline bolus. An increased dose may be administered 2 more times if previous administration is ineffective.
The nurse has just administered a dose of 0.5 mg atropine with a heart rate of 48/min and blood pressure of 90/62 mmHg. Which rhythm strip would indicate that the medication achieved the desired outcome?
Atropine is given to the client with symptomatic bradycardia. The desired outcome would be an increased in heart rate, evidence of normal sinus rhythm on the cardiac monitor and reversal of any clinical symptoms associated with the bradycardia
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? 1. Assess for dry, scaly skin on the lower legs 2. Assess for presence or absence of hair growth on lower extremities 3. Check for presence and quality of posterior tibial and dorsalis pedis pulses 4. Obtain a dietary history
Check for presence and quality of posterior tibial and dorsalis pedis pulses The nurse caring for a client with intermittent claudication from PAD should assess the adequacy of circulation to the extremities by palpating and assessing the quality of posterior tibial and dorsalis pedis pulses. The quality of circulation will guide the tx plan including risk factor modification, drug therapy, and possible surgical revascularization.
The charge nurse is assisting with a non emergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene? 1. Administers a one-time dose of IV midazolam 2. Disengages the "sync" function on the defibrillator 3. Places defibrillator pads on upper right and lower left chest 4. Turns off the client's oxygen and moves it away from the bed
Disengages the "sync" function on the defibrillator Synchronized cardioversion is a cardiac procedure used to convert tachyarrhythmias with a pulse to stable cardiac rhythms. Nurses preparing to perform cardioversion must verify that the defibrillator "sync" feature is engaged to prevent delivery of an asynchronous shock, which may cause life-threatening arrhythmias
The nurse is performing a cardiac assessment. Where does the nurse expect to feel the client's point of maximal impulse (PMI)?
During cardiac assessment, the nurse should palpate the PMI medial to the midclavicular line at the 4th or 5th intercostal space. Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement
The nurse is assessing for the presence of jugular venous distention (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 2. Head of the bed elevated to a 60-degree angle 3. Head of the bed elevated to a 90-degree angle 4. Head of the bed flat
Head of the bed elevated to a 45-degree angle The nurse should position the client with the head of the bed at a 30-to 45-degree angle to assess for the presence of JVD
