ATI Cardio
A nurse is caring for a client, following insertion of a permanent pacemaker, which of the following client statements, indicates a potential complication of the insertion procedure?
"I can't get rid of these hiccups." Hiccups can indicate that the pacemaker is stimulating the chest wall, or diaphragm, which can occur as a result of a lead wire perforation
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 11 o'clock which of the following statements by the client requires the nurse to contact the provider for possible rescheduling
"I smoked a cigarette this morning to calm my nerves about having this procedure" Smoking prior to this test can change the outcome and place as the client at additional risk the procedure should be rescheduled if the client has smoked before the test
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (GABG) in 2 hrs. Which of the following client statements indicates a need for further clarification by the nurse.
"I took my warfarin last night according to my usual schedule." Clients who are scheduled for a CABG should not take anticoagulants such as warfarin for several days prior to the surgery to prevent excessive bleeding
A nurse is providing health teaching to a group of clients, which of the following clients is at risk for developing peripheral arterial disease
A client who has diabetes, mellitus Diabetes, mellitus places the client at risk for micro vascular damage, and progressive peripheral arterial disease
A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry, which of the following areas of the strip should the nurse examining to observe for atrial depolarization
A is correct The nurse should examine this area, the P-wave, of the rhythm strip to evaluate for atrial depolarization
A nurse in the emergency department is assessing a client who has Bradydysrhythmia. Which of the following findings should the nurse monitor for?
Confusion Brady dysrhythmia can cause decreased systemic perfusion, which can lead to confusion there for the nurse should monitor the clients mental status
A nurse is providing discharge teaching to a client who has a prescription for trans dermal nitroglycerin patches, which of the following instruction should the nurse include in the teaching
Place the patch on an area of skin away from skin folds and joints The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly
The nurse is assessing a client who has pulmonary edema related to heart failure, which of the following findings indicate effective treatment of the clients condition
Absence of adventitious breath sounds Adventitious breath sounds occur when there is fluid in the lungs the absence of adventitious breath sounds indicates that the pulmonary edema is resolving
A nurse is an emergency department is caring for a client who has an anterior myocardial infarction. The clients history reveals they are one week postoperative following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated.
Assisting with thrombolytic therapy The nurse should recognize that major surgery within the previous three weeks is a contraindication for thrombolytic therapy
A nurse is caring for a client who has eight hour postoperative following a coronary artery bypass graft (GABG) which of the following findings should the nurse report
Blood pressure 160/80
A nurse is reviewing the laboratory results of several male clients who have peripheral artery disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values.
Cholesterol 190 mg/dL HDL 25mg/dL LDL 160mg/dL These laboratory values for HDL and LDL are outside of the expected reference range and indicates that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 for HDL is above 45 for males and above 55 for females and 4LDL is less than 130
A nurse is caring for a client who has one hour postoperative following an aortic aneurysm repair, which of the following findings can indicate shock and should be reported to the provider
Urine output of 20 mL/hr Your an output less than 30 is a manifestation of shock. Urine output is decreased due to composite Tory decreased blood flow to the kidneys, hypervolemia or graph thrombosis or rupture.
A nurse is caring for a client who has an onset of chest pain 24 hours ago. The nurse should identify that an increase in which of the following values is a diagnostic of a myocardial infarction.
Creatinine kinase-MB Creatinine kinase MB is the isoenzyme specific to the myocardium, elevated, creatinine kinase MB indicates myocardial muscle injury
A nurse is performing a cardiac assessment on a client identify the area the nurse should inspect when evaluating the point of maximal impulse, you will find hotspots to select in the artwork below select only the hotspot that corresponds to your answer
D is correct Inspection of this location allows the nurse to assess for Paul stations of the Apex area of the heart, which is considered the apical pulse or point of maximal impulse the point of maximal impulse is located at the left fifth intercostal space in the midclavicular line
A nurse in regency department is caring for a client who has a blood pressure of 254/139. The nurse recognizes that the client is in a hypertensive crisis which of the following action should the nurse take first
Elevate the head of the clients bed The greatest rest of this client is organ injury due to severe hypertension there for the first action, the nurse should take, is elevate the head of the clients bed to reduce blood pressure and promote oxygenation
A nurse is assessing a client who has a history of deep vein, thrombosis and is receiving warfare in which of the following findings should indicate to the nurse that the medication is effective
INR 2.0 The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep vein thrombosis, and is receiving warfarin to reduce the risk of new clot formation, and a stroke
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus, which of the following focused assessment should the nurse use to help differentiate between an arterial ulcer and a venous status ulcer
Inquire about the presence or absence of claudication Knowing if the client is experiencing claudication, helps differentiate Venus from arterial ulcers clients who have arterial ulcers experience claudication, but those who have venous ulcers do not
A nurse is caring for a client who is being treated for heart failure and has a prescription for Furosemide. the nurse should plan to monitor for which of the following adverse effects of this medication
Lightheadedness For Rosum, I'd can cause a substantial drop in blood pressure resulting in lightheadedness or dizziness
A nurse is planning a presentation for a group of clients who have hypertension which of the following lifestyle modification should the nurse include (select all that apply)
Limit, alcohol intake, regular exercise program, and tobacco cessation is correct
A nurse is teaching a client who has a new prescription for an ace inhibitor to treat hypertension the nurse should instruct the client to notify their provider if they experience which of the following adverse effects of this medication
Persistent cough A persistent cough is an adverse effect of ace inhibitors the client to report at this finding to the provider and discontinue the medication
A nurse is preparing a client for coronary angiography, which of the following findings. Should the nurse report to the provider prior to the procedure.
Previous allergic reaction to iodine The contrast medium used for coronary angiography is iodine based clients who have a history of allergic reaction to iodine might need a steroid or anti-histamine prior to the procedure
The nurse is caring for a client who was admitted for treatment of left, sided heart failure and is receiving intervenous loop diuretics and digitalis therapy. The client is experiencing weakness and a regular heart rate which of the following action should the nurse take first.
Review serum electrolyte values Weakness and irregular heart rate indicate that the client is at a greater risk for electrolyte, imbalance and adverse effects of loop diuretics the first action the nurse should take is to review the clients electrolyte values, particularly the potassium level because the client is at risk for dysrhythmias from hypokalemia
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation which of the following findings. Should the nurse plan to monitor for an report to the provider immediately
Slurred speech The greatest risk this client is injury from an embolus caused by the pooling of blood that can occur with atrial fabulation slurred speech can indicate an adequate circulation to the brain because of the endless therefore, the nurse report this morning to the provider Immediately
A nurse is caring for a client who is receiving heparin therapy and develops hematuria which of the following action should the nurse take if the client APTT is 96 seconds
Stop the heparin infusion The nurse should identify that the clients a PTT is above the critical value, and the client is displaying manifestations of bleeding. Therefore the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.
A nurse is monitoring a clients, ECG, monitor and notes. The clients rhythm has changed from normal sinus rhythm to super ventricular tachycardia. The nurse should prepare to assist with which of the following interventions.
Vagal stimulation The nurse should identify that vagal stimulation might temporarily convert the clients heart rate to normal sinus rhythm. The nurse should have a defibrillator or resuscitation equipment at the clients bedside because vagal stimulation can cause Bradydysrhythmias ventricluar dysrhythmias or asystole
A nurse is caring for a client who has endocarditis which of the following findings should the nurse recognize as a potential complication
Valvular disease. Valvular, disease, or damage often occurs as a result of inflammation or infection of the endocardium
A nurse is providing discharge, teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider.
Weight gain of 2 lbs in 24 hours When using the urgent versus non-urgent approach to client care the nurse to determine that the priority finding is a weight gain of 1.1 to 2 pounds in one day, the weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding
A nurse is providing teaching to a client who is today's postoperative following a heart transplant? Which of the following statements should the nurse include in the teaching?
You might no longer be able to feel chest pain Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart
A nurse is assessing a client who has dilated cardiomyopathy which of the following findings should the nurse expect
dyspnea on exertion The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy dyspnea on exertion, is due to ventricular, compromise, and reduced cardiac output
A nurse is assessing a client who has left sided heart failure which of the following manifestations should the nurse expect to find
weak peripheral pulses Weak, peripheral pulses are related to decreased cardiac output, resulting from left sided heart failure
