ATI Cardiovascular
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 exam to observe for atrial depolarization?
"A" - location was on P-wave QRS complex = ventricular depolarization T wave = ventricular repolarization
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse.
"D" - location was under the left nipple --------------------------- RATIONALE: • Inspection of this location allows the nurse to assess for pulsations 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 is providing teaching for a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching? a. "you might no longer be able to feel chest pain" b. "your level of activity tolerance will not change" c. "after 6 months, you will no longer need to restrict your sodium intake" d. "you will be able to stop taking immunosuppressants after 12 months"
"You might no longer be able to feel chest pain" --------------------------- RATIONALE: • Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.
A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The clients history reveals they are 1 week postoperative following an open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? a. administering IV morphine sulfate b. administering oxygen at 2 L/min nasal cannula c. helping the client to the bedside commode d. assisting with thrombolytic therapy
Assisting with thrombolytic therapy --------------------------- RATIONALE: • The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse recognize that an increase in which of the following is diagnostic of myocardial infarction (MI)? a. myoglobin b. c-reactive protein c. creatine kinase-MB d. homocysteine
Creatine kinase-MB --------------------------- RATIONALE: • Creatine kinase-MB is the isoenzyme specific to the myocardium. • Elevated creatine kinase-MB indicates myocardial muscle injury.
A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following findings should indicate to the nurse that the medication is effective? a. hemoglobin 14 g/dL b. minimal bruising of extremities c. decreased blood pressure d. INR 2.0
INR 2.0 --------------------------- RATIONALE: • 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 preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? a. hemoglobin 14.4 g/dL b. history of peripheral artery disease c. urine output 200 mL/4 hrs d. previous allergic reaction to shellfish
Previous allergic reaction to shellfish --------------------------- RATIONALE: • The contrast medium used for coronary angiography is iodine-based. • Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.
A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? a. obtain the client's current weight b. review serum electrolyte values c. determine the time of the last digoxin dose d. check the client's urine output
Review serum electrolyte values --------------------------- RATIONALE: • Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. • The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
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? a. "I can't get rid of these hiccups." b. "I feel dizzy when I stand." c. "My incision site stings." d. "I have a headache."
a. "I cannot get rid of these hiccups" --------------------------- RATIONALE: • 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 assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the clients condition? a. absence of adventitious breath sounds b. presence of a nonproductive cough c. decrease in respiratory rate at rest d. SaO2 86% on room air
a. absence of adventitious breath sounds --------------------------- RATIONALE: • 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 in an emergency room is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse monitor for? a. confusion b. friction rub c. hypertension d. dry skin
a. confusion --------------------------- RATIONALE: • Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? a. dyspnea on exertion b. tracheal deviation c. pericardial rub d. weight loss
a. dyspnea on exertion --------------------------- RATIONALE: • 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. tracheal deviation = tension pneumothorax pericardial rub = pericarditis weight loss = ventricular compromise & fluid retention *weight gain is expected in dilated cardiomyopathy
A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? (select all that apply) a. limited alcohol intake b. regular exercise program c. decreased magnesium intake d. reduced potassium intake e. tobacco cessation
a. limited alcohol intake b. regular exercise program c. tobacco cessation --------------------------- RATIONALE: • Clients who have hypertension should limit alcohol intake. • Clients who have hypertension should develop a regular exercise program to help reduce blood pressure. • Clients who have hypertension should have a goal of tobacco cessation because tobacco use exacerbates hypertension ______ • Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include. • Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include.
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 and report to the provider immediately? a. slurred speech b. irregular pulse c. dependent edema d. persistent fatigue
a. slurred speech --------------------------- RATIONALE: • The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. • Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
A nurse is providing discharge teaching for a client who has a heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? a. weight gain of 0.9 kg (2 lb) in 24 hr b. increase of 10 mm Hg in systolic blood pressure c. dyspnea with exertion d. dizziness when rising quickly
a. weight gain of 0.9 kg (2 lb) in 24 hrs --------------------------- RATIONALE: • When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. • This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately. dyspnea on exertion is a nonurgent finding that is expected for a client who has HF
A nurse is providing health teaching for a group of clients which of the following clients is at risk for developing peripheral arterial disease? a. a client who has hypothyroidism b. a client who has diabetes mellitus c. a client whose daily caloric intake consists of 25% fat d. a client who consumes two 12-oz (0.35-L) bottles of beer a day
b. a client who has diabetes mellitus --------------------------- RATIONALE: • Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease. 25% of fat is within the daily limits two 12-oz bottle of beer a day is considered moderate
A nurse is caring for a client who is 8 hr postoperative following a coronary artery graft (CABG). Which of the following client findings should the nurse report? a. mediastinal drainage 100 mL/hr b. blood pressure 160/80 mm Hg c. temperature 37.1C (98.8F) d. potassium 4.0 mEq/L
b. blood pressure 160/80 mmHg --------------------------- RATIONALE: • The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites. mediastinal drainage of up to 150 mL/hr is expected during this time.
A nurse is caring for a client who is being rated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication? a. shortness of breath b. lightheadedness c. dry cough d. metallic taste
b. lightheadedness --------------------------- RATIONALE: • Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.
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 on this medication? a. tendon pain b. persistent cough c. frequent urination d. constipation
b. persistent cough --------------------------- RATIONALE: • A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? a. apply the new patch to the same site as the previous patch. b. place the patch on an area of skin away from skin folds and joints. c. keep the patch on 24 hr per day. d. replace the patch at the onset of angina.
b. place the patch on an area of skin away from skin folds and joints --------------------------- RATIONALE: • 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. Pt. should have a patch-free interval of 10-12 hrs each day (prevents tolerance) Patches do not treat angina attacks bc they do not take effect immediately (used for ongoing prevention of attacks)
A nurse is monitoring a client ECG monitor and notes the clients rhythm has change from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions? a. initiate chest compressions b. vagal stimulation c. administration of atropine IV d. defibrillation
b. vagal stimulation --------------------------- RATIONALE: • The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. • The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find? a. increased abdominal girth b. weak peripheral pulses c. jugular venous neck distention d. dependent edema
b. weak peripheral pulses --------------------------- RATIONALE: • Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. All others are indicative of right-sided HF
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hours. Which of the following client statements indicates a need for further clarification by the nurse? a. "my arthritis is really bothering me because I haven't taken my aspirin in a week." b. "my blood pressure shouldn't be high because I took my blood pressure medication this morning." c. "I took my warfarin last night according to my usual schedule." d. "I will check my blood sugar because I took a reduced dose of insulin this morning."
c. "I took my warfarin last night according to my usual schedule" --------------------------- RATIONALE: • 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 reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values? a. cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL b. cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL c. cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL d. cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
c. cholesterol 190 HDL 25 LDL 160 --------------------------- RATIONALE: • These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. • The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.
A nurse in an emergency department s caring for a client who has a blood pressure of 254/139 mmhg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? a. initiate seizure precautions b. tell the client to report vision changes c. elevate the head of the client's bed d. start a peripheral IV
c. elevate the head of the client's bed --------------------------- RATIONALE: • The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? a. explore the client's family history of peripheral vascular disease. b. note the presence or absence of pain at the ulcer site. c. inquire about the presence or absence of claudication. d. ask if the client has had a recent infection.
c. inquire about the presence or absence of claudication --------------------------- RATIONALE: • Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. • Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
A nurse is caring for a postoperative client 1 hr following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? a. serosanguineous drainage on dressing b. severe pain with coughing c. urine output of 20 mL/hr d. increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F)
c. urine output of 20 mL/hr --------------------------- RATIONALE: • Urine output less than 30 mL/hr is a manifestation of shock. • Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? a. "I'm still hungry after the bowl of cereal I ate at 7 a.m." b. "I didn't take my heart pills this morning because the doctor told me not to." c. "I have had chest pain a couple of times since I saw my doctor in the office last week." d. "I smoked a cigarette this morning to calm my nerves about having this procedure."
d. "I smoked a cigarette this morning to calm my nerves about having this procedure" --------------------------- RATIONALE: • Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.
A nurse is caring for client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the clients aPTT is 96 seconds? a. increase the heparin infusion flow rate by 2 mL/hr b. continue to monitor the heparin infusion as prescribed c. request prothrombin time (PT) d. stop the heparin infusion
d. stop the heparin infusion --------------------------- RATIONALE: • The nurse should identify that the client's aPTT 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. aPTT of 96 seconds indicated excessive blood levels of heparin PT should be monitored for a client who is taking an oral anticoagulant
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? a. ventricular depolarization b. Guillain-Barre syndrome c. myelodysplastic syndrome d. valvular disease
d. valvular disease --------------------------- RATIONALE: • Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
