Cardiac Assessment Med Surg 2

A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) Select one or more: a. Low-density lipoprotein cholesterol: 160 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Total cholesterol: 280 mg/dL d. Triglycerides: 200 mg/dL e. Serum albumin: 4 g/dL

A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis. The correct answers are: Total cholesterol: 280 mg/dL, Triglycerides: 200 mg/dL, Low-density lipoprotein cholesterol: 160 mg/dL

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? Select one: a. A 59-year-old woman who smokes cigarettes daily b. A 36-year-old woman with aortic stenosis c. A 70-year-old man who had a cerebral vascular accident d. A 42-year-old man with pulmonary hypertension

Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure. The correct answer is: A 36-year-old woman with aortic stenosis

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? Select one: a. Preventricular contractions b. Symptomatic bradycardia c. Sinus tachycardia d. Atrial fibrillation

Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output. The correct answer is: Atrial fibrillation

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How should the nurse respond? Select one: a. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question. The correct answer is: "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? Select one: a. Cardiac rhythm and heart rate b. Ability to turn self in bed c. Allergies to iodine-based agents d. Client's level of anxiety

Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status. The correct answer is: Allergies to iodine-based agents

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching? Select one: a. "A nutritionist will provide you with information about your new diet." b. "The best way to lose weight is a high-protein, low-carbohydrate diet." c. "You should balance weight loss with consuming necessary nutrients." d. "If you exercise more frequently, you won't need to change your diet."

Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk. The correct answer is: "You should balance weight loss with consuming necessary nutrients."

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) Select one or more: a. Prepare for continuous blood pressure and pulse monitoring. b. Administer the client's prescribed beta blocker. c. Give the client nothing by mouth 3 to 6 hours before the procedure. d. Explain to the client that dobutamine will simulate exercise for this examination. e. Assist the provider to place a central venous access device.

Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure. The correct answers are: Prepare for continuous blood pressure and pulse monitoring., Give the client nothing by mouth 3 to 6 hours before the procedure., Explain to the client that dobutamine will simulate exercise for this examination.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." How should the nurse respond? Select one: a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "When did you start experiencing this indigestion?" c. "The provider has prescribed an antacid for you to take every morning." d. "What do you understand about what happened to you?"

Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain. The correct answer is: "What do you understand about what happened to you?"

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? Select one: a. Ask unlicensed assistive personnel to help bathe the client. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Administer oxygen therapy at 2 liters per nasal cannula.

Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities. The correct answer is: Schedule periods of exercise and rest during the day.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? Select one: a. "Clients who use cocaine are at risk for fatal dysrhythmias." b. "Substance abuse puts clients at risk for many health issues." c. "We can provide services for cessation of substance abuse." d. "The hospital requires that I ask you about cocaine use."

Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question. The correct answer is: "Clients who use cocaine are at risk for fatal dysrhythmias."

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure? Select one: a. "Do you have trouble breathing or chest pain?" b. "Do you have new-onset heaviness in your legs?" c. "Do you awake with breathlessness during the night?" d. "Are you able to walk upstairs without fatigue?"

Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure. The correct answer is: "Are you able to walk upstairs without fatigue?"

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? Select one: a. Dyspnea with activity b. Speech alterations c. Fatigue d. Sinus tachycardia

Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance. The correct answer is: Speech alterations

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) Select one or more: a. Hypertension b. Abdominal bloating c. Increased ejection fraction d. Shortness of breath e. New-onset bradycardia

Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction. The correct answers are: Shortness of breath, Abdominal bloating, New-onset bradycardia

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? Select one: a. "I have trouble remembering things." b. "I get short of breath when I climb stairs." c. "I have lost weight over the past month." d. "I see halos floating around my head."

Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure. The correct answer is: "I get short of breath when I climb stairs."

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) Select one or more: a. Decrease in urine output b. Increase in urine output c. Decrease in blood pressure d. Increase in cardiac output e. Increase in blood pressure f. Decrease in cardiac output

Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall. The correct answers are: Decrease in cardiac output, Increase in blood pressure, Decrease in urine output

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? Select one: a. Disorientation and confusion b. Numbness and tingling of the arm c. Excruciating pain on inspiration d. Left lateral chest wall pain

In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion. The correct answer is: Disorientation and confusion

A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? Select one: a. Immediately notify the health care provider of the elevated pressures. b. Increase the intravenous fluid rate because these readings are low. c. Compare the results with previous pulmonary artery pressure readings. d. Document the finding in the client's chart as the only action.

Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this client's readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider. The correct answer is: Compare the results with previous pulmonary artery pressure readings.

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) Select one or more: a. "I will drink at least 3 liters of water each day." b. "Using salt in moderation will reduce the workload of my heart." c. "Substituting fresh vegetables for canned ones will lower my salt intake." d. "I'll read the nutritional labels on food items for salt content." e. "I will eat oatmeal for breakfast instead of ham and eggs."

Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client should be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day. The correct answers are: "I'll read the nutritional labels on food items for salt content.", "I will eat oatmeal for breakfast instead of ham and eggs.", "Substituting fresh vegetables for canned ones will lower my salt intake."

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? Select one: a. "Lie on your side until the attack subsides." b. "Minimize or abstain from caffeine." c. "Take amiodarone (Cordarone) daily to prevent PACs." d. "Use your oxygen when you experience PACs."

PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them. The correct answer is: "Minimize or abstain from caffeine."

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 54 beats/min. Which action should the nurse take first? Select one: a. Document the finding in the chart. b. Assess the client's medications. c. Administer 1 mg of atropine. d. Initiate external pacing.

Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed. The correct answer is: Assess the client's medications.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) Select one or more: a. Teach the client about dietary restrictions. b. Encourage the client to take a baby aspirin each day. c. Confirm that an echocardiogram has been completed. d. Consult a social worker for additional resources. e. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor.

The Heart Failure Core Measure Set includes discharge instructions on diet, activity, medications, weight monitoring and plan for worsening symptoms, evaluation of left ventricular systolic function (usually with an echocardiogram), and prescribing an ACE inhibitor or angiotensin receptor blocker. Aspirin is not part of the Heart Failure Core Measure Set and is usually prescribed for clients who experience a myocardial infarction. Although the nurse may consult the social worker or case manager for additional resources, this is not part of the Core Measures. The correct answers are: Teach the client about dietary restrictions., Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor., Confirm that an echocardiogram has been completed.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) Select one or more: a. "Teach the client to perform deep-breathing exercises." b. "Use the same scale to weigh the client each morning." c. "Place the client on oxygen if the client becomes short of breath." d. "Accurately record intake and output." e. "Reposition the client every 2 hours."

The UAP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The UAP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. UAPs are not qualified to teach clients or assess the need for and provide oxygen therapy. The correct answers are: "Reposition the client every 2 hours.", "Accurately record intake and output.", "Use the same scale to weigh the client each morning."

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond? Select one: a. "Would you like information about advance directives?" b. "Do you want to come off the transplant list?" c. "I will arrange for a psychiatrist to speak with you." d. "Would you like to speak with a priest or chaplain?"

The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of pushing the client's issues off on a chaplain or psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option. The correct answer is: "Would you like information about advance directives?"

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) Select one or more: a. "Do not lift your left arm above the level of your shoulder for 8 weeks." b. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." c. "Report any pulse rates lower than your pacemaker settings." d. "Until your incision is healed, do not submerge your pacemaker. Only take showers." e. "If you feel weak, apply pressure over your generator."

The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker. The correct answers are: "Until your incision is healed, do not submerge your pacemaker. Only take showers.", "Report any pulse rates lower than your pacemaker settings.", "Do not lift your left arm above the level of your shoulder for 8 weeks."

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? Select one: a. Coarse crackles in bilateral lung bases b. Heart rate that speeds up and slows down c. Friction rub at the left lower sternal border d. Presence of a regular gallop rhythm

The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related. The correct answer is: Friction rub at the left lower sternal border

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? Select one: a. Nutrition preferences b. Immunization history c. Religious beliefs d. Medication reconciliation

The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client. The correct answer is: Medication reconciliation

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? Select one: a. A 45-year-old American Indian woman with diabetes mellitus b. A 32-year-old Asian-American man with colorectal cancer c. A 53-year-old postmenopausal woman who is on hormone therapy d. An 86-year-old man with a history of asthma

The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease. The correct answer is: A 45-year-old American Indian woman with diabetes mellitus

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's discharge teaching? Select one: a. "Change positions slowly to avoid hypotension." b. "Avoid large crowds and people who are sick." c. "Use a soft-bristled toothbrush and avoid flossing." d. "Check your heart rate before taking the medication."

These agents cause immune suppression, leaving the client more vulnerable to infection. The medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in heart rate. The correct answer is: "Avoid large crowds and people who are sick."

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? Select one: a. Test the equipment by delivering a smaller shock at 100 joules. b. Ensure that everyone is clear of contact with the client and the bed. c. Administer 1 mg of intravenous epinephrine. d. Make sure the defibrillator is set to the synchronous mode.

To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation. The correct answer is: Ensure that everyone is clear of contact with the client and the bed.

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) Select one or more: a. "Will you be able to afford your oxygen therapy?" b. "What spiritual beliefs may impact your recovery?" c. "What social support do you have at home?" d. "Are your bedroom and bathroom on the first floor?" e. "Are you able to accurately weigh yourself at home?"

To ensure safety upon discharge, the nurse should assess for structural barriers to functional ability, such as stairs. The nurse should also assess the client's available social support, which may include family, friends, and home health services. The client's ability to adhere to medication and treatments, including daily weights, should also be reviewed. The other questions do not address the client's safety upon discharge. The correct answers are: "Are your bedroom and bathroom on the first floor?", "What social support do you have at home?", "What spiritual beliefs may impact your recovery?"

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) Select one or more: a. Shortness of breath b. Fatigue despite adequate rest c. Indigestion d. Hypertension e. Abdominal pain

Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms-indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome. The correct answers are: Fatigue despite adequate rest, Indigestion, Shortness of breath

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) Select one or more: a. Smoking cessation b. Foods high in potassium c. Stress reduction and management d. Avoiding vagal stimulation e. Adverse effects of medications

A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances. The correct answers are: Smoking cessation, Stress reduction and management, Adverse effects of medications

A nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 30 beats/min on the cardiac monitor. Which assessment should the nurse complete next? Select one: a. Pulmonary auscultation b. Level of consciousness c. Pulse strength and amplitude d. Mobility and gait stability

A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority. The correct answer is: Level of consciousness

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? Select one: a. Slurred speech and confusion b. Discomfort in the left leg c. Bruising at the insertion site d. Urinary output less than intake

A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the client's fluid status. Neurologic changes would take priority. The correct answer is: Slurred speech and confusion

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching? Select one: a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Check your pulse daily." d. "Avoid using aspirin-containing products."

Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated. The correct answer is: "Avoid using salt substitutes."

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) Select one or more: a. A 42-year-old man recovering from coronary artery bypass graft surgery b. An 80-year-old man with a bacterial infection of the respiratory tract c. A 59-year-old woman recovering from a hysterectomy d. An 88-year-old woman with a stage III sacral ulcer e. A 36-year-old woman with systemic lupus erythematosus (SLE)

Acute pericarditis is most commonly associated acute exacerbations of systemic connective tissue disease, including SLE; with Dressler's syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure ulcers do not increase clients' risk for acute pericarditis. The correct answers are: A 36-year-old woman with systemic lupus erythematosus (SLE), A 42-year-old man recovering from coronary artery bypass graft surgery, An 80-year-old man with a bacterial infection of the respiratory tract

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? Select one: a. A 53-year-old female who reports substernal pain that radiates to her abdomen b. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest c. A 49-year-old male who reports moderate pain that is worse on inspiration d. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers

All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the client's chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction. The correct answer is: A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? Select one: a. An 80-year-old with chronic obstructive pulmonary disease b. A 50-year-old who is post coronary artery bypass graft surgery c. A 45-year-old who takes an aspirin daily d. A 78-year-old who had a carotid endarterectomy

Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation. The correct answer is: A 50-year-old who is post coronary artery bypass graft surgery

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? Select one: a. Lidocaine (Xylocaine) b. Atropine (Sal-Tropine) c. Warfarin (Coumadin) d. Sotalol (Betapace)

Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication. The correct answer is: Warfarin (Coumadin)

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? Select one: a. "Limit your intake of caffeinated drinks to one a day." b. "Avoid strenuous exercise such as running." c. "Avoid straining while having a bowel movement." d. "Make certain that your bath water is warm."

Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition. The correct answer is: "Avoid straining while having a bowel movement."

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) Select one or more: a. Abdominal bloating b. Weight gain c. Cardiac murmur d. Osler's nodes e. Night sweats

Clinical manifestations of infective endocarditis include fever with chills, night sweats, malaise and fatigue, anorexia and weight loss, cardiac murmur, and Osler's nodes on palms of the hands and soles of the feet. Abdominal bloating is a manifestation of heart transplantation rejection. The correct answers are: Night sweats, Cardiac murmur, Osler's nodes

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? Select one: a. Mid-sternal chest pain b. P wave touching the T wave c. Mild orthostatic hypotension d. Increased urine output

Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death. The correct answer is: Mid-sternal chest pain

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) Select one or more: a. Pulmonary embolism b. Thrombophlebitis c. Myocardial infarction d. Stroke e. Cardiac tamponade

Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations. The correct answers are: Thrombophlebitis, Pulmonary embolism, Cardiac tamponade

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." How should the nurse respond? Select one: a. "You are lucky to have such a devoted daughter." b. "Would you like to talk more about this?" c. "It is normal to feel as though you are a burden." d. "Would you like to meet with the chaplain?"

Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client's concerns and do not allow the nurse to obtain more information to provide client-centered care. The correct answer is: "Would you like to talk more about this?"

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? Select one: a. Muted systolic murmur b. Upper extremity weakness c. Dyspnea on exertion d. Oxygen saturation of 92%

Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis. The correct answer is: Dyspnea on exertion

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? Select one: a. Position the client on the left side. b. Ensure a tongue blade is available. c. Turn off oxygen therapy. d. Administer intravenous adenosine.

For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position. The correct answer is: Turn off oxygen therapy.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? Select one: a. "Hold this medication if your pulse rate is below 80 beats/min." b. "Do not take this medication within 1 hour of taking an antacid." c. "Avoid taking aspirin or aspirin-containing products." d. "Increase your intake of foods that are high in potassium."

Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy. The correct answer is: "Do not take this medication within 1 hour of taking an antacid."

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?Select one: a. Location A b. Location D c. Location B d. Location C

The aortic valve is auscultated in the second intercostal space just to the right of the sternum. The correct answer is: Location A

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? Select one: a. Assess capillary refill and temperature. b. Administer sublingual nitroglycerin. c. Administer intravenous diltiazem (Cardizem). d. Assess vital signs and level of consciousness.

In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture. The correct answer is: Assess vital signs and level of consciousness.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) Select one or more: a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Rhythm changes on the cardiac monitor d. Expanding groin hematoma e. Warmth and redness at the site

In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours. The correct answers are: Serum potassium of 2.9 mEq/L, Expanding groin hematoma, Rhythm changes on the cardiac monitor

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? Select one: a. Apply an ice pack to the client's chest. b. Sit the client up with a pillow to lean forward on. c. Provide a neck rub, especially on the left side. d. Allow the client to lie in bed with the lights down.

Pain from acute pericarditis may worsen when the client lays supine. The nurse should position the client in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain. The correct answer is: Sit the client up with a pillow to lean forward on.

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use? Select one: a. Bleeding precautions b. Standard Precautions c. Reverse isolation d. Contact isolation

The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions should be used. Bleeding precautions or reverse or contact isolation is not necessary. The correct answer is: Standard Precautions

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? Select one: a. Schedule an electrocardiogram just before the MRI. b. Instruct the client to increase fluid intake the day before the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Notify the health care provider before scheduling the MRI.

The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. The correct answer is: Notify the health care provider before scheduling the MRI.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." How should the nurse respond? Select one: a. "Would you like to speak with a chaplain prior to surgery?" b. "This is a routine surgery and the risk of death is very low." c. "Tell me more about your concerns about the surgery." d. "What support systems do you have to assist you?"

The nurse should discuss the client's feelings and concerns related to the surgery. The nurse should not provide false hope or push the client's concerns off on the chaplain. The nurse should address support systems after addressing the client's current issue. The correct answer is: "Tell me more about your concerns about the surgery."

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? Select one: a. Call the health care provider immediately. b. Assess for symptoms of left-sided heart failure. c. Transfer the client to the intensive care unit. d. Document this as a normal finding.

The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted. The correct answer is: Assess for symptoms of left-sided heart failure.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? Select one: a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema. The correct answer is: "My shoes fit tighter by the end of the day."