cardiac medsurg questions
A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? A. Headache B. Hemoptysis C. Nausea D. Diarrhea
nausea
A nurse is providing teaching about lifestyle changes to a client who experienced a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?
"Before taking my medication, I will count my radial pulse rate."
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." Answer Rationale: With this response, the nurse uses the therapeutic communication technique of presenting reality by indicating her perception of the situation for the client
)A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
"DIC is caused by abnormal coagulation involving fibrinogen."
A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching?
"I can have yogurt as a dessert."
A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency
necrosis
A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur
indicates turbulent blood flow through a valve. Answer Rationale: Turbulent blood flow through a valve generates a murmur, possibly due to a malfunctioning valve, increased blood flow, or some type of defect in the structures of or around the heart.
A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect?
dyspnea with hiccups
A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?
"It requires lying quietly on one side." Answer Rationale: For an echocardiogram, the client lies quietly on the left side with slight head elevation
)A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?
"I plan to slow down if I am tired the day after exercising." Answer Rationale: Clients who experience chest pain or dyspnea while exercising or experience fatigue the next day are probably advancing the activity too quickly and should slow down
A nurse is providing information to a client who is scheduled for an exercise electrocardiography test. Which of the following client statements indicates an understanding of the teaching? A. "I will not drink coffee 4 hr prior to my test." B. "I can eat a light meal 1 hr prior to the test." C. "I can have a cigarette up to 30 min prior to the test." D. "I will take my heart medication on the day of the test."
"I will not drink coffee 4 hr prior to my test."
A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching? A. "I will ask my provider to change my contraception to an intrauterine device." B. "I will notify my doctor before I have dental procedures." C. "I will avoid using antiseptic mouthwash for oral care." D. "I will wear a mask when I go out in public."
"I will notify my doctor before I have dental procedures."
A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching?
"I'll take my heart medications the morning of my test." Answer Rationale: The provider will give the client specific instructions about his medications, but generally the client should avoid medications that will prevent fluctuations in heart rate during the test, such as calcium channel blockers and beta blockers.
A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? A. "Request a provider's prescription when traveling to alert airport security." B. "Stand at least 3 feet away while using a microwave." C. "Keep your cell phone 6 inches away from your pacemaker when making a call." D. "Avoid showering for the first 2 weeks following surgery."
"Keep your cell phone 6 inches away from your pacemaker when making a call."
A nurse is teaching a 70-year-old client about risk factors for heart failure. The client has mild asthma, diabetes mellitus, and coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? A. "My diabetes will not increase my risk of heart failure." B. "My asthma makes it more likely for me to have heart failure." C. "My age does not increase my risk of heart failure." D. "My coronary artery disease is a risk factor for heart failure."
"My coronary artery disease is a risk factor for heart failure."
A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching?
"The pacemaker can be checked from home by using the telephone." Answer Rationale: The initial pacemaker check is performed at the clinic. Following this initial examination, follow-up pacemaker checks can happen remotely from the client's home. Using a telephone transmitting device, the client can transmit basic information electronically from the pacemaker to the clinic. The client will return to the clinic annually for a more thorough pacemaker check.
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
"These tests help determine the degree of damage to the heart tissues." Answer Rationale: Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels
A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? A. "Exertion often brings on pain." B. "Variant angina occurs randomly at various times." c. "Variant angina can cause changes on your electrocardiogram." D. "Reducing your cholesterol can help you experience less pain."
"Variant angina can cause changes on your electrocardiogram."
A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?
"You will notice a small hematoma at the incision site."
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride
0.9% sodium chloride
A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply.) A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." C. "You'll feel a cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr."
A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure."
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Jugular vein distension B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever
A. Jugular vein distension B. Moist crackles D. Increased heart rate
A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply.) A. Nausea and vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea
A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom
A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade
Acidosis
A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take?
Administer antihypertensive medication for blood pressure
A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? A. Absent pedal pulses B. Ankle swelling C. Hair loss D. Skin atrophy
Ankle swelling
A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?
Atrial depolarization Answer Rationale: The P wave reflects atrial depolarization, typically initiated in the sinoatrial node.
A nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take? A. Check for hypertension B. Auscultate for loud, bounding heart sounds C. Auscultate blood pressure for pulsus paradoxus D. Check for a pulse deficit
Auscultate blood pressure for pulsus paradoxus
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly
B. Crackles in the lung bases
A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking Check Answer Question Feedback Close Explanation
B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking
A nurse is reviewing the medical record of a client who has heart failure. Which of the following findings should the nurse expect? (Click on "Exhibit NCLEX 3" under Resources on the right-hand side for additional information about the client) A. BNP of 200 pg/mL B. Bradycardia C. Fluid restriction of 3 L per day D. 4 g sodium diet Check Answer Question Feedback Close Explanation
BNP of 200 pg/mL
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Blood pressure 115/68 mmHg Answer Rationale: The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock
A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? A. Cholesterol level 195 mg/dL B. Elevated HDL levels C. Elevated LDL levels D. Triglyceride level 135 mg
C. Elevated LDL levels
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (Select all that apply.) A. Use a 5 mL syringe to flush the line B. Cleanse the insertion site with half-strength hydrogen peroxide C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use
C. Flush the line with sterile 0.9% sodium chloride before and after medication administration D. Access the PICC for blood sampling E. Perform a heparin flush of the line at least daily when not in use
A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm
C. Report of sudden, severe back pain
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?
Cardiac dysrhythmias Answer Rationale: This client's potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression.
A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.)
Check peripheral pulses in the affected extremity. Keep the client's hip and leg extended. Have the client remain in bed up to 6 hr
A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions
Chicken breast and corn on the cob
)A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
Confusion Answer Rationale: Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.
A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension
Correct Answers: B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension
)A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?
Decrease in systolic pressure by more than 10 mm Hg during inspiration Answer Rationale: The nurse should expect a client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or cardiac tamponade
)A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
Defibrillation Answer Rationale: The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependent edema
Dependent edema
A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. Sunburned appearance with desquamation
Dry, pale skin with minimal body hair
A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock Dysrhythmias C. Heart failure D. Pulmonary edema
Dysrhythmias
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
Elective cardioversion Answer Rationale: Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment
A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect?
Elevated ST segments
A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?
Elevated central venous pressure (CVP). Answer Rationale: CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure.
)A charge nurse is teaching a group of nurses about agonists and antagonists. The nurse should include in the teaching that which of the following agonist medications binds to receptors and causes activation that affects the cardiovascular system?
Epinephrine Answer Rationale: The nurse should include that epinephrine is an agonist that activates the receptors that affect the cardiovascular system in clients who are at risk for cardiac collapse
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?
Epinephrine Answer Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Excessive thrombosis and bleeding
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?
Fatigue Answer Rationale: The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia
A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations?
Fatigue Answer Rationale: Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness.
)A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin?
Feverfew Answer Rationale: The nurse should instruct the client to avoid taking feverfew with aspirin because it suppresses platelet aggregation and places the client at risk for bleeding when taken with aspirin
)A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?
Frothy sputum Answer Rationale: Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness
)A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level?
Furosemide
)A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?
Have the client lie flat in bed. Answer Rationale: The nurse should have the client on lie flat in bed. Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.
A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?
Hemodynamic status Answer Rationale: A pulmonary artery catheter is inserted into the pulmonary artery and monitors a client's hemodynamic status by measuring pulmonary artery pressures and cardiac output
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
Hypovolemia Answer Rationale: A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis
A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation
Impaired circulation
A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect?
Increased hematocrit level
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary artery pressure
Increased pulmonary congestion
)A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Increased respiratory rate Answer Rationale: When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.
A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation laboratory studies from the client B. Apply pneumatic compression boots to the client C. Request a referral for a speech-language pathologist D. Keep the client NPO
Keep the client NPO
A nurse is admitting a client who has a serum calcium level of 12.3 mg/ dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment
Lethargy Answer Rationale: A serum calcium level of 12.3 mg/dL is above the expected reference range. The nurse should monitor the client for lethargy, generalized weakness, and confusion.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back discomfort
Lower back discomfort
A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? A. Instruct the client about a long-term cardiac conditioning program B. Administer scheduled doses of acetaminophen C. Check for peak laboratory markers of myocardial damage D. Monitor for bleeding
Monitor for bleeding
A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A.Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C.Same polarity as the usual QRS complexes D.Immediate resumption of the usual rhythm
Much greater amplitude than the usual QRS complexes
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Muffled heart sounds . Answer Rationale: Muffled heart sounds are a key indicator of cardiac tamponade because of the excess amount of fluid surrounding the hear
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Obtain a 12-lead ECG. Answer Rationale: This client's potassium level is above the expected reference range of 3.5-5.0 mEq/L and is at risk for dysrhythmias as well as cardiac arrest. Therefore, the nurse should obtain a 12-lead ECG to monitor for cardiac changes
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? Oliguria Answer Rationale: ?
Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?
Packed RBCs Answer Rationale: Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock.
A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change?
Potassium 2.8 mEq/L
A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Palpate the blood pressure and inflate the cuff above the systolic pressure. Deflate the cuff slowly and listen for the first audible sounds. Identify the first BP sounds audible on expiration and then on inspiration. Subtract the inspiratory pressure from the expiratory pressure. Inspect for jugular venous distention and notify the provider.
A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?
Perform neurovascular checks with vital signs. Answer Rationale: The nurse should assess color, temperature, and pulse in the affected extremity and monitor the client for neurovascular changes that can indicate a stroke, such as slurred speech and visual disturbances
A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors?
Peripheral vascular resistance increases.
A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection." B. "Platelets help break down clots in the body." C. "Platelets plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen."
Platelets plug breaks in blood vessels."
A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication?
Potassium Answer Rationale: Digoxin is a cardiac glycoside medication used to improve myocardial contractility, increasing stroke volume and cardiac output in a client who has heart failure. During therapy, the nurse should closely monitor the client's potassium level as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias.
A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? .
Prolonged QT intervals
A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?
QT interval Answer Rationale: The QT interval reflects the time it takes for ventricular depolarization and repolarization. The nurse should measure the QT interval from the start of the QRS complex to the end of the T wave
The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate
Radial pulse in the left arm Answer Rationale: Palpating the client's pulse distal to the insertion site is essential for evaluating possible thrombophlebitis and vessel occlusion. The left radial pulse should be strong and essentially equal to the right radial pulse.
A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations
Substernal chest pain
A nurse is showing a client who has right-sided heart failure an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava
Superior vena cava
A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes B. Premature ventricular complexes at 12/min C. Telemetry monitoring showing pacing spikes with no QRS complexes D. Hiccups
Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes
A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings?
The client is experiencing premature atrial contractions. Answer Rationale: Pulse pressure devices require the presence of optimal arterial waveforms in order to capture accurate data. Therefore, a dysrhythmia, such as premature atrial contractions, will compromise the readings
)A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?
The client should hold his cell phone on the side opposite the ICD. Answer Rationale: The client should keep his cellular phone on the side opposite the ICD, as close proximity could interfere with the ICD's function.
)A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?
The laboratory values are prolonged.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?
Troponin I Answer Rationale: Cardiac troponin I and cardiac troponin T are biochemical markers that are specific to myocardial cell injury. A client who has myocardial cell damage can have elevated troponin levels within 2 to 3 hr. Cardiac troponin I levels can peak in 10 to 24 hr and stay elevated for 7 to 10 days. Cardiac troponin T levels can peak within 10 to 24 hr stay elevated for 10 to 14 days
A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?
Troponin I Answer Rationale: The troponins (I and T) are proteins that only exist in cardiac muscle and enter the bloodstream within a few hours of myocardial injury. They are the most specific indicator of myocardial damage.
A nurse is reviewing the menu selections of a client who has heart failure and anticipates discharge to home the following day. Which of the following lunch choices should the nurse identify as an indication that the client understands his dietary instructions? A. Turkey on whole-wheat bread B. Hamburger and french fries C. Frankfurter on a white roll D. Macaroni and cheese
Turkey on whole-wheat bread
A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? A. Warm the unit of blood to room temperature before administering it B. Administer acetaminophen prior to the blood transfusion C. Give an antihistamine prior to the transfusion D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate
Use a transfusion pump to regulate and maintain the transfusion at a slower rate
A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion?
Ventricular dysrhythmias
A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli
Ventricular dysrhythmias
A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect?
Weight gain of 1 kg (2.2 lb) in 1 day
A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. "I should check my heart rate at the same time each day." B. "I don't have to take my antihypertensive medications now that I have a pacemaker." C. "I should keep a pressure dressing over the generator until the incision is healed." D. "I cannot stand in front of our new microwave oven when it is on."
a
A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction?
acute confusion
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?
coarse crackles
A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect? A. Chest pain is relieved soon after resting. B. Nitroglycerin relieves chest pain. C. Physical exertion does not precipitate chest pain. D. Chest pain lasts for longer than 15 min.
d
A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters?
the heart rate times the stroke volume
