cardiac

1. A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings. DIF: Cognitive Level: Comprehension/Understanding REF: p. 746 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 2. A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? a. Increase in stroke volume b. Decrease in tissue perfusion c. Increase in oxygen saturation d. Decrease in arterial vasoconstriction ANS: B In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 3. The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes cigarettes daily d. Older man who has had a myocardial infarction ANS: A 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 (CAD), and hypertension. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 4. The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? a. "I have been drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions." ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure. DIF: Cognitive Level: Comprehension/Understanding REF: p. 748 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment) 5. A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? a. "Please come into the clinic for an evaluation." b. "Increase your fluid intake during waking hours." c. "Use an over-the-counter cough suppressant." d. "Sleep on two pillows to facilitate postnasal drainage." ANS: A The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 6. The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath." ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure. DIF: Cognitive Level: Comprehension/Understanding REF: p. 748 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment) 7. The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans. ANS: B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 8. The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit. ANS: A 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 9. A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure." ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. DIF: Cognitive Level: Knowledge/Remembering REF: p. 749 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning 10. A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed. ANS: D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation) 11. A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction. ANS: A Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 12. A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily." ANS: A Angiotensin-converting enzyme (ACE) inhibitors 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning) 13. The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia. ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 14. The client who just started taking isosorbide dinitrate (Imdur) reports a headache. What is the nurse's best action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen. ANS: D The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 15. The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level. ANS: B Intravenous nitroglycerin and morphine will decrease the client's blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client's glucose levels should not be affected by these medications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Implementation) 16. The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid." ANS: D 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 is too high for this cutoff. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 17. A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? a. Cough b. Headache c. Pulse of 62 beats/min d. Potassium of 2.9 mEq/L ANS: D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Analysis) 18. The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? a. Decrease in oxygen saturation from 98% to 95% b. Respiratory rate change from 22 to 28 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Increase in heart rate from 86 to 100 beats/min ANS: C A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Evaluation) 19. The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate ANS: A Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 20. A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing." ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 21. A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assess respiratory status. b. Monitor electrolyte levels. c. Administer intravenous fluids. d. Insert a Foley catheter. ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) 22. The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 23. The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic pressure ANS: C In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assessed. DIF: Cognitive Level: Knowledge/Remembering REF: p. 760 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 24. A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs." ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning 25. The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education? a. "I will be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K, like spinach." d. "I will use an electric razor instead of a straight razor to shave." ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation) 26. The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about? a. Family history of coronary artery disease b. Recent travel to Third World countries c. Pet ownership, especially cats with litter boxes d. History of a systemic infection within the past month ANS: D The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 27. The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) 28. A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regularly gallop rhythm d. Coarse crackles in bilateral lung bases ANS: B 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. DIF: Cognitive Level: Knowledge/Remembering REF: p. 765 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 29. The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have only two alcoholic drinks daily." ANS: C The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 30. The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures. b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure. c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes. d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke. ANS: C 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. DIF: Cognitive Level: Comprehension/Understanding REF: p. 769 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Implementation) 31. A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication." ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 32. A client with end-stage heart failure 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." What is the nurse's best response? a. "Would you like to speak with a priest or chaplain?" b. "I will consult a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?" ANS: D 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms) MSC: Integrated Process: Nursing Process (Implementation) 33. The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?" ANS: B 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Evaluation) 34. An older adult client with heart failure 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." What is the nurse's best response? a. "Would you like to talk about this more?" b. "You're lucky to have such a devoted daughter." c. "You must feel as though you are a burden." d. "Would you like an antidepressant medication?" ANS: A 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychological Integrity (Therapeutic Communication) MSC: Integrated Process: Caring 35. An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? a. Echocardiography b. Chest x-ray c. T4 and thyroid-stimulating hormone (TSH) d. Arterial blood gas ANS: A Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 36. The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on the left side ANS: A Placing the client in high Fowler's position, with pillows under the arms, allows for maximum chest expansion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation) 37. The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength." ANS: B Gathering all supplies needed for a chore at one time decreases the amount of energy needed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 38. A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action? a. Administer the Vasotec. b. Recheck the blood pressure. c. Hold the Vasotec. d. Notify the health care provider. ANS: A The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Planning) 39. A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer furosemide (Lasix) first. ANS: A Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE 1. The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. S3/S4 summation gallop f. Cough worsens at night ANS: A, B, E, F Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle. DIF: Cognitive Level: Knowledge/Remembering REF: Chart 37-1, p. 749 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 2. The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria ANS: A, B, E, F The hematocrit is low (should be 42.6%), indicating a dilutional ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.

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A client's cardiac status is being observed by telemetry monitoring. The nurse observes a P wave that changes shape in lead II. What conclusion does the nurse make about the P wave? a. It originates from an ectopic focus. b. The P wave was replaced by U waves. c. It is from the sinoatrial (SA) node. d. Multiple P waves are present. ANS: A If the P wave is firing consistently from the SA node, the P wave will have a consistent shape in a given lead. If the impulse is from an ectopic focus, then the P wave will vary in shape in that lead. DIF: Cognitive Level: Comprehension/Understanding REF: p. 715 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 2. The nurse is assessing the client's electrocardiography (ECG). What does the P wave on the ECG tracing represent? a. Contraction of the atria b. Contraction of the ventricles c. Depolarization of the atria d. Depolarization of the ventricles ANS: C The ECG tracing of a P wave represents electrical changes caused by atrial depolarization. DIF: Cognitive Level: Knowledge/Remembering REF: p. 715 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 3. A nurse notes that the PR interval on a client's electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take? a. Assess serum cardiac enzymes. b. Administer 1 mg epinephrine IV. c. Administer oxygen via nasal cannula. d. Document the finding in the client's chart. ANS: D The PR interval normally ranges from 0.12 to 0.20 second. This is a normal finding, so the nurse simply documents this. No further action is required. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 4. When analyzing a client's electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites. ANS: D Normal rhythm shows one P wave preceding each QRS, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. DIF: Cognitive Level: Comprehension/Understanding REF: p. 718 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 5. The nurse observes a prominent U wave on the client's electrocardiograph (ECG) tracing. What is the most appropriate action for the nurse to take? a. Document the finding as a normal variant. b. Review the client's daily electrolyte results. c. Move the crash cart closer to the client's room. d. Call for an immediate electrocardiogram. ANS: B Prominent U waves may be the result of hypokalemia. The nurse should review the client's daily electrolyte results. Although documentation is important, this is not a normal variant. Moving the crash cart closer to the room may or may not be warranted. The client does not need an immediate ECG. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 6. The client's heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take? a. Evaluate for a respirator disorder. b. Assess the client for chest pain. c. Document the finding in the chart. d. Administer antidysrhythmic drugs. ANS: C Sinus dysrhythmia is noted when the heart rate increases slightly during inspiration and decreases slightly during expiration. Sinus dysrhythmia is a variant of normal sinus rhythm that is frequently observed in healthy children and adults. No other actions are needed. DIF: Cognitive Level: Comprehension/Understanding REF: p. 718 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 7. A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave ANS: A 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis) 8. A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? a. Atropine (Atropine) b. Digoxin (Lanoxin) c. Lidocaine (Xylocaine) d. Metoprolol (Lopressor) ANS: A Atropine is a cholinergic antagonist that inhibits parasympathetically-induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate. The other medications are not appropriate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) 9. A client experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. What instruction does the nurse include in the client's teaching plan? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take quinidine (Cardioquin) daily to prevent PACs." ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent bouts of 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 10. The nurse identifies a client's rhythm to be a sustained supraventricular tachycardia. What medication does the nurse administer? a. Atropine (Atropine) b. Epinephrine (Adrenalin) c. Lidocaine (Xylocaine) d. Diltiazem (Cardizem) ANS: D Diltiazem, a calcium channel blocker, slows depolarization through the conduction system and is commonly used as an agent to terminate a sustained episode of supraventricular tachycardia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) 11. A client has a heart rate averaging 56 beats/min with no adverse symptoms. What activity modifications does the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm (100° F)." b. "Avoid bearing down or straining while having a bowel movement." c. "Avoid strenuous exercise, such as running, during the late afternoon." d. "Limit your intake of caffeinated drinks to no more than 2 cups per day." ANS: B 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation) 12. The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation? a. Middle-aged client who takes an aspirin daily b. Client who is dismissed after coronary artery bypass surgery c. Older adult client after a carotid endarterectomy d. Client with chronic obstructive pulmonary disease ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft (CABG) surgery. The other conditions do not place a client at higher risk for atrial fibrillation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 13. The nurse is caring for a client on a cardiac monitor. The monitor shows a rapid rhythm with a "saw tooth" configuration. What physical assessment findings does the nurse expect? a. Presence of a split S1 and wheezing b. Anorexia and gastric distress c. Shortness of breath and anxiety d. Hypertension and mental status changes ANS: C The rhythm described is atrial flutter with a rapid ventricular response. Rapid atrial flutter may manifest with palpitations, shortness of breath, and anxiety. Syncope, angina, and evidence of heart failure also may be present. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 14. The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity ANS: B 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 15. The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Atropine) d. Lidocaine (Xylocaine) ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. The other drugs are not appropriate for this complication. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) 16. The nurse is caring for a client admitted for myocardial infarction. The client's monitor shows frequent premature ventricular contractions (PVCs). What dysrhythmia does the nurse remain alert for? a. Sinus tachycardia b. Rapid atrial flutter c. Ventricular tachycardia d. Atrioventricular junctional rhythm ANS: C With an acute myocardial infarction (MI), the onset of PVCs may be considered as a warning that could herald the onset of ventricular tachycardia or ventricular fibrillation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis) 17. A client with myocardial ischemia is having frequent early, wide ventricular complexes seen on the cardiac monitor. Which medication does the nurse administer? a. Lanoxin (Digoxin) b. Amiodarone (Cordarone) c. Dobutamine (Dobutamine) d. Atropine sulfate (Atropisol) ANS: B Early, wide ventricular complexes are premature ventricular contractions (PVCs). Amiodarone, an antidysrhythmic, is the treatment of choice for frequent PVCs. The other medications are not appropriate for this condition. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis) 18. The nurse has administered adenosine (Adenocard). What is the expected therapeutic response? a. Increased intraocular pressure b. A brief tonic-clonic seizure c. A short period of asystole d. Hypertensive crisis ANS: C Clients usually respond to this medication with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. DIF: Cognitive Level: Comprehension/Understanding REF: p. 733 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis) 19. A client's electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurse's first action? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR). ANS: A The first action that the nurse should take when ventricular tachycardia is observed is to assess the client's airway, breathing, and level of consciousness. If the client is unconscious or has experienced respiratory arrest, defibrillation and CPR are begun. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 20. A client with unstable ventricular tachycardia is receiving amiodarone by intravenous infusion. The nurse notes that the client's heart rate has decreased from 68 to 50 beats/min. The client is asymptomatic. What is the nurse's priority intervention? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer a precordial thump. d. Place the client in a side-lying position. ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. A precordial thump is not required at this time because the client still has a heart rate. A side-lying position will not increase the client's heart rate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation) 21. A client with ischemic heart disease has an electrocardiograph (ECG) tracing that shows a PR interval of 0.24 second. What is the nurse's best action? a. Document the finding in the chart. b. Measure blood pressure. c. Notify the health care provider. d. Administer oxygen. ANS: A This prolonged PR interval indicates a first-degree heart block. First-degree heart block in a stable client requires no intervention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Implementation) 22. The physician is about to perform carotid sinus massage on a client with supraventricular tachycardia. What equipment is most important for the nurse to have ready? a. Emesis basin b. Magnesium sulfate c. Resuscitation cart d. Padded tongue blade ANS: C Complications of this procedure include bradydysrhythmias, asystole, ventricular fibrillation, and cerebral damage. The resuscitation cart, complete with defibrillator, should be available whenever this procedure is initiated. The other equipment is not needed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Planning) 23. The nurse is caring for a client with a complete heart block (third-degree atrioventricular [AV] block). What is the nurse's priority intervention? a. Perform a cardioversion. b. Assist with carotid massage. c. Begin external pacing. d. Administer adenosine (Adenocard) IV. ANS: C The nurse would expect the client with complete heart block or third-degree AV block to be paced externally until the client can be scheduled for a permanent pacemaker. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Planning) 24. A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability ANS: C A heart rate of 40 beats/min or less, with widened QRS complexes, could have hemodynamic consequences, and the client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lightheadedness, confusion, syncope, and seizure activity. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 25. The nurse is caring for a client with a temporary pacemaker. The client's bedside monitor shows a spike followed by a QRS complex. What is the nurse's best action? a. Remove the pacemaker; it is not needed. b. Decrease the threshold of the pacemaker. c. Document the finding in the client's chart. d. Set the pacemaker to the synchronous mode. ANS: C A spike followed by a QRS complex indicates "capture," meaning that the pacemaker has successfully depolarized or captured the ventricle. No action other than documentation of this finding is necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation) 26. A client with ventricular tachycardia (VT) is unresponsive and has no pulse. The nurse calls for assistance and a defibrillator. What is the nurse's priority intervention while waiting for the defibrillator to arrive? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation. c. Start an 18-gauge IV in the antecubital. d. Ask the client's family about code status. ANS: B A client with pulseless VT should be defibrillated immediately. If the defibrillator is not available, the nurse should initiate cardiopulmonary resuscitation (CPR) and then should defibrillate as soon as possible. Basic life support (BLS) is the basis of emergency cardiac care; if the client does not have an IV already, this can wait until others have arrived to help. Providing good quality CPR is vital. The client should have already been assessed for code status. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 27. A client has an epicardial pacemaker. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiograph (ECG) tracing. How does the nurse interpret this event? a. Loss of capture b. Ventricular fibrillation c. Failure to sense d. A normal tracing ANS: A In epicardial 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment) 28. The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating a client? a. Make sure the defibrillator is set to the synchronous mode. b. Deliver a precordial thump to the upper portion of the sternum. c. Test the equipment by delivering a smaller shock at 100 J. d. Ensure that all personnel are clear of contact with the client and the bed. ANS: D 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 thumb can be delivered when no defibrillator is available. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Defibrillation is done in asynchronous mode. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of Equipment) MSC: Integrated Process: Nursing Process (Implementation) 29. The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately? a. 2/4 bilateral peripheral edema b. Heart rate of 56 beats/min c. Temperature of 96° F (35.5° C) d. Muffled heart sounds ANS: D In the postimplantation period, the nurse should be alert for complications of cardiac tamponade, bleeding, and dysrhythmias. Muffled heart sounds are a manifestation of cardiac tamponade. Edema and a lower temperature would not be indicative of a complication of this procedure. Bradycardia might need intervention, but this client's heart rate is not critically low. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Evaluation) 30. A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the client's discharge teaching? a. "Do not submerge your pacemaker, take only showers." b. "Report pulse rates lower than your pacemaker setting." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having an MRI." ANS: B 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 31. The nurse is providing discharge instructions for a client with an implantable cardioverter-defibrillator (ICD). What statement by the client indicates a good understanding of the instructions? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I can't perform activities that increase my heart rate." d. "Now I can discontinue my antidysrhythmic medication." ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 32. A nurse assesses the following electrocardiography (ECG) strip from a client's telemetry monitor. What does the nurse chart as the client's ventricular heart rate? a. 40 beats/min b. 80 beats/min c. 120 beats/min d. 160 beats/min ANS: B Precisely 6 seconds is represented by 150 small blocks on ECG paper. The number of R-R intervals, representing ventricular depolarization episodes present in 6 seconds, can be multiplied by 10 to calculate the ventricular heart rate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 33. The nurse is assessing a client's ECG. What is the nurse's interpretation of the following ECG strip? a. Sinus rhythm with premature ventricular contractions (PVCs) b. Ventricular tachycardia c. Ventricular fibrillation d. Sinus rhythm with premature atrial contractions (PACs) ANS: A Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometime precedes atrial depolarization. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 34. The nurse notes the following rhythm on a client's telemetry monitor. How does the nurse interpret these findings? a. Ventricular tachycardia b. Second-degree heart block c. Supraventricular tachycardia d. Premature ventricular contractions ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 35. A nurse assesses the following ECG strip from a client's telemetry monitor. What does the nurse do next? a. Measure hourly urine output. b. Assess the client's vital signs. c. Administer 0.5 mg atropine IV. d. Prepare for external pacing. ANS: B Assessing the client's vital signs allows the nurse to determine if he or she is stable or unstable and symptomatic with the bradycardia. The client's stability with the bradycardia will determine the need for specific interventions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 36. The nurse is alerted to a client's telemetry monitor. After assessing the following ECG, what is the nurse's priority intervention? a. Start a large-bore IV. b. Administer atropine. c. Prepare for intubation. d. Perform defibrillation. ANS: D The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. If the client does not already have an IV , other members of the team can insert one after defibrillation. Likewise, intubation can occur later if necessary. Atropine is not given for ventricular fibrillation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology) MSC: Integrated Process: Nursing Process (Intervention) MULTIPLE RESPONSE 1. A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Increase in blood pressure d. Decrease in blood pressure e. Increase in urine output ANS: A, D Consistently elevated heart rates initially cause blood pressure and cardiac output to increase. However, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.

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The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected? a. Faint S1 and S2 sounds b. Decreased cardiac output c. Increased blood pressure d. Absent peripheral pulses ANS: B The myocardium is the layer responsible for the contractile force of the heart. Damage to this layer can result in decreased cardiac output. This most likely would result in decreased blood pressure and strength of peripheral pulses. Absent peripheral pulses would be caused by an arterial occlusion. S1 and S2 most likely would not be affected. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 2. The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if the client's mean arterial blood pressure decreases below 60 mm Hg? a. Increased cardiac output b. Hypertension c. Chest pain d. Decreased heart rate ANS: C Coronary artery blood flow occurs primarily during diastole. Mean arterial pressure (MAP) of 60 mg Hg is necessary for adequate blood flow to coronary arteries, and MAP of 60 to 70 mm Hg is necessary for adequate perfusion to major body organs. If MAP decreases to below 60 mm Hg, the client with cardiac disease may have chest pain. Cardiac output most likely would decrease, and blood pressure also would decrease. Heart rate may increase as the body initiates compensatory mechanisms. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 3. The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What additional assessment finding does the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial (SA) node. This results in an increase in heart rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 4. The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the nurse expect? a. Blood pressure increase of 10% b. Increasing respiratory rate c. Increased cardiac output d. Pulse decrease from 100 to 80 beats/min ANS: D Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased heart rate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment) 5. The nurse is assessing clients at a community health center. Which client does the nurse determine is at high risk for cardiovascular disease? a. Older adult man with a history of asthma b. Asian-American man with colorectal cancer c. American Indian woman with diabetes mellitus d. Postmenopausal woman on hormone therapy ANS: C 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. DIF: Cognitive Level: Knowledge/Remembering REF: pp. 692-693 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment) 6. The nurse is obtaining a client's health history. Which illness alerts the nurse to the possibility of abnormal heart valves? a. Tuberculosis b. Recurrent viral pneumonia c. Rheumatic fever d. Asthma ANS: C Rheumatic fever is an inflammatory disease that typically is caused by infection with group A beta-hemolytic streptococci that can affect the endocardium. DIF: Cognitive Level: Knowledge/Remembering REF: p. 694 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment) 7. A nurse is performing an admission assessment on an older adult client with multiple chronic diseases. The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first? a. Document the finding in the chart. b. Evaluate for a pulse deficit. c. Assess the client's medications. d. Administer 1 mg of atropine. ANS: C 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 to be needed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis) 8. The nurse is assessing clients at a clinic. Which activity takes priority? a. Teaching smoking cessation to a middle-aged woman who smokes b. Planning an exercise regimen with a woman with a sedentary lifestyle c. Teaching an older man who is moderately obese to keep a food diary d. Assessing a man with familial coronary artery disease for specific risk factors ANS: A All of these risk factors contribute to the development of cardiovascular disease, but cigarette smoking is a major risk factor for both coronary artery disease and peripheral vascular disease. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Nursing Process (Assessment) 9. The nurse is assessing a client in the emergency department. Which client statement alerts the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month." ANS: A Dyspnea on exertion (DOE) 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 10. The nurse is assessing a client newly admitted to the medical unit. Which statement made by the client alerts the nurse to the presence of edema? 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." ANS: B 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 11. When obtaining a client's vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse's best intervention? a. Call the health care provider and report the finding. b. Reassess the client's blood pressure at the next yearly physical. c. Administer an additional antihypertensive medication to the client. d. Teach the client lifestyle modifications to decrease blood pressure. ANS: D Prehypertension has been designated as 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic. These clients are at higher risk for developing hypertension. The client needs to institute dietary and activity changes to help decrease blood pressure. The reading is not high enough for the nurse to call the health care provider. No indications for administering medications are known. Because the client has prehypertension, the nurse should intervene now to help prevent the development of frank hypertension. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment) 12. The nurse is performing a focused cardiac assessment. What assessment finding should be reported to the health care provider? a. Bruit heard on the side of the neck b. Bounding peripheral pulses c. Pulse rate of 90 beats/min d. Blood pressure of 140/90 mm Hg ANS: A A bruit is a swishing sound that may develop in narrowed arteries. Bruits usually are associated with atherosclerotic disease. This finding may indicate atherosclerotic disease of the carotid arteries, and further evaluation is needed. Bounding pulses, a pulse rate of 90 beats/min, and a blood pressure of 140/90 mm Hg are not assessment findings that require immediate interventions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 13. A client consistently reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What nursing assessment takes priority at this time? a. Pulse oximetry b. Blood pressure c. Respiratory rate d. Neurologic evaluation ANS: B Dizziness and lightheadedness on moving from a supine to a sitting or standing position may be symptoms of postural hypotension. Orthostatic blood pressure measurements (decrease of more than 20 mm Hg systolic, decrease of more than 10 mm Hg diastolic, and 10% to 20% increase in heart rate) are used to determine the presence of postural hypotension. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 14. The nurse is assessing an older adult client who is experiencing a myocardial infarction. What clinical manifestation does the nurse expect in this client? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm ANS: C In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations could also be related to the myocardial infarction. However, the nurse is more concerned about the new onset of disorientation or confusion caused by decreased perfusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 15. A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means. What is the nurse's best response? a. "It is a rushing sound that blood makes moving through narrow places." b. "It's the sound of the heart muscle stretching in an area of weakness." c. "It's a term doctors use to describe the efficiency of blood circulation." d. "It is the sound the heart makes when it is has an increased workload." ANS: A Murmurs reflect turbulent blood flow through normal or abnormal valves. The significance of a murmur depends on its cause. Some murmurs are associated with a healthy heart that ejects blood quickly and turbulently from the left ventricle. Other murmurs may be indicators of severe valve, vessel, or heart problems. DIF: Cognitive Level: Comprehension/Understanding REF: p. 700 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Communication and Documentation 16. A client has returned from a cardiac angiography via the left femoral artery. Two hours after the procedure, the nurse notes that the left pedal pulse is weak. What is the nurse's best action? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4. ANS: C Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Evaluation) 17. The nurse is recovering a client after a left-sided cardiac catheterization. What assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg ANS: C A left-sided cardiac catheterization specifically increases the risk for a cerebrovascular accident (CVA). 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment) 18. The nurse is preparing a client for a cardiac catheterization. What assessment is a priority before the procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine and shellfish ANS: D 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 knowledge. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error Prevention) MSC: Integrated Process: Nursing Process (Assessment) 19. The client is scheduled for a resting electrocardiography. Which statement by the client indicates a good understanding of the preprocedure teaching? a. "I cannot eat or drink before the electrocardiography." b. "I must lie as still as possible during the procedure." c. "I am likely to feel warmth as the dye enters the heart." d. "I will increase my fluid intake on the day of the procedure." ANS: B Resting electrocardiography is noninvasive and painless and requires the client to be connected to a portable electrocardiographic monitor. Movement can cause artifacts and can interfere with the accuracy of the recording. The client does not have to be NPO before the procedure, and no dye is used. No reason to increase the client's fluid intake is known. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Planning) 20. The nurse is monitoring a client undergoing an exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped? a. Heart rate increases to 140 beats/min b. Blood pressure of 100/80 mm Hg c. Respiratory rate exceeds 36 breaths/min d. Significant ST-segment depression ANS: D This electrocardiographic finding is associated with myocardial ischemia and could signal a possible myocardial infarction if the physical activity is continued or increased. The other findings do not indicate emergent assessments. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Evaluation) 21. A client who is scheduled for an echocardiography today asks why this test is being performed. What is the nurse's best response? a. "This procedure is a noninvasive way to assess the structure of the heart." b. "This procedure assesses for abnormal electrical impulses within the heart." c. "This procedure will evaluate the oxygen saturation in your blood." d. "This procedure assesses for blockages within the coronary arteries." ANS: A Echocardiography is performed to assess the structure and function of the heart, especially the valves and wall motion. Coronary arteries are not assessed with echocardiography, and neither is the electrical conduction system. DIF: Cognitive Level: Knowledge/Remembering REF: p. 706 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning 22. The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the heart. The client's history includes a previous myocardial infarction and pacemaker implantation. Which action by the nurse is most appropriate? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI. ANS: B The magnetic fields of the magnetic resonance imager 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 cardiac enzymes, an electrocardiogram, or increased fluids. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Planning) 23. The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. What is the nurse's first intervention? a. Compare the results with previous readings. b. Increase the IV fluid rate because these readings are low. c. Immediately notify the physician of the elevated pressures. d. Document the finding and continue to monitor. ANS: A Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although these readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Evaluation) 24. The nurse is preparing to measure a client's pulmonary artery wedge pressure (PAWP). In what position will the nurse place the client for the most accurate results? a. Supine, with the head elevated to 45 degrees b. Supine, with the head elevated to 30 degrees c. Reverse Trendelenburg position at 15 degrees d. Supine, with the head of the bed flat ANS: A To measure PAWP accurately, the client should be placed in supine position, with the head elevated to 45 degrees. DIF: Cognitive Level: Comprehension/Understanding REF: p. 709 TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Implementation) 25. The nurse is caring for a client with an 80% blockage of the right coronary artery (RCA). While waiting for bypass surgery, what is essential for the nurse to have available? a. Furosemide (Lasix) b. External pacemaker c. Lidocaine d. Central venous access ANS: B The right coronary artery supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial (SA) node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Planning) 26. The nurse is caring for a client with pericarditis. What assessment finding correlates with this disorder? a. Pericardial friction rub b. Systolic murmur c. Ventricular gallop d. Paradoxical splitting ANS: A A pericardial friction rub originates from the pericardial sac and is heard in clients with pericarditis. The other findings are not associated with pericarditis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 27. The nurse is auscultating heart tones on an older client and hears the following sound. What is the nurse's best action? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the medications. ANS: B The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment) 28. The nurse is auscultating cardiac tones. Where should the nurse listen to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D ANS: A The aortic valve is auscultated in the second intercostal space just to the right of the sternum. DIF: Cognitive Level: Comprehension/Understanding REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment) MULTIPLE RESPONSE 1. A client with a history of renal insufficiency is scheduled for a cardiac catheterization. What does the nurse expect to do for this client before the catheterization? (Select all that apply.) a. Insert a Foley catheter. b. Administer IV fluids. c. Assess for allergies to iodine. d. Assess laboratory results. e. Assess and mark pulses. f. Insert a central venous catheter. g. Have the client sign the consent. ANS: B, C, D, E, G If the client has kidney disease (as indicated by laboratory results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish. The contrast medium used during the catheterization contains iodine. Pulses need to be marked for ease in locating them after the procedure. Findings need to be properly documented, and the primary care provider and other members of the health care team need to be notified of abnormal findings. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation) 2. A female client is admitted to the emergency department. Which symptoms cause the nurse to order an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal fullness e. Shortness of breath f. Feeling of choking g. Abdominal pain ANS: B, C, D, E, F Women may not have chest pain 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 3. A client is recovering after a coronary catheterization. What assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor ANS: B, D, E In the first few postprocedure hours, 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment) 4. When reviewing a client's laboratory results, which findings alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol of 280 mg/dL b. High-density cholesterol of 50 mg/dL c. Triglycerides of 200 mg/dL d. Serum albumin of 4 g/dL e. Low-density cholesterol of 160 mg/dL ANS: A, C, E A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

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