Cardiac Passpoint

A client takes isosorbide dinitrate as an antianginal medication. Which statement indicates that the client understands the adverse effects of the drug?

"I'll need to change positions slowly so I won't get dizzy."

THe nurse is assessing a client who is at risk for cardiac tamponade from chest trauma sustained in a motorcycle accident. What is the client's pulse pressure if the BP is 108/82.

26

The nurse is assessing a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. What should the nurse do immediately?

Assess vital signs

Which client is at risk for pulmonary embolism? A client with:

DVT

What instructions should the nurse give the client who will be starting a prescription for simvastatin 40 mg/day client? Select all that apply.

If you miss a dose, take it when you remember it Report muscle pain or tenderness to your HCP Continue to follow a diet that is low in saturated fats

A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediate;y after surgery?

Maintain circulation

A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply.

Orthopnea cough crackles

The recipient of a donated organ asks the nurse, What did the donor die from?. Which response by the nurse is most appropriate?

The transplant coordinator can give you information about the donor's medical history.

A client is scheduled for a cardiac catheterization. The nurse should do which preprocedural tasks? Select all that apply.

Verify the client has stopped taking anticoagulants if instructed by the provider Check for iodine sensitivty Verify that written consent has been obtained Withhold food and oral fluids before the procedure

A client is receiving digoxin, and the pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should do what first?

Withhold the digoxin

A client is about to undergo cardiac catheterization for which informed consent was obtained. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed?

Withhold the medication and notify the physician immediately.

Which client is at greatest risk for Buerger's disease?

a 29-year-old male with a 14-year history of cigarette smoking.

The nurse is administering adenosine to a client with supraventricular tachycardia. What is the expected therapeutic response?

a short period of asystole

A client has been diagnosed with atrial fibrillation. The HCP prescribed warfarin to be taken on a daily basis. The nurse instructs the client to avoid using which OTC medication while taking warfarin?

aspirin

A client in the ED reported vomiting and diarrhea for the previous 24 hours. The client's BP is 90/60 mm Hg, respiration is 20 bpm, HR is 92 bpm, and temp 99.5 F. Which intervention will the nurse perform first?

assess for dehydration

A client is taking sprinolactone. Which change in the diet should the nurse teach the client to make taking this drug?

avoid eating foods high in potassium

Metoprolol is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension who has been initially treated with furosemide and rampril. The nurse should evaluate the client for which expected therapeutic effect?

decrease in heart rate

A client comes to the ED complaining of chest pain. An ECG reveals myocardial ischemia and an anterior-wall MI. Which ECG characteristic does the nurse expect to see?

elevated ST segment

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected?

loss of hair on the lower leg

The nurse is assessing the ankle-brachial index (ABI) for a client with peripheral vascular disease. The highest systolic pressure for each ankle is 80 mm Hg and the highest brachial pressure is 160 mm Hg. What does this client's ABI indicate?

mild to moderate insufficiency

A client has been diagnosed with peripheral arterial occlusive disease. In order to promote circulation to the extremities, the nurse should instruct the client to:

participate in a regular walking program.

A client with a UTI exhibits these vital signs; blood pressure of 90/60 mm Hg, respiratory rate of 24 breaths per minute, and heart rate 100 beats per minute. Which nursing action would be mostappropriate for this client?

placing the client in modified Trendelenburg position

A client is admitted for a revascularization procedure for arterosclerosis in the left iliac artery. What should the nurse do to promote in the extremities?

position the left leg or below the body's horizontal plane

What is the highest priority in the plan of care for a client with peripheral vascular problems?

promote arterial and venous circulation

On a routine visit to the health care provider, a client with chronic arterial occlusive disease reports quitting smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?

taking daily walks

When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should:

teach the client to put on clothing on the affected side first

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. THe client's cholesterol profile is: total cholesterol 265, LDL 139, HDL 32. The client asks the nurse how to lower their cholesterol. The nurse should tell the client that:

the nurse will ask the dietitician to talk with the client about modifying their diet

A client has an International normalized ratio (INR) of 1.6, creatine kinase-MB (CK-MB) of 90 μ/L, troponin 2.1 ng/L, and myoglobin 90 μg/L. Which result requires the nurse to take action?

troponin of 2.1

The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. Which comment by the client indicates the client needs further education?

"I know I shouldn't drive after taking my furosemide."

The nurse is teaching a client about actions to control manifestations of left-sided heart failure. Which statement by the client indicates appropriate understanding?

"If I have trouble breathing, I will sit in my recliner with my head up."

The nurse is caring for a client prescribed IV heparin for treatment of thromboembolism. The client is prescribed 18 units/kg/hr. The client weighs 145 lb (66 kg). The heparin comes from the pharmacy as 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round to the nearest whole number

12

When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum?

2 in (5 cm)

The rapid response team has been called to manage an unwitnessed cardiac arrest in a client's hospital room. How long should the nurse estimate the maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage?

4 to 6 minutes

A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply.

Check post op CBC, INR, PTT and platelet levels Confirm availability of blood products Monitor the mediastinal chest tube drainage

A nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that they think they are going to die before a donor heart is found. The client also tells the nurse that they have not been attending a church but wants to talk with a priest. What action should the nurse take?

Contact the clergy member who is assigned to the transplant team.

A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained? 1. "This implanted defibrillator will protect me against some of those bad rhythms my heart goes into." 2. "I wonder if there is any other way to prevent these bad rhythms." 3. "The physician will make a small incision in my chest wall and place the generator there." 4. "A wire from the generator will be attached to my heart."

I wonder if there is any other way to prevent these bad rhythms.

A client who requested a DNR order upon admission to the hospital now states a desire for the medical team to do everything possible to help the client get better. THe client is concerned about the DNR order. Which response by the nurse is best?

It isn't a problem to rescind your DNR order; I'll let your physcian know your wishes right away.

The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply.

Reorient frequently to time, place and situation Arrange for familiar pictures or special items at bedside Spend time with the client, establishing a trusting relationship

A client with end-stage heart failure is preparing for discharge. The client and their caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave the client feeling isolated. Which suggestion by the home care nurse best addresses this concern?

Set up the hospital bed in the family room so the client can be part of household activities.

Which is the most appropriate diet for a client during the acute phase of myocardial infarction (MI)?

Small, easily digested meals

A visiting nurse is teaching a client with heart failure about taking their medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene?

Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications.

A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which finding requires immediate nursing action?

The client has become more somnolent.

A nurse administers the first dose of nadolol to a client with a blood pressure of 180/96. During an assessment 4 hours later, which information indicates that the client needs immediate intervention?

The client has wheezing throughout the lung fields.

The nurse is monitoring a client with a pacemaker. Which finding shows that the client's pacemaker is functioning correctly?

The nurse observed a spike on the electrocardiogram (EKG) with pacing initiated.

What measure should the nurse take that will be most helpful in preventing wound infection when changing a client's dressing after coronary artery bypass surgery?

Wash hands before changing the dressing

A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The health care provider (HCP) has prescribed 60 mg of enoxaparin subcutaneously. Before administering the drug, the nurse checks the client's laboratory results. (See image.) Based on these results, what should the nurse do?

Withhold the dose of the medication and contact the HCP.

The nurse is caring for a client with peripheral artery disease (PAD) who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediateattention from the nurse?

a change in the intensity of the pulse from the baseline

A nurse is caring for 4 clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?

a client 4 days postoperative after mitral valve replacement

Which client admitted to the ED should the nurse see first?

a client experiencing a ripping sensation in the chest

A client developed cardiogenic shock after a severe MI and has now developed acute renal failure. The clients family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family?

a decrease in the blood flow through the kidneys

Which assessment finding supports the administration of protamine sulfate?

aPTT 3.5-5 times normal

Three days after surgery to insert a mechanical mitral valve, the client asks what can be done to muffle the clicking sound since it is embarrassing and others will know an artificial valve is in the heart. The nurse response should reflect the understanding that the client may be experiencing which concern?

anxiety related to altered body image

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?

aorta

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

aortic insufficiency

The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stockings. What instructions should the nurse include in the teaching plan?

apply the elastic stockings before getting out of bed remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes

A client is admitted to the hospital through the ED with chest pain. Which nursing intervention is the priority?

assessing troponin 1 levels

A client who has a history of bacterial endocarditis is scheduled to have oral surgery to remove a tooth. What should the nurse instruct the client to do?

be sure the dentist prescribes a prophylactic antibiotic prior to the oral surgery.

The nurse is assessing a client with chronic bronchitis. For which finding should the nurse suspect that the client is developing right-sided heart failure?

bilateral edema of the feet and ankles

A nurse is preparing a teaching plan for a male client newly prescribed atenolol. Which information is important for the nurse to teach this client?

causes and treatments for erectile dysfunction

A nurse is caring for a client with type 2 diabetes who has had a MI and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention?

control the pain and support breathing and oxygenation

A client with a cerebral embolus is receiving IV recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy?

dissolved emboli

The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:

encourage the client to avoid standing in one position for long periods of time.

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals DM, HTN, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before the admission. Which history finding is a major risk factor for infective endocarditis?

history of aortic valve replacement

The plan of care for a client with hypertension taking propranolol hydrochloride should include:

instructing the client to notify the health care provider of irregular or slowed pulse rate.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should

keep the affected leg level or slightly dependent.

A client prescribed enalapril reports symptoms of a persistent dry cough. What is the nurse's bestaction?

notify the HCP

The nurse teaches a client with heart failure to take oral furosemide in the morning. What is the expected outcome for taking this drug in the morning? The client will:

obtain more sleep

When performing cardiopulmonary resuscitation (CPR), which finding indicates that external chest compressions are effective?

palpable pulse

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first?

pedal pulses

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort?

red, warm, palpable linear cord along the vein that is painful on palpation

A client whose condition remains stable after a myocardial infarction gradually increases activity. To determine whether the activity is appropriate for the client the nurse should assess the client for

respiratory rate

A client in the ED with a cardiac dysrhythmia is to receive a prescribed dose of procainamide. For which conditions in the client's history would the nurse withhold the medication until the order is clarified? SATA

second-degree heart block myasthenia gravis systemic lupus erythematosus

A client is admitted with chest pain, fever, and joint pain 4 weeks after experiencing an acute inferior wall myocardial infarction. Which laboratory value should the nurse address?

sedimentation rate (ESR) 49 mm/hr

While the nurse is assisting a client to ambulate as part of a cardiac rehab program, the client has midsternal burning. What should the nurse do next?

stop and assess the client further

While transferring a load of firewood from the front driveway to the backyard woodpile at 11 a.m., the client experienced a heaviness in the chest and dyspnea. The client stopped working and rested, and the pain subsided. At noon, the pain returned. At 12:30 p.m., the client's spouse took the client to the emergency department. Around 1:30 p.m., the health care provider diagnosed an anterior myocardial infarction (MI). The nurse should anticipate which orders by the health care provider?

sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry

A client with second-degree heart block is admitted to the coronary care unit. The nurse closely monitors the client's HR and rhythm. When interpreting the client's ECG strip, the nurse knows that the QRS complex represents:

ventricular depolarization

A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action?

weight gain of 2.5 kg (5.5 lb) in 24 hours

An older client with diabetes has been maintained on metformin has been scheduled for a cardiac cath. The nurse should verify that the HCP has written which prescription for taking the metformin before the procedure?

withhold the metformin