Cardiac Quiz
A client asks the nurse why it is important to be weighed every day if he or she has right-sided heart failure. How will the nurse respond?
"Weight is the best indication that you are gaining or losing fluid.
A client admitted to the coronary care unit with a myocardial infarction begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats/min, and cold, clammy skin. What is the nurse's best first action?
. Notify the physician.
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?
An increase in heart rate and respiratory rate
Why is the administration of aspirin recommended along with nitroglycerin when a client is experiencing angina-like chest pain?
Aspirin inhibits platelet aggregation and clot formation.
A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention?
Assessing respiratory status
An 82-year-old client is admitted with a suspected myocardial infarction. What specific clinical manifestation of myocardial infarction would the nurse expect to see in an older adult?
Disorientation or confusion
The client who has undergone coronary artery bypass surgery graft (CABG) has a serum potassium level of 4.5 mEq/L. What would be the nurse's best action?
Document the finding as the only action.
An older adult client is admitted with fluid volume excess. Which diagnostic or laboratory study would best assist in the diagnosis of heart failure?
Echocardiography
Which client statement alerts the nurse to possible heart failure?
I have to stop halfway up the stairs to catch my breath.
A nurse is caring for a client admitted to the hospital with a complaint of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states that there is no change in the level of discomfort experienced. What would be the nurse's best action?
Notify the health care provider.
The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not yet be advanced to the next level?
Onset of chest pain
A client with heart failure is going through rehabilitation to increase his or her activity tolerance. The nurse will stop the client's activity if which symptom is assessed?
Systolic blood pressure change from 136 to 96 mm Hg
An older adult client with heart failure has developed atrial fibrillation. What diagnostic or laboratory test would the nurse expect to be ordered?
T4 (thyroxine) and TSH (thyroid-stimulating hormone)
he client with a history of stable angina states that he has recently experienced an increase in the number of attacks and the intensity of the pain. What should the nurse suspect?
The client has developed unstable angina
A nurse is taking the history of a client with suspected coronary artery disease. Recently, the client has had episodes of chest discomfort while mowing the lawn with a push mower. The chest discomfort subsides when the client rests. What conclusion can the nurse draw from this
The client may have stable angina.
A client with a history of heart failure is being discharged. Which instruction will assist the client in the prevention of complications associated with heart failure?
Weigh yourself daily wearing the same amount of clothing."