Cardio

A nurse must obtain a client's apical pulse. Mark where the nurse should place the stethoscope.

The heart's apex is between the fifth and sixth ribs at the midclavicular line. It is closest to the chest wall here, so auscultation is easier.

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? (Select all that apply.) 1.Anxiety 2.Chest pain 3.Irregular pulse 4.Fear of losing control 5.Feelings of depersonalization

1.Anxiety 2.Chest pain 3.Irregular pulse

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? (Select all that apply.) 1.Decreased urine 2.Hypotension 3.Dyspnea 4.Dry mucous membranes 5.Pulmonary edema 6.Poor skin turgor

1.Decreased urine 2.Hypotension 4.Dry mucous membranes 6.Poor skin turgor

What clinical indicators are the nurse most likely to identify when taking the admission history of a client with right ventricular failure? (Select all that apply.) 1.Edema 2.Vertigo 3.Polyuria 4.Dyspnea 5.Palpitations

1.Edema 4.Dyspnea

During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions. 1.Elevate the head of the bed to 45 degrees 2.Reduce the flow rate of the transfusion 3.Administer furosemide (Lasix) per provider prescription 4.Apply oxygen via nasal cannula 5.Document findings in the client record

1.Elevate the head of the bed to 45 degrees Incorrect 4.Apply oxygen via nasal cannula 2.Reduce the flow rate of the transfusion 3.Administer furosemide (Lasix) per provider prescription 5.Document findings in the client record These symptoms represent circulatory overload. First, the nurse's priority is to facilitate gas exchange by elevating the head of the bed, then applying oxygen. Next, the transfusion rate should be slowed to reduce further circulatory overload and client compromise, followed by the administration of a diuretic to reduce circulating volume. Lastly, the findings and interventions should be documented accordingly.

A client is receiving total parenteral nutrition solution. Potassium has not been added to the solution. The nurse monitors the client for which signs of hypokalemia? (Select all that apply.) 1.Muscle weakness 2.Metabolic alkalosis 3.Cardiac dysrhythmias 4.Serum potassium of 5.5 mEq/L 5.Respiratory rate of 24 or higher

1.Muscle weakness 3.Cardiac dysrhythmias

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding? 1.Oliguria 2.Bradypnea 3.Pulse deficit 4.High potassium levels

1.Oliguria

A client is discharged with a prescription for sustained-release nitroglycerin. What should the nurse teach the client about sustained-release nitroglycerin? 1.Swallow the capsule whole 2.Take milk with the medication 3.Hold the tablet under the tongue 4.Note a stinging feeling when the drug is under the tongue

1.Swallow the capsule whole

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? 1.Syncope 2.Headache 3.Tachycardia 4.Hemiparesis

1.Syncope

Laboratory results of a client's blood after chemotherapy indicate bone marrow depression. What should the nurse encourage the client to do? (Select all that apply.) 1.Use a soft toothbrush. 2.Sleep with the head of the bed elevated. 3.Increase activity levels and take frequent walks. 4.Drink more citrus juices and eat more citrus fruits. 5.Read the ingredients in over-the-counter drugs before taking them

1.Use a soft toothbrush. 5.Read the ingredients in over-the-counter drugs before taking them

A nurse is assessing a middle-aged female client for the presence of risk factors associated with coronary heart disease. Which risk factor carries a greater risk for women than for men? 1.Obesity 2.Hypertension 3.Diabetes mellitus 4.Cigarette smoking

3.Diabetes mellitus

A client who had a myocardial infarction receives a prescription for a beta-blocker and a nitroglycerin patch. The nurse determines that the purpose of the nitroglycerin patch is to decrease the: 1.Pulse rate, thereby strengthening cardiac contractility 2.Cardiac output, thereby reducing the cardiac workload 3.Preload of the heart, thereby reducing the cardiac workload 4.Coronary artery lumens, thereby reducing peripheral resistance

3.Preload of the heart, thereby reducing the cardiac workload

Digoxin (Lanoxin) and furosemide (Lasix) are prescribed for a client with the diagnosis of pulmonary edema. What client response to digoxin is unrelated to toxicity? 1.Nausea 2.Yellow vision 3.Irregular pulse 4.Pulse of 64

4.Pulse of 64

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client? 1.Warm, flushed skin 2.Increased pulse pressure 3.Lethargy with confusion 4.Reduced peripheral pulses

4.Reduced peripheral pulses

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. What locations on the client's body should the nurse assess? (Select all that apply.) 1.Sclera 2.Nail beds 3.Lining of eyelids 4.Palms of hands 5.Bony prominences

2.Nail beds 3.Lining of eyelids 4.Palms of hands

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand? 1.Plaque from within the veins is abraded. 2.The dilated saphenous veins are removed. 3.Superficial veins are anastomosed to deep veins. 4.An umbrella filter is placed in the large affected veins

2.The dilated saphenous veins are removed.

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? (Select all that apply.) 1.Anorexia 2.Vomiting 3.Constipation 4.Muscle weakness 5.Irregular heart rate

2.Vomiting 4.Muscle weakness 5.Irregular heart rate

Which client should a nurse consider the greatest risk for developing hypernatremia? 1. 52-year-old who is receiving 0.45% NaCl intravenously 2. 76-year-old who developed syndrome of inappropriate antidiurectic hormone secretion (SIADH) as a result of head trauma 3. 63-year-old who has had watery diarrhea since traveling abroad 4. 48-year-old who is admitted with a diagnosis of Addison disease

3. 63-year-old who has had watery diarrhea since traveling abroad

A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? (Select all that apply.) 1.Nausea 2.Melena 3.Purpura 4.Diarrhea 5.Hematuria

2.Melena 3.Purpura 5.Hematuria

A client with hypertension is scheduled for a scan and electrolyte studies. During an interview with the nurse, the client exclaims, "I don't know why I just can't get a prescription for high blood pressure pills; that probably is all it is. I'm missing work by being here." Which is the best response by the nurse? 1."It might not be high blood pressure. We have to be sure." 2."It's frustrating to miss work and not know for sure what's wrong." 3."I know it's frustrating, but you need to have a diagnostic workup." 4."Maybe you could ask your health care provider if the tests could be done on separate days."

2."It's frustrating to miss work and not know for sure what's wrong."

A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which parameters should the nurse consider to determine the safe resumption of sexual activity? (Select all that apply.) 1.The client and partner are not fearful of sexual intimacy 2.At least between 4 and 6 weeks after the myocardial infarction 3.When the client feels emotionally ready to resume sexual activity 4.The point at which two flights of stairs can be climbed without dyspnea 5.Laboratory data showing that enzyme results have returned to preinfarction levels

2.At least between 4 and 6 weeks after the myocardial infarction 4.The point at which two flights of stairs can be climbed without dyspnea

A nurse assesses a client's intravenous site. What clinical finding leads the nurse to conclude that the intravenous (IV) site has been infiltrated? (Select all that apply.) 1.Redness along the vein 2.Coolness of skin near the insertion site 3.Swelling around the insertion site 4.Cessation in flow of solution 5.Vein feels hard and cordlike

2.Coolness of skin near the insertion site 3.Swelling around the insertion site 4.Cessation in flow of solution

What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1.Arterial spasm 2.Heart muscle ischemia 3.Blocking of the coronary veins 4.Irritation of nerve endings in the cardiac plexus

2.Heart muscle ischemia

While obtaining a health history, a nurse expects a client admitted to the hospital with chronic heart failure to report: 1.Tingling in the upper extremities 2.Feeling bloated after eating 3.A need to use three pillows at night to sleep 4.Swelling of the ankles that is more apparent in the morning

3.A need to use three pillows at night to sleep

A health care provider makes the diagnosis that an obese client has primary (essential) hypertension. What is the priority information that the nurse should include when preparing a teaching plan for this client? 1.Causes of the hypertension 2.Need for exercise three times a week 3.Foods recommended on a low-calorie and low-sodium diet 4.Complications that involve the vascular and neurological systems

3.Foods recommended on a low-calorie and low-sodium diet

When discussing the therapeutic regimen of vitamin B12 for pernicious anemia with a client, the nurse explains that: 1.Weekly Z-track injections provide needed control 2.Daily intramuscular injections are required for control 3.Intramuscular injections once a month will maintain control 4.Oral tablets of vitamin B12 taken daily will provide symptom control

3.Intramuscular injections once a month will maintain control

A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of: 1.Inadequate arterial blood supply." 2.Delayed healing of tissues after an injury." 3.Increased production of melanin in the area." 4.Leakage of red blood cells through the vascular wall."

4.Leakage of red blood cells through the vascular wall."

A client with a history of hypertension and left ventricular failure arrives for a scheduled clinic appointment and tells the nurse, "My feet are killing me. These shoes got so tight." The nurse's best initial action is to: 1.Weigh the client 2.Notify the primary health care provider 3.Take the client's pulse rate 4.Listen to the client's breath sounds

4.Listen to the client's breath sounds

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? 1.History of hypertensive disease 2.Emboli associated with atrial fibrillation 3.Developmental defect of the arterial wall 4.Inappropriate paroxysmal neural discharge

Emboli associated with atrial fibrillation