Cardio

A client is admitted post motor vehicle crash. The health care provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40 and the heart rate has risen from 82 to 121. The nurse knows that the most likely reason for the assessment findings is:

Hemorrhagic shock The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, the nurse should be prepared to administer:

Protamine sulfate Protamine sulfate binds with heparin sodium to form a physiologically inert complex; it corrects clotting deficits. Vitamin K counteracts the effects of drugs like warfarin sodium (Coumadin). Panheparin is an alternate name for heparin sodium. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin.

Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment?

Signs of bleeding Assessment for bleeding is a priority when administering a thrombolytic agent because it may lead to hemorrhage. The heart rate is not affected. Electrolyte levels are not affected. Tissue compatibility is not necessary.

A client had an acute myocardial infarction. For which life-threatening complication should the nurse monitor during the first 48 hours?

Ventricular tachycardia Approximately 40% to 50% of all deaths result from the life-threatening dysrhythmia of ventricular tachycardia. Pulmonary edema may occur but can be treated aggressively with the expectation of a recovery. Pulmonary embolism may occur but can be treated so that the client recovers. Left ventricular heart failure will be more likely to occur.

The nurse provides discharge instructions for a 40-year-old woman who is newly diagnosed with cardiomyopathy. Which statement, if made by the patient, indicates that further teaching is necessary?

"I can drink alcohol in moderation." Patients with cardiomyopathy should avoid alcohol consumption, especially in patients with alcohol-related dilated cardiomyopathy. Avoiding heavy lifting and stress, as well as family members learning CPR, are recommended teaching points.

The nurse performs discharge teaching for a 68-year-old man who is newly diagnosed with infective endocarditis with a history of IV substance abuse. Which statement by the patient indicates to the nurse that teaching was successful?

"I will inform my dentist about my hospitalization for infective endocarditis." Patients with infective endocarditis should inform their dental providers of their health history. Antibiotic prophylaxis is recommended for patients with a history of infective endocarditis who have certain dental procedures performed. Antibiotics are not indicated before genitourinary or gastrointestinal procedures unless an infection is present. Patients should immediately report the presence of fever or clinical manifestations indicating heart failure to their health care provider.

What is the most important information the nurse can give a client who was just diagnosed with hypertension?

"Long-term follow-up care is necessary." Hypertension can affect other body tissues, such as the kidneys and eyes; follow-up care and adherence to the therapeutic regimen (e.g., medications, diet, and exercise) are imperative. Hypertension often is asymptomatic, not symptomatic. The client should maintain routine (e.g., daily, weekly) records of blood pressure results as advised. The medication regimen should be followed exactly as prescribed; doses are adjusted by the health care provider.

A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?

2 to 2 ½ inches The sternum must be depressed at least 2 inches to compress the heart adequately between the sternum and vertebrae and to simulate cardiac pumping action. ¾ to 1 inch , ½ to ¾ inch, and 1 to 1 ½ inches are ineffectual for an adult.

The nurse is monitoring the ECGs of several patients on a cardiac telemetry unit. The patients are directly visible to the nurse, and all of the patients are observed to be sitting up and talking with visitors. Which patient's rhythm would require the nurse to take immediate action?

A 52-year-old man with premature ventricular contractions (PVCs) at a rate of 12 per minute Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs most likely must be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents.

A 38-year-old teacher who reported dizziness and shortness of breath while supervising recess is admitted with a dysrhythmia. Which medication, if ordered, requires the nurse to carefully monitor the patient for asystole?

Adenosine (Adenocard) IV adenosine (Adenocard) is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's ECG continuously because a brief period of asystole after adenosine administration is common and expected. Atropine sulfate increases heart rate, whereas lanoxin and metoprolol slow the heart rate.

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes ventricular irritability on the screen. What medication should the nurse prepare to administer?

Amiodarone (Cordarone) Amiodarone decreases the irritability of the ventricles by prolonging the duration of the action potential and refractory period. It is used in the treatment of ventricular dysrhythmias. Digoxin slows and strengthens ventricular contractions; it will not rapidly correct ectopic beats. Furosemide, a diuretic, does not affect ectopic foci. Norepinephrine is a sympathomimetic and is not the drug of choice for ventricular irritability.

A 54-year-old male patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first?

Assist the patient to a sitting position with arms on the overbed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

A client with a history of heart failure and hypertension is admitted with reports of syncope. Which prescribed medication should the nurse prepare to administer based on the ECG rhythm strip image?

Atropine This rhythm strip reflects sinus bradycardia. Sinus bradycardia has PQRST complexes within acceptable limits, but the rate is less than 60 beats per minute. In this strip the PR interval is 0.16, the rhythm is regular, and the rate is 40 beats per minute. Atropine, an anticholinergic that increases the heart rate, is administered when the heart rate is so slow that it causes symptoms. Digoxin is a cardiac glycoside that slows the heart rate. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that slows the heart rate. Metoprolol is a beta blocker that slows the heart rate.

A client is receiving hydrochlorothiazide (HCTZ). What should the nurse monitor to best determine the effectiveness of the client's hydrochlorothiazide therapy?

Blood pressure Diuretics promote urinary excretion, which reduces the volume of fluid in the intravascular compartment, thus lowering blood pressure. Assessing the extent of edema is subjective and difficult; blood pressure is an objective assessment that measures intravascular pressure. The serum sodium level remains stable unless the dosage is excessive; an altered sodium level is not a therapeutic response. Although specific gravity decreases with increased urinary output, this does not reflect the desired reduction in intravascular pressure.

A client is receiving doxorubicin (Adriamycin) as part of a chemotherapy protocol. The nurse should assess the client for which major life-threatening side effect of doxorubicin?

Cardiotoxicity Heart failure and dysrhythmias are the primary life-threatening toxic effects unique to doxorubicin. When bone marrow is depressed to precarious levels, the dose is altered or blood components administered. Pulmonary fibrosis is not a side effect of doxorubicin or of any of the other antineoplastic agents. Ulcerative stomatitis is an uncomfortable side effect to doxorubicin, but it is not life threatening as are the primary life-threatening toxic effects unique to doxorubicin.

A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit the client's vital signs remained stable for one hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first?

Check the dressing on the incision The data indicate impending shock; the dressing should be assessed for signs of hemorrhage. Although increasing the intravenous flow rate may be done eventually, it is not the priority and requires a health care provider's prescription. There are no signs of respiratory distress; if hemorrhage is confirmed, the supine position is preferable. The client may be hemorrhaging and needs immediate intervention.

A 55-year-old female patient develops acute pericarditis after a myocardial infarction. It is most important for the nurse to assess for which clinical manifestation of a possible complication?

Decreased blood pressure with tachycardia Cardiac tamponade is a serious complication of acute pericarditis. Signs and symptoms indicating cardiac tamponade include narrowed pulse pressure, tachypnea, tachycardia, a decreased cardiac output, and decreased blood pressure. The other symptoms are consistent with acute pericarditis.

A client with stage III Hodgkin disease is started on ABVD therapy, a multiple drug regimen. The client asks why so many drugs need to be given all at once. Which is the best response by the nurse?

Each drug destroys the cancer cell at a different time in the cell cycle Cells are vulnerable to specific drugs through the stages of mitosis, and a combination bombards the malignant cells at various stages. The side effects of a drug are not ameliorated by a combination with others. Although the statement several drugs are used to destroy cells that are not susceptible to radiation therapy is true, it is not the reason for using a combination of drugs. Although there is more than one stage of Hodgkin disease, this is not the reason for using a combination of drugs.

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is:

Elevate the head of the bed and obtain vital signs The client's ability to speak indicates that the client is breathing. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Checking the vital signs after this is the first step in assessing the cause of the distress. Discontinuing the IV access line may cause unnecessary discomfort if it must be restarted; there are too few data to call the health care provider at this time. There is not enough information to support calling the health care provider and obtaining a prescription for a sedative; further assessment is required. There is no information to support assessing for allergies and changing the IV to an intermittent infusion device; assessment for allergies should be done on admission.

A client with a history of thrombophlebitis and varicosities is to have a herniorrhaphy for an incarcerated hernia. What primary nursing action should be implemented postoperatively considering the client's medical history?

Encourage the client to turn often and to exercise the legs regularly Because of the client's history and the site of the surgery, thrombi are likely to develop; activity is a preventive measure. Raising the foot of the bed alone will not prevent thrombi; activity is necessary. Dangling and getting out of bed will provide little exercise if the client only sits on the bed or in a chair. Also, a health care provider's prescription is needed. Although body alignment is important for all clients, it will not discourage thrombus formation.

The nurse helps a client create a list of appropriate food choices to maintain a 2-gram sodium diet that recently has been prescribed for the client. The nurse also assesses the client's cooking habits. The client tells the nurse that, at home, all food is cooked without salt. The nurse concludes that further teaching is needed when the client places what food items on the list of appropriate food choices?

Fillet of sole, baked potato, lettuce and tomato salad, fresh fruit cup, and milk Mixed fruit salad bowl with cottage cheese, crackers, celery, sweet pickles, and teahas the highest sodium content. Soft-cooked egg, salt-free toast, jelly, skim milk, baked chicken, boiled potatoes, broccoli, coffee, fillet of sole, baked potato, lettuce and tomato salad, and fresh fruit cup are low in sodium.

A client is admitted to the coronary intensive care unit. What is the first step when the nurse is developing a discharge teaching plan for this client?

Identifying the client's needs For teaching to be meaningful, the client must have a need to learn; also, readiness to learn is part of this assessment. The nurse determines expected outcomes depending on mutually desired goals; also, this is not the first step when developing a discharge teaching plan. Exploring the client's community resources is not the initial step; assessment of learning needs comes first. Assessing the client's personal support system is not the initial intervention; the client's needs must be assessed first.

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition?

Increased pressure within the circulatory system Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure, fluid moves into the tissues, causing edema, and into the abdominal cavity, causing ascites; ascites leads to an increased abdominal girth. There is no loss of the cellular constituents in blood with right ventricular heart failure. Ascites is the accumulation of fluid in an extracellular space, not intracellular. The opposite of rapid diffusion of solutes and solvents into plasma results when there is a pressure increase in the systemic circulation.

The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively?

Maintaining a reduced blood pressure Maintaining a low blood pressure reduces the risk of aortic rupture. Administering supplemental oxygen may or may not be necessary. Keeping the client in a supine position may or may not be necessary. Monitoring will help identify whether an aneurysm has ruptured, but it will not prevent rupture.

A 72-year-old man with a history of aortic stenosis is admitted to the emergency department. He reports severe left-sided chest pressure radiating to the jaw. Which medication, if ordered by the health care provider, should the nurse question?

Nitroglycerin Aspirin, oxygen, nitroglycerin, and morphine sulfate are all commonly used to treat acute chest pain suspected to be caused by myocardial ischemia. However, nitroglycerin should be used cautiously or avoided in patients with aortic stenosis as a significant reduction in blood pressure may occur. Chest pain can worsen because of a drop in blood pressure.

A nurse assesses a client for orthostatic hypotension. The results are: Lying - heart rate = 70 beats/minute B/P - 110/70 Sitting - heart rate = 78 beats/minute B/P - 106/66 Standing - heart rate = 85 beats/minute B/P - 100/64 The nurse would expect which primary health care provider prescription?

No prescription change. The assessment findings do not indicate postural hypotension. There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving IV fluid to this client could result in a fluid imbalance in this client.

A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit? Select all that apply.

Oliguria Hypotension Tenting tissue turgor

A nurse attaches electrocardiogram (ECG) leads to a client who is admitted to the hospital for chest pain. When monitoring the ECG strip, the nurse identifies that depolarization of the atria is occurring when which waveform in the illustration is present?

P wave

A client is brought to the emergency department with chest pain. A myocardial infarction is suspected and 500 mL of D5W with 50 mg of nitroglycerin intravenously (IV) has been prescribed. The nurse should monitor the client for what most common side effect?

Postural hypotension The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure; orthostatic hypotension can occur. Syncope is infrequent when nitroglycerin is given intravenously. Nausea and vomiting may occur but are not the most common side effects of IV nitroglycerin. Cherry red lips and cheeks occur with carbon monoxide poisoning.

The nurse is teaching a community group about preventing rheumatic fever. What information should the nurse include?

Prompt recognition and treatment of streptococcal pharyngitis The nurse should emphasize the need for prompt and adequate treatment of streptococcal pharyngitis infection, which can lead to the complication of rheumatic fever.

Warfarin (Coumadin) is prescribed for a client who has been receiving intravenous (IV) heparin for a partial occlusion of the left common carotid artery. The client expresses concern about why both drugs are needed at the same time. The nurse explains that this approach:

Provides an anticoagulant intravenously until the oral drug reaches therapeutic levels. Warfarin is administered orally for two or three days to achieve the desired effect on the international normalized ratio (INR) level before heparin is discontinued. These drugs do not dissolve clots already present. Because each drug affects a different part of the coagulation mechanism, dosages must be adjusted separately. That this approach immediately provides maximum protection against clot formation does not account for the reason for the administration of both drugs; warfarin will not exert an immediate therapeutic effect.

The nurse administers oxygen to a client during the early postoperative period after open heart surgery. Why is this necessary?

Reduced oxygen levels can stimulate dysrhythmias Inadequate oxygenation can cause premature ventricular complexes. Although clients have closed-chest drainage in place, it does not explain why adequate oxygenation is important. Hypoxia can precipitate respiratory acidosis; hyperventilation causes respiratory alkalosis. The reverse is true; postoperative pain can increase the respiratory rate.

A client admitted to the hospital for chest pain is diagnosed with angina. The nurse should teach the client that the most common characteristic of anginal pain is that it is:

Relieved by rest Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload. Angina usually is precipitated by exertion, emotion, or a heavy meal. Anginal pain usually is described as tightness, indigestion, or heaviness. Nitroglycerin dilates coronary arteries, which increases oxygen to the myocardium, decreasing pain.

The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to an 82-year-old man admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication?

Serum potassium level Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)?

Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

After surgery a client's fever does not respond to antipyretics. The health care provider prescribes that the client be placed on a hypothermia blanket. A response to hypothermia therapy that the nurse should prevent is:

Shivering Shivering should be prevented; peripheral vasoconstriction increases the temperature, the circulatory rate, and oxygen consumption. Vomiting is not a response to hypothermia therapy. Dehydration is not a response to hypothermia therapy; presence of a fever can cause dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance. Hypotension is not a response to hypothermia therapy; hypotension can occur with dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance.

The client's heart monitor shows a regular rhythm made up of wide and bizarre looking QRS complexes and no P waves. The rate is 30 beats per minute. The nurse realizes that this rhythm emerges when the:

Sinoatrial (SA) and atrioventricular (AV) nodes fail to initiate an impulse. Idioventricular rhythm is an escape rhythm that is generated by the Purkinje fibers. This rhythm emerges only when the SA and AV nodes fail to initiate an impulse. The Purkinje fibers are capable of an intrinsic rate of 20 to 40 beats per minute. Because this last pacemaker is located in the ventricles, the QRS complex appears wide and bizarre with a slow rate. No P waves are present.

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to avoid the potential danger of inducing ventricular fibrillation during cardioversion?

Synchronizer switch is in the "on" position. The precordial shock during cardioversion must not be delivered on the T wave, or ventricular fibrillation may ensue. By placing the synchronizer in the "on" position, the machine is preset so that it will not deliver the shock on the T wave. The energy level may be set from 50 to 100 W/sec. Skin electrodes applied after the T wave and an alarm system of the cardiac monitor functioning simultaneously will not ensure that the shock is not delivered on the T wave.

A client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital. What should the nurse expect to identify when completing the admission assessment?

Tender mass in the left upper abdomen Splenomegaly usually accompanies chronic myelogenous leukemia; the spleen usually is gross, palpable, and tender and necessitates removal. The spleen is located high in the abdomen on the left side and usually is not palpable unless it is enlarged. The urinary output is not affected with these conditions. With leukemia and splenomegaly there is increased destruction of blood cells; the erythrocyte count will be low. Polydipsia, increased appetite, and urinary frequency are not associated with leukemia or splenomegaly, but rather diabetes.

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client two days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of:

Tissue necrosis The body's inflammatory response to myocardial necrosis causes an elevation of temperature as well as leukocytosis within 24 to 48 hours after the event. Venous thrombosis is not an expected finding after a myocardial infarction. Pulmonary infarction is not an expected finding after a myocardial infarction. Respiratory infection is not common after myocardial infarction.

Cardioversion is attempted for a 64-year-old man with atrial flutter and a rapid ventricular response. After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately?

Turn the synchronizer switch to the "off" position and recharge the device. Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation. Fluids, additional assessment, or treatment of pain alone will not restore an effective heart rhythm.

A nurse is teaching a health class to older adult women about heart disease. The nurse discusses the most common prodromal symptom reported by women with acute coronary heart disease that usually is not experienced by men. What response indicates that a woman understood the teaching?

Unusual fatigue Studies indicate that women who had myocardial infarctions frequently experienced unusual prodromal fatigue; also, during the prodromal period, women more frequently experience upper abdominal fullness instigated by exertion or emotional stress. Substernal pressure that radiates to the neck is experienced more often by men than by women during the acute period of a myocardial infarction. Although women do experience the other symptoms, they do not occur as frequently as fatigue.

A client who had a coronary artery bypass graft six months ago is being discharged after a recent hospitalization for an exacerbation of emphysema. What should the nurse teach the client?

Wear a scarf or mask over the mouth in cold weather. Wearing a scarf or mask over the mouth in cold weather helps to warm the air, thereby preventing bronchospasm. Taking one aspirin every other day requires a health care provider's prescription and is used to prevent clotting; it does not influence the respiratory tract. Drinking a cup of warm tea before going to bed at night is not recommended unless it is decaffeinated; tea contains caffeine, a stimulant, which may interfere with sleep. Bronchodilators cause gastrointestinal irritation and should not be taken on an empty stomach.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

Weight & Smoking Obesity is a modifiable risk factor that is associated with coronary artery disease (CAD); an increased fat intake contributes to an increased serum cholesterol and atherosclerosis. Smoking, which constricts the blood vessels, is a modifiable risk factor for CAD. Family history is not a modifiable risk factor for CAD because one cannot control heredity. The incidence of CAD does increase with age. However, age is not a modifiable risk factor. Height is unrelated to the incidence of CAD.

The nurse performs discharge teaching for a 74-year-old woman with an implantable cardioverter-defibrillator. Which statement by the patient indicates to the nurse that further teaching is needed?

"I can expect redness and swelling of the incision site for a few days." Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care provider immediately. Teach the patient to inform airport security of presence of ICD because it may set off the metal detector. If hand-held screening wand is used, it should not be placed directly over the ICD. Teach the patient to avoid standing near antitheft devices in doorways of stores and public buildings, and to walk through them at a normal pace. Caregivers should learn cardiopulmonary resuscitation (CPR).

At a clinic visit, the nurse provides dietary teaching for a 56-year-old woman who was recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement?

"I will limit the amount of milk and cheese in my diet." Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.

A nurse teaches a client with varicose veins about prevention of a thromboembolus. Which statement regarding preventive measures indicates that the client requires further teaching?

"I will massage my legs twice a day." Massaging the legs twice a day is unsafe if a thrombus is present because it may dislodge and cause an embolus. Fluids decrease blood viscosity, reducing the risk for thrombus formation. Elastic stockings physically compress veins, preventing venous stasis and lowering the risk for thrombus formation. Range-of-motion exercises prevent venous stasis and promote muscle tone; they propel venous blood toward the heart, facilitated by venous one-way valves.

A 50-year-old man who develops third-degree heart block reports feeling chest pressure and shortness of breath. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing?

"The device delivers a current through your skin that can be uncomfortable." Before initiating transcutaneous pacing (TCP) therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable. Pacing for complete heart block will not convert the heart rhythm to normal. Overdrive pacing is used for very fast heart rates. Transcutaneous pacing is delivered through pacing pads adhered to the skin.

A70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate?

"The medication prevents blood clots from forming in your heart." Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

Four near-drowning victims are admitted to the emergency department. The nurse determines that which victim is at greatest risk for hypovolemia?

50-year-old rescued from the ocean The high osmotic pressure of the salt water draws fluid from the vascular space into the alveoli, causing hypovolemia. This involves aspiration of hypotonic freshwater, which causes fluid to move into the vascular system, leading to fluid overload. A lake, bathtub, and backyard pool don't use salt water, so there is less risk.

Where should the nurse expect the first heart sound (S1) to be the loudest when auscultating a client's heart?

Apex of the heart is produced by closure of the mitral and tricuspid valves; it is best heard at the apex of the heart. The base of the heart is where the second heart sound (S2) is best heard; S2 is produced by closure of the aortic and pulmonic valves. Left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. Right lateral border covers a large area; the only auscultatory area near it is the aortic area.

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client?

Apply elastic stockings before arising. Applying stockings while the legs are horizontal before arising ensures that stockings are in place before dependent edema occurs. The nurse legally cannot recommend medications. Warm soaks resolve inflammation; they do not prevent development of thrombophlebitis. Although helpful, following the prescribed exercise program will not provide continuous support for the veins, which is necessary.

A health care provider prescribes ophthalmic drops for a client. What should a nurse include in the instructions for a client learning to self-administer eye drops?

Apply pressure to the nasolacrimal duct after instillation. Applying pressure prevents absorption into the duct, which may lead to systemic effects. Lying on the unaffected side is indicated for ear drops. Tilting the head back and looking up facilitate the instillation of eye drops. Eye drops should be instilled into the conjuctival sac, not on the pupil. Closing the eyes tightly will force drops out of the eye.

What is the priority nursing action when caring for a client with disseminated intravascular coagulation?

Avoid giving intramuscular injections. Massive amounts of clots formed in the microcirculation deplete platelets and clotting factors, leading to bleeding; the trauma of an injection may cause excessive bleeding. Monitoring for Homan sign is associated with thrombophlebitis. Taking temperatures via the rectal route could be traumatic and precipitate bleeding. Applying sequential compression stockings is done to prevent thrombophlebitis.

A nurse is providing discharge instructions about digoxin (Lanoxin). Which response should a nurse include as a reason for a client to withhold the digoxin?

Blurred vision Visual disturbances, such as blurred or yellow vision, may be evidence of digoxin toxicity. Chest pain is not a toxic effect of digoxin. Persistent hiccups (singultus) are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin toxicity; it may be a sign of a therapeutic response to the drug, an improved cardiac output.

A client had a pneumonectomy. For which postoperative complication that is specific to this type of surgery should the nurse assess this client?

Cardiac overload Cardiac overload can be caused by the loss of the large vascular lung or a mediastinal shift. A brain attack is not unique to a pneumonectomy. Renal failure is not unique to a pneumonectomy. Internal bleeding is not unique to a pneumonectomy.

A client who is to have sclerotherapy asks the nurse, "How did I get varicose veins?" What etiology should the nurse take into consideration when formulating a response?

Defective valves within the veins Varicose veins are dilated veins that occur as a result of incompetent valves. Varicosities may result from heredity factors, prolonged standing (which puts strain on the valves), and abdominal pressure on the large veins of the lower abdomen as occurs during pregnancy. Prolonged standing increases pressure on the valves within the veins. Compression of leg muscles on the veins limits venous pooling. Varicose veins increase the risk for thrombophlebitis; thrombophlebitis does not cause varicose veins.

A nurse is caring for a client with a history of hypertension who was admitted to the hospital with aphasia. A bruit is heard over the left carotid artery, and the pulse is irregular. What is a reason for the aphasia that the nurse should consider?

Emboli associated with atrial fibrillation Emboli, which may occur from atrial fibrillation, cause complete occlusion of vessels; usually, middle cerebral arteries are involved. The infarct may cause hemiplegia, aphasia, or spatial perceptual deficits. Hypertension is a disease that may cause spasm of the arteries but does not cause anatomic occlusion. Developmental defects in the arterial wall are associated with saccular aneurysms. Seizures, not aphasia, are caused by inappropriate paroxysmal discharge.

A client comes to the clinic for a physical and asks to be tested for acquired immunodeficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for HIV?

Enzyme-linked immunosorbent assay (ELISA) The ELISA is the first screening test done to detect serum antibodies that bind to human immunodeficiency virus (HIV) antigens on test plates. The CD4 T cell count is not a screening test; it is done to monitor the progression of HIV infection and response to treatment. The Western blot test is not done first; the Western blot is done to validate repeatedly reactive ELISA results. The polymerase chain reaction test is not an initial screening test; it is done when there are consistently inconclusive test results with previous screening tests.

Which action should the nurse take first when a client's gravity flow IV rate is too slow?

Evaluate the appearance of the catheter insertion site. If infiltration or phlebitis is responsible for the decreased flow rate, the IV catheter must be removed and restarted in a new site. Repositioning the client's arm will do nothing if the catheter is not in a vein; this is not the priority. If the catheter is not in a vein, this action will be unsafe because fluid will enter interstitial tissues. Although determining the amount of fluid that should have been absorbed eventually will be done, this intervention will not resolve the cause of the problem; this is not the priority.

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?

Pulse of 64 beats/min A pulse of 64 beats/min is acceptable when the client is receiving digoxin; digoxin lengthens the atrioventricular conduction time, which slows the heart rate; toxicity may be present if the heart rate drops to less than 60 beats/min. Nausea is a symptom of toxicity; nausea and vomiting can occur because of gastric irritation and its action at central nervous system sites. Yellow vision is a symptom of toxicity; xanthopsia (yellow vision) is caused by digoxin's effect on visual cones. An irregular pulse is a sign of toxicity; premature nodal or ventricular impulses and varying degrees of heart block can occur because of slowed transmission of impulses through the atrioventricular node.

A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data?

Failure to stimulate the heart If pacemaker spikes are present, the pacemaker is firing appropriately but the lack of resulting QRS complexes indicates that it is not stimulating or "capturing" the heart. Loss of battery power is indicated by a slowing or irregular heart rate. Each pacemaker spike should be followed by a QRS complex. A fixed or asynchronous pacemaker is designed to work independently of the client's intrinsic rhythm.

When auscultating a client's heart, the nurse understands that the first heart sound is produced by the closure of the:

Mitral and tricuspid valves Closure of the atrioventricular valves, the mitral and tricuspid, produces the first heart sound (S1). Aortic and tricuspid valves and mitral and pulmonic valves do not close simultaneously. Aortic and pulmonic valves are the semilunar valves; closure of these valves produces the

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment?

Pulsating abdominal mass As the heart contracts, an expanding midline mass can be palpated to the left of the umbilicus. Signs of shock are not definitive for an abdominal aortic aneurysm unless the aneurysm ruptures. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not definitive for an abdominal aortic aneurysm.

The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS, then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the provider that the client's rhythm is a:

Second degree AV block Mobitz I (Wenckebach). Also called Mobitz I or Wenckebach phenomenon, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. The nurse expects the client to describe the chest pain as:

Severe, intense Blockage of myocardial blood supply causes accumulation of unoxidized metabolites in the muscle; this affects nerve endings and causes severe, intense chest pain. Burning chest pain is not the type of pain associated with a myocardial infarction. Mild chest pain, radiating toward the abdomen, is not the type of pain associated with a myocardial infarction. Nitroglycerin relieves pain associated with angina, not pain associated with myocardial infarction.

During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client's rectum. What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client's bowel movements?

Slowing of the heart Disimpaction can cause vagal stimulation, which slows the heart. The vagus is the principal nerve of the parasympathetic portion of the autonomic nervous system, and its axon terminals release acetylcholine. The response of the viscera to acetylcholine varies, but in general the organ is in a relaxed state. Increased pulse rate is an action of the sympathetic nervous system (accelerator nerve) caused by the release of norepinephrine. Stimulation of the sympathetic nervous system dilates bronchioles in the lungs; the vagus nerve constricts them. There are parasympathetic fibers to the coronary blood vessels; sympathetic impulses dilate these vessels.

In addition to atrial fibrillation, what ventricular rhythm exhibited by a client does the nurse determine may be converted to a sinus rhythm by cardioversion?

Super ventricular tachycardia Cardioversion involves administration of precordial shock, which is synchronized with the R wave to interrupt the heart rate. It is used for atrial fibrillation, supraventricular tachycardia, and ventricular tachycardia with a pulse when pharmaceutical preparations fail. The heart is stopped by the electric stimulation, and it is hoped that the sinoatrial (SA) node will take over as pacemaker. Because there are no R waves, cardioversion should not be done. Premature ventricular complexes suggest an irritable myocardium and generally respond well to antidysrhythmic agents.

When performing a physical assessment, the nurse identifies bilateral varicose veins. What does the nurse expect the client to report about the legs?

Worsening ankle edema as the day progresses. When the legs are dependent, gravity and incompetent valves promote increased hydrostatic pressure in leg veins; as a result, fluid moves into the interstitial spaces. Clients report feeling an ache or heaviness in the legs, not burning sensations. Calf pain when the feet are dorsiflexed, which is referred to as Homan sign, most often is associated with thrombophlebitis. Increasing sensitivity of the legs to cold reflects inadequate arterial blood supply; arterial circulation is not affected by varicose veins.