Cardiovascular
Which statement indicates that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump? "This device increases how hard the heart has to work." "This device decreases the heart's need for oxygen." "This device helps stop life-threatening heart rhythms." "This device decreases the blood flow in the heart."
"This device decreases the heart's need for oxygen."
A nurse is caring for a client with pulmonary edema. The physician writes the accompanying orders. Which order should the nurse clarify? morphine I.V. 2 mg every 2 hours P.R.N. for shortness of breath 0.9% normal saline solution I.V. at 150 ml/hour furosemide I.V. 40 mg every 6 hours dobutamine 5 mcg/kg/minute I.V.
0.9% normal saline solution I.V. at 150 ml/hour
During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use? 2 mg I.M. 1 mg I.V. 2 mg I.V. 0.6 mg I.M.
1 mg I.V.
Which complication does a third heart sound (S3) indicate? increased atrial contractions ventricular dilation systemic hypertension aortic valve malfunction
ventricular dilation
A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to: keep a daily record of urine output. weigh daily. take blood pressure daily. have a serum potassium level drawn weekly.
weigh daily.
The nurse teaches the client with a demand pacemaker that the device functions by providing stimuli to the heart muscle: when the heart rate falls below a specified level. when the heart begins to beat irregularly. constantly, resulting in a predetermined heart rate. whenever ventricular fibrillation occurs.
when the heart rate falls below a specified level.
A health care provider (HCP) prescribes 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in how many minutes? 30 minutes 10 minutes 20 minutes 5 minutes
20 minutes
Furosemide 40 mg intravenous push is prescribed. Furosemide 10 mg/mL is available. How many mL should the nurse should administer? Record your answer using a whole number.
4
A nurse has found a client unconscious and not breathing. Arrange interventions in order of priority. All options must be used.
Activate emergency response system. Perform chest compressions at a rate of at least 100/minute. Provide 30 compressions. Perform head tilt-chin lift. Provide two ventilations.
A client has had a cardiac catheterization. The femoral dressing has a bright bloody drainage. What should the nurse do first? Assess the airway. Administer oxygen. Assess the pulse in the left extremity. Apply pressure to the site.
Apply pressure to the site.
A client is taking spironolactone. Which change in the diet should the nurse teach the client to make when taking this drug? Restrict sodium intake. Avoid eating foods high in potassium. Maintain a fluid intake of 3,000 mL/day. Incorporate iron-rich foods into the diet.
Avoid eating foods high in potassium.
A client on telemetry reports that they have been having chest pain. The hospital unit has standing orders that allow the nurse to begin treating the client before notifying the physician. Place the following nursing actions in proper chronological order. Use all options.
Check vital signs, particularly blood pressure. Administer sublingual nitroglycerin. Evaluate the effectiveness of the treatment given. Document the effectiveness of the treatment given. Report findings to the physician.
What is the major goal of nursing care for a client with heart failure and pulmonary edema? Decrease peripheral edema. Increase cardiac output. Improve respiratory status. Enhance comfort.
Increase cardiac output.
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first? Increase the oxygen flow rate from 2 to 4 L/min. Call the health care provider (HCP) immediately. Obtain a sample for arterial blood gas analysis. Provide reassurance to the client.
Increase the oxygen flow rate from 2 to 4 L/min.
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs? Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase aldosterone secretion. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to reduce secretion of aldosterone and antidiuretic hormone. Low blood pressure triggers the baroreceptors to decrease sympathetic nervous system stimulation.
Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.
A nurse is assessing a client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. After determining that other vital signs are normal, what should the nurse do first? Notify the health care provider (HCP). Call the rapid response team. Elevate the head of the bed. Administer pain medication.
Notify the health care provider (HCP).
The nurse walks into the room and finds that a client who has just had surgery is diaphoretic, appears to have no respirations, and has a barely palpable pulse. What should the nurse do first? Start rescue breathing. Open the airway. Start cardiac compressions. Activate emergency response system.
Open the airway.
The client has had hypertension for 20 years. The nurse should assess the client for? Renal insufficiency and failure. Valvular heart disease. Endocarditis. Peptic ulcer disease.
Renal insufficiency and failure.
When the nurse is obtaining a health history from an older adult, which information in the history is a risk factor associated with deep vein thrombosis (DVT)? The client walks 30 minutes every day. The client wears support stockings. The client recently had abdominal surgery. The client lives alone.
The client recently had abdominal surgery.
A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? The fine ventricular fibrillation changes to coarse ventricular fibrillation. The ventricular rate is increasing. The number of premature ventricular contractions is decreasing. The absent pulse is now palpable.
The number of premature ventricular contractions is decreasing.
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? Administer the medication as prescribed. Assess the client for signs of bruising on the extremities. Withhold the dose of the medication and contact the HCP. Contact the pharmacist for a lower dose of the medication.
Withhold the dose of the medication and contact the HCP.
The nurse is administering adenosine to a client with supraventricular tachycardia. What is the expected therapeutic response? an increase in blood pressure A brief feeling of numbness and tingling of extremities a short period of asystole a brief episode of ventricular tachycardia
a short period of asystole
Which assessment finding supports the administration of protamine sulfate? INR 8 aPTT 3.5-5 times normal RBCs of 5.4 million/mm3 platelets of 152
aPTT 3.5-5 times normal
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an antibiotic. antihypertensive. anticonvulsant. anticoagulant.
anticoagulant.
A client has been diagnosed with atrial fibrillation. The health care provider prescribed warfarin to be taken on a daily basis. The nurse instructs the client to avoid using which over-the-counter medication while taking warfarin? digoxin diphenhydramine aspirin pseudoephedrine
aspirin
A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority intervention at this time? delivering a precordial thump assessing the client defibrillating the client calling the resuscitation team
assessing the client
A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? monitoring the white blood cell count monitoring the platelet count assessing troponin 1 levels assessing B-type natriuretic peptide levels
assessing troponin 1 levels
Which condition most commonly results in coronary artery disease (CAD)? atherosclerosis myocardial infarction renal failure diabetes mellitus
atherosclerosis
The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The client has understood the instruction when the client identifies which potential complications? Select all that apply. weight loss of 2 lb (0.9 kg) in 1 day weight gain of 2 lb (0.9 kg) or more in 1 day having to sleep sitting up in a reclining chair becoming increasingly short of breath at rest high intake of sodium for breakfast
becoming increasingly short of breath at rest weight gain of 2 lb (0.9 kg) or more in 1 day having to sleep sitting up in a reclining chair
The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? blood pressure blood pressure pulse rate oxygen saturation respiratory rate
blood pressure
A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? respiration 26 breaths/minute pulse rate of 84 beats/minute blood pressure 84/52 mm Hg temperature of 100.2° F (37.9° C)
blood pressure 84/52 mm Hg
In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to sudden vascular fluid shifting. postural hypotension. vestibular dysfunction. bradyarrhythmia.
bradyarrhythmia.
A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity? protein carbohydrate fat water
carbohydrate
A client has atrial fibrillation. The nurse should monitor the client for which condition? ventricular fibrillation cerebrovascular accident cardiac arrest heart block
cerebrovascular accident
Metoprolol is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension who has been initially treated with furosemide and ramipril. The nurse should evaluate the client for which expected therapeutic effect? increase in urine output. improvement in blood sugar levels. decrease in heart rate. lessening of fatigue.
decrease in heart rate.
The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? metoprolol furosemide dopamine enalapril
dopamine
The nurse should assess the client with left-sided heart failure for which findings? Select all that apply. crackles right upper quadrant pain decreased oxygen saturation levels jugular vein distention (JVD) dyspnea oliguria
dyspnea crackles oliguria decreased oxygen saturation levels
A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? elevated ST segment prolonged PR interval absent Q wave widened QRS complex
elevated ST segment
A nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first assess the client for a carotid pulse. open the airway. call for help. establish unresponsiveness.
establish unresponsiveness.
The nurse obtains a pulse rate of 116 beats/min (bpm) before administering digoxin to a client with heart failure who has been receiving digoxin for 2 weeks. The nurse should: assess the client's respiratory rate. evaluate the client's cardiac rhythm. withhold the digoxin and take the pulse again in 15 minutes. administer the digoxin.
evaluate the client's cardiac rhythm.
A physician orders esmolol for a client with supraventricular tachycardia. During esmolol therapy, the nurse should monitor the client's:
heart rate and blood pressure.
In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload? hemorrhage, sepsis, and anaphylaxis fluid overload, sepsis, and vasodilation myocardial infarction, fluid overload, and diuresis third spacing, heart failure, and diuresis
hemorrhage, sepsis, and anaphylaxis
The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance? hyperkalemia hypermagnesemia hyponatremia hypocalcemia
hyperkalemia
The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse? scheduling a pacemaker insertion insertion of an I.V. line immediate defibrillation administration of digoxin
immediate defibrillation
A nurse knows that the major clinical use of dobutamine is to treat hypotension. prevent sinus bradycardia. treat hypertension. increase cardiac output.
increase cardiac output.
What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? cardiac pacemaker defibrillator intra-aortic balloon pump hypothermia-hyperthermia machine
intra-aortic balloon pump
A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about: left end-diastolic pressure. cardiac output. cardiac index. right atrial blood flow.
left end-diastolic pressure.
Indicate on the illustration where the nurse would place the other electrode of the automated external defibrillator on a victim who has collapsed and does not have a pulse.
left subclavian
The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention? restricting fluid intake elevating the feet low-sodium diet walking for 20 minutes three times a week
low-sodium diet
A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. What should the nurse include in the plan of care for this client?
monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (PT/INR)
The nurse is assessing the neurovascular status of a client's right arm, which has just had a cast applied. The nurse should notify the health care provider when which symptom occurs? no pain on passive movement of the fingers. nail bed capillary refill time of 10 seconds slight swelling of the fingers localized pain in the right arm
nail bed capillary refill time of 10 seconds
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? calcium potassium platelet count white blood cell (WBC) count
potassium
A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? magnesium level of 2.5 mg/dl (0.1 mmol/L) sodium level of 152 mEq/L (152 mmol/L) calcium level of 7.5 mg/dl (0.4 mmol/L) potassium level of 3.1 mEq/L (3.1 mmol/L)
potassium level of 3.1 mEq/L (3.1 mmol/L)
A client with acute chest pain is receiving I.V. morphine sulfate. Which is an expected effect of morphine? Select all that apply. prevents ventricular remodeling reduces blood pressure and heart rate reduces anxiety and fear reduces myocardial oxygen consumption promotes reduction in respiratory rate
reduces myocardial oxygen consumption reduces blood pressure and heart rate reduces anxiety and fea
A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? medullary sponge kidney croup severe staphylococcal infection rheumatic fever
rheumatic fever
Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication? rib fracture emesis gastrointestinal bleeding myocardial infarction
rib fracture
A nurse is preparing a staff education program on innovative devices in pulmonary circulation. Beginning with basic concepts, place the following structures in chronological order to trace the pathway of normal pulmonary circulation. All options must be used.
right ventricle pulmonary artery arterioles alveoli pulmonary vein left atrium
The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used.
Position electrodes on the chest. Take vital signs. Administer the prescribed dose of morphine. Obtain a history of which drugs the client has used recently
A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking? carvedilol amiodarone procainamide diltiazem hydrochloride
carvedilol
Which signs and symptoms would the nurse expect in a client with angina? Select all that apply. chest pressure bradycardia jaw pain chest tightness slowed respiratory rate general muscle aching
chest tightness chest pressure jaw pain
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? confusion, urine output 15 mL over the last 2 hours, orthopnea blood pressure 110/62 mm Hg, atrial fibrillation with heart rate 82, bilateral basilar crackles SpO2 92% on 2 L nasal cannula, respirations 20 breaths/min, 1+ edema of lower extremities weight gain of 1 kg in 3 days, blood pressure 130/80 mm Hg, mild dyspnea with exercise
confusion, urine output 15 mL over the last 2 hours, orthopnea
What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine? "Morphine decreases blood pressure and increases your heart's ability to stretch." "Morphine increases your heart's ability to stretch and squeeze and decreases pain." "Morphine decreases the heart's need for oxygen and also makes your heart not work as hard." "Morphine is a medication that is commonly administered for pain control."
"Morphine decreases the heart's need for oxygen and also makes your heart not work as hard."
A client diagnosed concurrently with myocardial infarction and atrial fibrillation is prescribed rivaroxaban and asks the nurse the purpose of this medication. How should the nurse respond? "This medication prevents clots which reduces your risk of another heart attack." "This medication is a blood thinner which will make it easier to move blood through your arteries." "Rivaroxaban can reduce your risk for stroke related to having atrial fibrillation." "Rivaroxaban is an oral anticoagulant medication used to prevent your blood from clotting." SUBMIT ANSWER
"Rivaroxaban can reduce your risk for stroke related to having atrial fibrillation."
A client, hospitalized with heart failure, is receiving digoxin and furosemide intravenously and now has continuous ringing in the ears. What is the appropriate action for the nurse to take at this time? Obtain a digoxin level to check for toxicity. Ask the client about taking aspirin in addition to other medications. Discontinue the furosemide and notify the health care provider (HCP). Note the observation in the medical record and plan to reassess in 2 hours.
Discontinue the furosemide and notify the health care provider (HCP).
Following a coronary artery bypass graft (CABG), a client reports chest "fullness," anxiety, and dizziness. Vital signs are pulse 108, respirations 24, and blood pressure 94/62mmHg on inhalation, and 108/70mmHg on expiration. The nurse prints a lead II electrocardiogram (ECG) strip for interpretation and identifies an amplitude decrease in the QRS complex. What intervention would have the highest priority? Increase oxygen delivery to 3L by nasal cannula. Administer morphine sulfate 2mg intravenous push (I.V.P.). Prepare the client for emergency pericardiocentesis. Place the client in Trendelenburg position.
Prepare the client for emergency pericardiocentesis.
A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply. Administer nitroglycerin. Administer acetaminophen Administer morphine. Insert a Foley catheter. Administer aspirin. Provide oxygen.
Provide oxygen. Administer nitroglycerin. Administer aspirin. Administer morphine
A nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation. Why is this check so important? The shock must be synchronized with the client's T wave. The defibrillator will not deliver a shock if the synchronizer switch is turned on. The defibrillator will not deliver a shock if the shock delivery is set at 400. The delivered shock must be synchronized with the client's QRS complex.
The defibrillator will not deliver a shock if the synchronizer switch is turned on.
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which are expected findings on assessment? Select all that apply. vasoconstriction in skin, GI tract, and kidneys increased heart rate fluid overload decreased cardiac output decreased pulmonary perfusion SUBMIT ANSWER
decreased cardiac output increased heart rate vasoconstriction in skin, GI tract, and kidneys fluid overload
A nurse is awaiting the arrival of a client from the emergency department with a diagnosis of anterior wall myocardial infarction. In caring for this client, the nurse would be alert for which signs and symptoms of left-sided heart failure? Select all that apply. crackles dyspnea jugular vein distention skin tenting hepatomegaly tachycardia
dyspnea crackles tachycardia
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? "My feet are bigger than normal." "I sleep on three pillows each night." "My pants don't fit around my waist." "I don't have the same appetite I used to." SUBMIT ANSWER
"I sleep on three pillows each night."
A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the client is admitted to the coronary care unit? Evaluate the client's pain. Begin telemetry monitoring. Auscultate heart sounds. Obtain a health history.
Begin telemetry monitoring.
A nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The blood pressure is 80/50 mm Hg and the client reports dizziness. What is the nurse's priority action? Notify the attending physician. Administer atropine 0.5 mg I.V. push as ordered. Administer a 500 ml I.V. bolus of normal saline solution (0.9% NaCl). Administer lidocaine 100 mg I.V. push as ordered.
Administer atropine 0.5 mg I.V. push as ordered.
A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority? A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. A client's monitor shows sinus tachycardia with frequent premature atrial contractions (PACs). A client's monitor shows frequent paced beats with capture. A client's cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions.
A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation.
A client with chest pain is prescribed intravenous nitroglycerin. Which finding is of greatest concern for the nurse initiating the nitroglycerin drip? ST elevation is present on the electrocardiogram. Serum potassium is 3.5 mEq/L (3.5 mmol/L). Heart rate is 61 bpm. Blood pressure is 88/46 mm Hg.
Blood pressure is 88/46 mm Hg.
A nurse notes that the client's PR interval is .17 and the QRS complex is .10. What action should the nurse take next? Document the findings. Give 2 liters of oxygen via nasal cannula. Administer the ordered nitroglycerin paste. Request a 12-lead electrocardiogram.
Document the findings.
A client is admitted with shortness of breath, a brain natriuretic peptide (BNP) level of 615 pg/mL, and pedal edema. Which actions should the nurse take next? Select all that apply. Raise the feet on pillows. Schedule an exercise stress test. Give oxygen by mask. Increase dietary calcium. Initiate I.V. diuretic therapy.
Initiate I.V. diuretic therapy. Give oxygen by mask.
The nurse is developing a discharge teaching plan for a client who had a graft insertion for an abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. See the chart. Based on the data and expected outcomes, which area should the nurse emphasize in the teaching plan? food intake tissue perfusion skin integrity fluid volume
tissue perfusion
The nurse evaluates the client's understanding of nutritional modifications to manage hypertension. The nurse knows the teaching was successful when the client makes what statement? "I should eliminate caffeine from my diet to lower my blood pressure." "A glass of red wine each day will lower my blood pressure." "If I include less fat in my diet, I'll lower my blood pressure." "Limiting my salt intake to 2 grams per day will lower my blood pressure."
"Limiting my salt intake to 2 grams per day will lower my blood pressure."
A newly admitted client reports taking digoxin and warfarin. Which statement would the nurse include in the discharge instructions? "Limit foods high in potassium, such as bananas." "Notify your healthcare provider if you experiences visual changes." "Increase your calorie intake if your appetite decreases." "Report your morning and afternoon heart rates to your healthcare provider."
"Notify your healthcare provider if you experiences visual changes."
A client prescribed enalapril reports symptoms of a persistent dry cough. What is the nurse's best action? Administer dextromethorphan. Assess the client's oxygenation status. Review medication administration with the client. Notify the health care provider.
Notify the health care provider. SUBMIT ANSWER
The nurse is reviewing the electrocardiogram of a client who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best action? Determine whether the rhythm is irregular, coinciding with inspiration and expiration. Notify the healthcare provider. Teach the client about risks for coronary artery disease. Document the finding in the medical record.
Notify the healthcare provider.
The nurse is caring for a client with a third heart sound. Which action is indicated? Observe for sluggish skin turgor. Assess the client's lungs for crackles. Place the client on a cardiac monitor. Place the client flat in bed.
Assess the client's lungs for crackles.
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first? Administer a bolus of lidocaine. Call the health care provider (HCP). Activate the rapid response team. Assess the client's orientation and vital signs.
Assess the client's orientation and vital signs.
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? Monitor the laboratory values. Observe the puncture site for swelling and bleeding. Observe neurologic function every 15 minutes. Monitor skin warmth and turgor.
Observe the puncture site for swelling and bleeding.
A client in the intensive care unit has an arterial line that reads 58/30 mm Hg on the monitor. What is the nurse's first action? Place the client in the Trendelenburg position. Flush the catheter. Recalibrate the arterial line. Obtain a manual blood pressure.
Obtain a manual blood pressure.
A nurse is preparing a client for cardiac catheterization. The nurse must provide which nursing intervention immediately when the client returns to their room after the procedure? Force fluids for 6 hours after the procedure. Apply ice to the puncture site for 12 hours post procedure. Assess the puncture site frequently for hematoma formation or bleeding. Administer the prescribed analgesia.
Assess the puncture site frequently for hematoma formation or bleeding.
A client with heart failure has not slept for the past 3 nights because of dyspnea. Arterial blood gas (ABG) analysis reveals pH, 7.32; PaO2, 79 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 29 mEq/L. What is the priority nursing intervention for this client? Ask whether the client has been taking furosemide as ordered. Establish venous access with an I.V. (intravenous) line. Apply oxygen via nasal cannula at 2 L/min. Elevate the head of the bed so it is easier for the client to breathe.
Apply oxygen via nasal cannula at 2 L/min.
When teaching the client with hypertension to avoid orthostatic hypotension, the nurse should provide which instructions? Select all that apply. Plan regular times for taking medications. Avoid excessive alcohol intake. Avoid standing still for long periods. Avoid hot baths. Arise slowly from bed.
Arise slowly from bed. Avoid standing still for long periods.
A middle-aged man collapses in the emergency department waiting room. What should the nurse do first? Watch the victim's chest for respirations. Ask the client to state his name. Perform the chin-tilt to open the victim's airway. Feel for any air movement from the victim's nose or mouth.
Ask the client to state his name.
The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? Assess respiratory status. Weigh the client. Draw blood for laboratory studies. Insert a Foley catheter.
Assess respiratory status.
A client presents with a heart rate of 30 beats/min. The nurse notes a pacemaker in the client's right upper chest wall. What is the nurse's priority action? Review the medical record to determine when the pacemaker was placed. Administer atropine. Assess the blood pressure. Assess capillary refill.
Assess the blood pressure.
The nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What action should the nurse take after realizing the mistake? Hold the next dose of digoxin. Assess the client and notify the physician. Give the prescribed 0.125 mg as soon as possible. No action is needed because of the small dose difference.
Assess the client and notify the physician.
A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take? Assess the client's airway, breathing, pulses, and level of conciseness. Defibrillate the client. Begin cardiopulmonary resuscitation (CPR). Apply the external pacemaker.
Assess the client's airway, breathing, pulses, and level of conciseness.
A client arrives at the emergency department with severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. Suddenly, the client collapses and becomes unresponsive. What is the priority action by the nurse? Activate the emergency response team. Maintain an open airway. Initiate ventilations before chest compressions. Initiate chest compressions before ventilations.
Initiate chest compressions before ventilations.
The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? Prothrombin time, 1.5 to 2.5 times the normal control. Thrombin clotting time, 10 to 15 seconds. Partial thromboplastin time, 1.5 to 2.5 times the normal control. International Normalized Ratio, 2 to 3 seconds.
Partial thromboplastin time, 1.5 to 2.5 times the normal control.
Upon assessment of third-degree heart block on the monitor, what should the nurse do first? Place transcutaneous pads on the client. Begin cardiopulmonary resuscitation (CPR). Prepare for defibrillation. Call a code.
Place transcutaneous pads on the client.
A client was transferring a load of fire wood from their front driveway to the backyard woodpile at 10 a.m. when the client experienced a heaviness in their chest and dyspnea. The client stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., the client's spouse took them to the emergency department. Around 2:30 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician? streptokinase, aspirin, and morphine administration sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry morphine administration, stress testing, and admission to the cardiac care unit serial liver enzyme testing, telemetry, and a lidocaine infusion
sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? Platelet count Partial thromboplastin time (PTT) Prothrombin time (PT) Bleeding time
Prothrombin time (PT)
The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just don't feel good." What actions should the nurse take? Select all that apply. Stay with and reassure the client. Make a quick check on other assigned clients before spending the time required to take care of this client. Confirm the client's vital signs and complete a quick assessment. Call the health care provider (HCP) and report the situation using SBAR format. Place the client in the semi-Fowler's position. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team.
Confirm the client's vital signs and complete a quick assessment. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. Place the client in the semi-Fowler's position. Stay with and reassure the client. Call the health care provider (HCP) and report the situation using SBAR format.
The nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing interventions should the nurse include in the care plan for the next 8 hours? Select all that apply. Check the dressing and access site for bleeding. Allow the client to sit upright for meals. Allow use of the bedside commode. Keep the extremity straight. Maintain pressure over the femoral access site. Monitor the vital signs every 4 hours.
Maintain pressure over the femoral access site. Check the dressing and access site for bleeding. Keep the extremity straight.
A client with hypertension visits the health clinic for a routine checkup. The nurse measures the client's blood pressure at 184/92 mm Hg and notes a 5-lb (2.3-kg) weight gain within the past month. Which nursing diagnosis reflects the most serious problem in managing a client with hypertension? Imbalanced nutrition: More than body requirements Noncompliance (nonadherence to therapeutic regimen) Excess fluid volume Deficient knowledge (disease process)
Noncompliance (nonadherence to therapeutic regimen)
A client is admitted to the telemetry unit with atrial fibrillation. What is the appropriate action of the nurse? Select all that apply. assess for changes in level of consciousness monitor for decreased deep tendon reflexes Apply sequential compression device administer warfarin Apply continuous cardiac monitoring
administer warfarin Apply sequential compression device Apply continuous cardiac monitoring assess for changes in level of consciousness
A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time? fear related to threat of death activity Intolerance related to decreased cardiac output ineffective tissue perfusion (cardiopulmonary) related to arrhythmia social isolation related to restricted visiting hours in the ICU
ineffective tissue perfusion (cardiopulmonary) related to arrhythmia
The nurse is assessing a client who has had a myocardial infarction. The nurse reviews the client's ECG strip (view the figure) and notices a premature ventricular contraction (PVC). Identify the PVC on this cardiac rhythm strip.
its obvious
After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first? the anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today the client with heart failure who is having some difficulty breathing the coronary bypass client asking for pain medication for "11 of 10" pain in the donor site the client admitted during the previous shift with new-onset controlled atrial fibrillation, who has a call light on
the client with heart failure who is having some difficulty breathing
Which signs and symptoms might a nurse observe in a client having an adverse reaction to a loop diuretic? Select all that apply. hyperactive bowel sounds irregular pulse weakness decreased muscle tone potassium level of 3.1 mEq/L ventricular arrhythmias
weakness irregular pulse decreased muscle tone potassium level of 3.1 mEq/L ventricular arrhythmias
