cardiovascular
A client is being discharged to home following recovery from an anterior myocardial infarction with recurrent angina. The client will be taking diltiazem, isosorbide dinitrate, and nitroglycerin sublingually as needed, and the nurse reinforces information to the client about the medications. Which statement by the client indicates a need for further teaching about the medications? 1"I will store these medications in a cool place away from light. "2"All three of these medications will increase blood flow to my heart. "3"All three of these medications will help decrease the intensity of my chest pain. "4"I should notify my doctor immediately if I experience headaches with any of these medications."
correct answer: "4"I should notify my doctor immediately if I experience headaches with any of these medications." Rationale: Because of the vasodilating effects of nitrates, headache is a common side effect. Medical attention is not needed unless the headaches increase in severity or frequency. All three medications are nitrates, which improve myocardial circulation by dilating coronary arteries and collateral vessels, thus increasing blood flow to the heart. These medications are used to help prevent the frequency, intensity, and duration of anginal attacks. Nitrates should be stored in a cool place and in a dark container. Heat and light cause these medications to break down and lose their potency.
A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? 1Baked turkey 2Tomato soup 3Boiled shrimp 4Chicken gumbo
correct answer: 1.Baked turkey Rationale: Regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium.
The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? 1Tea 2Cola 3Coffee 4Lemonade
correct answer: 4Lemonade Rationale: A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.
The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? "1"This diet will help lower my blood pressure. "2"Fresh foods such as fruits and vegetables are high in sodium. "3"This diet is not a replacement for my antihypertensive medications. "4"The reason I need to lower my salt intake is to reduce fluid retention."
correct answer: "2"Fresh foods such as fruits and vegetables are high in sodium. Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Fresh foods such as fruits and vegetables are low in sodium.
The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement? 1"Smoking cessation is very important. "2"Moving to a warmer climate should help. "3"Sources of caffeine should be eliminated from the diet. "4"Taking nifedipine as prescribed will decrease vessel spasm."
correct answer: "2"Moving to a warmer climate should help. Rationale: Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.
The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? 1"Are you having any nausea? "2"Where is the pain located? "3"Are you allergic to any medications? "4"Do you have your nitroglycerin with you?"
correct answer: "2"Where is the pain located? Rationale: If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, precipitating factors, location, radiation, and quality. Although options 1, 3, and 4 may be components of the assessment, these would not be the initial assessment questions in this situation.
An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem? 1"Can you describe the pain to me? "2"Have you ever had this pain before? "3"Does the pain get worse when you breathe in? "4"Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"
correct answer: "3"Does the pain get worse when you breathe in? Rationale: Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Describing the pain, asking if it has occurred in the past, and rating the pain using a pain scale may or may not help determine the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.
The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1"I need to substitute eggs and milk for meat. "2"I will eliminate all cholesterol and fat from my diet. "3"I should routinely use polyunsaturated oils in my diet ."4"I need to seriously consider becoming a strict vegetarian."
correct answer: "3"I should routinely use polyunsaturated oils in my diet Rationale: The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hyperlipidemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
The nurse finds a client tensing while lying in bed staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!" Which is the nurse's best response? 1""Would you like a mild sedative to help you relax? "2"Oh, don't worry, the weather is supposed to be sunny and clear today. "3"Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works? "4"I can appreciate your concerns. Your family can stay with you tonight if you want them to."
correct answer: "3"Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works? Rationale: The nurse should initially respond to validate the client's concern and then should determine the client's knowledge level of the cardiac monitor. This gives the nurse an opportunity to do client education if necessary. Bringing in the family, friends, or chaplain as an alternate resource may provide the client with additional psychological support. Pharmacological interventions should be considered only if necessary. Minimizing the client's concern is a communication block.
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? "1"Herbal substances are not safe and should never be used "2"I will teach you how to take your blood pressure so that it can be monitored closely. "3"You will need to talk to your primary health care provider (PHCP) before using an herbal substance. "4"If you take an herbal substance, you will need to have your blood pressure checked frequently."
correct answer: "3"You will need to talk to your primary health care provider (PHCP) before using an herbal substance. Rationale: Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects, because the combination may lead to an excessive reaction or unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the PHCP.
A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? 1"I am considering cutting my workload. "2"I need to cut down on cigarette smoking. "3"I am so relieved that my heart is repaired. "4"I need to adhere to my dietary restrictions."
correct answer: "4"I need to adhere to my dietary restrictions." Rationale: Following the angioplasty, the client needs to be instructed about specific dietary restrictions that must be followed. Following the recommended dietary and lifestyle changes helps prevent further atherosclerosis. Abrupt closure of the artery can occur if the recommended dietary and lifestyle changes are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.
The nurse is giving discharge instructions to the client with varicose veins. The nurse realizes there is a need for further teaching when the client makes which statement? "I" need to watch my diet to lose weight. "2"I should put my elastic support hose on when I get up ."3"I want to start taking the herbal supplement, bilberry. "4"I need to sit as much as possible with my legs elevated."
correct answer: "4"I need to sit as much as possible with my legs elevated." Rationale: Treatment of varicose veins includes using elastic support hose, exercising the legs and feet periodically throughout the day, and elevating the legs whenever possible. Prolonged standing, sitting, or crossing the legs is to be avoided. Weight reduction is recommended for patients who are obese.
A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6°F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question would the nurse ask the client first? 1"Do you exercise regularly? "2"Would you consider losing weight? "3"Is there a history of diabetes mellitus in your family? "4"When was the last time you had your blood pressure checked?"
correct answer: "4"When was the last time you had your blood pressure checked?" Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.
The licensed practical nurse (LPN) in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The LPN immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply. 1Administering oxygen 2Inserting a Foley catheter 3Administering furosemide 4Administering morphine sulfate intravenously 5Transporting the client to the coronary care unit 6Placing the client in a low-Fowler's side-lying position
correct answer: 1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. During pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.
A client is scheduled for a dipyridamole thallium scan. The nurse would check to make sure that the client has not consumed which substance before the procedure? 1Caffeine 2Fatty meal 3Excess sugar 4Milk products
correct answer: 1.Caffeine Rationale: This test is an alternative to the exercise stress test. Dipyridamole dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine as well as aminophylline or theophylline forms of medication should be withheld. Aminophylline is the antagonist to dipyridamole.
A client is diagnosed with disseminated intravascular coagulopathy (DIC). The nurse would become concerned with which laboratory values? Select all that apply. 1Increased D-dimer 2Decreased hemoglobin 3Increased platelet count 4Decreased fibrinogen level 5Decreased prothrombin level
correct answer: 1.Increased D-dimer 2.Decreased hemoglobin 4.Decreased fibrinogen level Rationale: DIC laboratory studies will reveal a decreased hemoglobin and low platelet count. The prothrombin and activated partial thromboplastin times will be increased. The fibrinogen level is reduced, and the fibrin degradation products level is increased. The D-dimer result is elevated.
A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? 1Restricting the client's potassium intake 2Encouraging the client to rest after meals 3Administering the heparin with a 25-gauge needle 4Holding the digoxin for a heart rate less than 60 beats per minute
correct answer: 1.Restricting the client's potassium intake Rationale: Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. Restricting potassium makes the client more prone to digoxin toxicity. Digoxin should be held and the health care provider notified when the client's heart rate is less than 60 beats per minute unless otherwise prescribed. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged.
The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition? 1Shock 2Kidney dysfunction 3Respiratory insufficiency 4Increased intracranial pressure
correct answer: 1.Shock Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat and slightly elevating the head and shoulders. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, which is vital to the treatment of shock. The remaining conditions would not benefit from and in some cases would be worsened by this position.
A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse would check the client's medical history for which item? 1Smoking history 2Recent exposure to allergens 3History of recent insect bites 4Familial tendency toward peripheral vascular disease
correct answer: 1.Smoking history Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.
The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions would the nurse anticipate? Select all that apply. 1The client should be placed on a cardiac monitor. 2The PHCP massages the carotid artery for a full minute. 3The head should be turned toward the side to be massaged. 4Rhythm strips should be obtained before, during, and after the procedure.5Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.
correct answer: 1.The client should be placed on a cardiac monitor. Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. This eliminates option 3. The PHCP or cardiologist will massage only one carotid artery for a few seconds to determine whether a change in cardiac rhythm occurs. This eliminates option 2. The client needs to be on a cardiac monitor throughout the procedure, and rhythm strips should be obtained before, during, and after the procedure. Continue to monitor the client's cardiac rhythm as well as vital signs and level of consciousness.
A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure? 1Digoxin 2Warfarin 3Amiodarone 4Potassium chloride
correct answer: 1Digoxin Rationale: Digoxin strengthens the heartbeat and decreases the heart rate. It is used in the treatment of heart failure. Potassium chloride increases the potassium level. Although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. Warfarin and amiodarone do not treat heart failure.
The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse would implement which action? 1Review the intake and output records for the last 2 days. 2Prescribe daily weights starting on the following morning. 3Change the time of diuretic administration from morning to evening 4Request a sodium restriction of 1 g/day from the health care provider.
correct answer: 1Review the intake and output records for the last 2 days. Rationale: Edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg). To determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.
The nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. What are included in the discharge plan? Select all that apply. 1Smoking cessation 2Get a flue vaccination 3Avoid aspirin products 4Decrease protein in diet 5Limit activity in cold weather 6Check blood pressure and pulse
correct answer: 1Smoking cessation 2Get a flue vaccination 5Limit activity in cold weather 6Check blood pressure and pulse Rationale: Treatment of angina includes reducing modifiable risk factors (smoking, overweight and obesity, high blood pressure). Low-dose aspirin is prescribed as an anticoagulant to reduce the risk of a myocardial infarction. Activity in cold weather frequently triggers an angina attack. Diet should be low in fat and cholesterol. A flu vaccination will decrease the risk of infection.
The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? 1Surgical tourniquet 2Dry sterile dressings 3Incentive spirometer 4Over-the-bed trapeze
correct answer: 1Surgical tourniquet Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore, a surgical tourniquet needs to be readily available in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.
The nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which are characteristics of this illness? Select all that apply. 1The cough is harsh and metallic. 2Inspiratory stridor may be present. 3Symptoms usually worsen at night and are better during the day. 4Symptoms usually worsen during the day and are relieved during sleep. 5It is usually preceded by several days of upper respiratory infection symptoms.
correct answer: 1The cough is harsh and metallic. 2Inspiratory stridor may be present. 3Symptoms usually worsen at night and are better during the day. 5It is usually preceded by several days of upper respiratory infection symptoms. Rationale: Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. It is characterized by a sudden onset of a harsh, metallic cough; sore throat; and inspiratory stridor. Symptoms usually worsen at night and are better in the day.
A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition? 1Hypovolemia 2Acute kidney injury 3Glomerulonephritis 4Urinary tract infection
correct answer: 2.Acute kidney injury Rationale: The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.
A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse would take which action first? 1Check the client's vital signs. 2Assist the client to sit or lie down. 3Administer sublingual nitroglycerin. 4Apply nasal oxygen at a rate of 2 L/min.
correct answer: 2.Assist the client to sit or lie down. Rationale: Chest pain is caused by an imbalance between myocardial oxygen supply and demand. During episodes of pain, the nurse first limits the client's activity and assists the client to a position of comfort, checks the vital signs, administers oxygen and medication according to protocol, and obtains a 12-lead electrocardiogram.
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 1Strict bed rest for 24 hours 2Bathroom privileges and self-care activities 3Unrestricted activities because the client is monitored 4Unsupervised hallway ambulation with distances less than 200 feet
correct answer: 2.Bathroom privileges and self-care activities Rationale: Upon transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).
A client asks the nurse about metabolic syndrome and what it means. The teaching plan would include which characteristics that define metabolic syndrome? Select all that apply. 1The triglyceride level is not considered in the diagnosis of metabolic syndrome. 2Blood pressure is elevated with systolic values greater than 130 mm Hg and diastolic values greater than 85 mm Hg. 3Fasting blood glucose levels are greater than 200 mg/dL, or the client is taking medication for glucose control. 4The client has abdominal obesity with a waist greater than 40 inches in males and greater than 35 inches in females. 5High density lipoprotein (HDL) cholesterol is greater than 40 mg/dL for males or 50 mg/dL in females or on drug treatment.
correct answer: 2.Blood pressure is elevated with systolic values greater than 130 mm Hg and diastolic values greater than 85 mm Hg. 4.The client has abdominal obesity with a waist greater than 40 inches in males and greater than 35 inches in females. Rationale: Metabolic syndrome is a condition in which the client has metabolic factors that put the client at risk for developing diabetes type 2 and cardiovascular disease. Abdominal obesity with increased waist measurements (males greater than 40 inches, females greater than 35 inches) is part of the syndrome, as is elevated blood pressure with systolic elevation greater than 130 mm Hg and diastolic greater than 85 mm Hg. Blood glucose levels are greater than 100 mg/dL, not 200 mg/dL. Triglyceride levels are part of the metabolic syndrome, and levels greater than 150 mg/dL are part of the syndrome. High density lipoprotein (HDL) cholesterol is less than 40 mg/dL in males and 50 mg/dL in females in the syndrome. HDL is the good cholesterol and should be greater than 35 mg/dL.
A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse would do which action first? 1Call a code blue. 2Check the client status and lead placement. 3Call the primary health care provider (PHCP). 4Press the recorder button on the ECG console.
correct answer: 2.Check the client status and lead placement. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.
A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? 1Apples 2Cheese 3Oranges 4Skim milk
correct answer: 2.Cheese Rationale: Fruits, vegetables, and skim milk contain minimal amounts of fat. Cheese is high in fat.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally? 1Rhonchi 2Crackles 3Wheezes Diminished breath sounds
correct answer: 2.Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.
An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? 1Angry 2Denial 3Phobic 4Obsessive-compulsive
correct answer: 2.Denial Rationale: Denial is the most common reaction when a client has a myocardial infarction or anginal pain. No angry behavior was identified in the question. Phobias and obsessive-compulsive disorders are mental health diagnoses.
The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? 1Pulsatile abdominal mass 2Hyperactive bowel sounds in the area 3Systolic bruit over the area of the mass 4Subjective sensation of "heart beating" in the abdomen
correct answer: 2.Hyperactive bowel sounds in the area Rationale: Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not specifically related to an abdominal aortic aneurysm.
The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1Limiting movement and abduction of the left arm 2Limiting movement and abduction of the right arm 3Assisting the client to get out of bed and ambulate with a walker 4Having the physical therapist do active range of motion to the right arm
correct answer: 2.Limiting movement and abduction of the right arm Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.
The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse would make which determination about the client's neurovascular status 1Moderately impaired, and the surgeon should be called 2Normal, caused by increased blood flow through the leg 3Slightly deteriorating and should be monitored for another hour 4Adequate from an arterial approach, but venous complications are arising
correct answer: 2.Normal, caused by increased blood flow through the leg Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.
The nurse is monitoring a client following cardioversion. Which observations would be of highest priority to the nurse? 1Blood pressure 2Status of airway 3Oxygen flow rate 4Level of consciousness
correct answer: 2.Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.
The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health? 1Knowledge of when it is safe to resume sexual activity 2The ability to take an accurate pulse in either the wrist or neck 3An understanding of the importance of proper microwave oven usage 4An understanding of why vigorous arm and shoulder movement must be avoided initially
correct answer: 2.The ability to take an accurate pulse in either the wrist or neck Rationale: Clients with permanent pacemakers must be able to accurately take their pulse in the wrist and/or neck. The client needs to identify any variation in the pulse rate or rhythm and immediately report the variation to the health care provider. Clients can safely operate microwave ovens, radios, electric blankets, lawn mowers, leaf blowers, and cars (proper grounding must be ensured if the client is to operate electrical items). Sexual activity is not resumed until 6 weeks after surgery. The arms and shoulders should not be moved vigorously for 6 weeks after insertion. The remaining options do not have the same impact on long-term cardiac health as does the correct option.
The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse would include which items on a list of suggestions to be given to the client? Select all that apply. 1Wear elastic stockings. 2Be careful not to injure the legs or feet. 3Use a heating pad on the legs to aid vasodilation. 4Walk each day to increase circulation to the legs. 5Cut down on the amount of fats consumed in the diet.
correct answer: 2Be careful not to injure the legs or feet. 4Walk each day to increase circulation to the legs. 5Cut down on the amount of fats consumed in the diet. Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.
The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse would perform which action? 1Suction the client vigorously. 2Place the client in high-Fowler's position. 3Begin assembling medications that are anticipated to be given. 4Call the respiratory therapy department to request a ventilator.
correct answer: 2Place the client in high-Fowler's position. Rationale: The client in pulmonary edema is placed in the high-Fowler's position if the blood pressure is adequate. Vigorous suctioning may deplete the client of vital oxygen at a time when the respiratory system is compromised. Assembling medications is useful but not critical to the immediate well-being of the client. The client may or may not need mechanical ventilation.
A client has an inoperable abdominal aortic aneurysm (AAA). Which measure would the nurse anticipate reinforcing when teaching the client? 1Bed rest 2Restricting fluids 3Antihypertensives 4Maintaining a low-fiber diet
correct answer: 3.Antihypertensives Rationale: The medical treatment for abdominal aortic aneurysm is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bed rest. A low-fiber diet is not helpful and will cause constipation.
The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition? 1Dyspnea 2Hacking cough 3Dependent edema 4Crackles on lung auscultation
correct answer: 3.Dependent edema Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.
A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a beta blocker, digoxin, and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which assessment data supports this diagnosis? 1Dyspnea, edema, and palpitations 2Chest pain, hypotension, and paresthesia 3Double vision, loss of appetite, and nausea 4Constipation, dry mouth, and sleep disorder
correct answer: 3.Double vision, loss of appetite, and nausea Rationale: Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence.
While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur? 1Lub-dub sounds 2Scratchy, leathery heart noise 3Gentle, blowing or swooshing noise 4Abrupt, high-pitched snapping noise
correct answer: 3.Gentle, blowing or swooshing noise Rationale: A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. It occurs from increased or abnormal blood flow through the valves of the heart. Lub-dub sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound that occurs with pericarditis. A click is described as an abrupt, high-pitched snapping sound.
The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? 1Having the client void before surgery 2Completing a preoperative checklist 3Marking the location of the pedal pulses on the right leg 4Checking the results of any baseline coagulation studies
correct answer: 3.Marking the location of the pedal pulses on the right leg Rationale: A problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.
A client has been diagnosed with Prinzmetal's angina. The nurse reviews the medical record and notes which accompanying characteristics? Select all that apply. 1Relieved by rest 2Occurs after exercise 3Prolonged severe pain 4Nitroglycerine relieves the pain 5Happens at the same time each day
correct answer: 3.Prolonged severe pain 5.Happens at the same time each day Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets.
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring? 1Pneumonia 2Pulmonary edema 3Pulmonary embolism 4Myocardial infarction
correct answer: 3.Pulmonary embolism Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.
A client is admitted to the hospital with possible rheumatic endocarditis. The nurse would check for a history of which type of infection? 1Viral infection 2Yeast infection 3Streptococcal infection 4Staphylococcal infection
correct answer: 3.Streptococcal infection Rationale: Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis. Options 1, 2, and 4 are incorrect.
A client has a prescription for niacin. The nurse determines that the client understands the importance of this therapy if the client verbalizes the importance of which periodic monitoring? 1The creatinine level 2Renal function studies 3The serum cholesterol level 4The blood urea nitrogen level
correct answer: 3.The serum cholesterol level Rationale: Niacin is used as adjunctive therapy in the management of hyperlipidemia. This is used in conjunction with a low-fat, low-cholesterol diet; exercise; and smoking cessation. Serum cholesterol and triglyceride levels are monitored periodically to assess the effectiveness of therapy. The laboratory studies in options 1, 2, and 4 assess renal function.
For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? 1Elevating the legs when in bed 2Sleeping in the supine position 3Using a bedside commode for stools 4Seasoning beef with a meat tenderizer
correct answer: 3.Using a bedside commode for stools Rationale: Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client's legs would increase venous return to the heart and result in an increase in cardiac workload. The supine position can increase respiratory effort and decrease oxygenation, which increases cardiac workload. Meat tenderizers are high in sodium. Sodium contributes to hypertension, which increases cardiac workload.
A client is diagnosed with thrombophlebitis. The nurse would tell the client that which prescription is indicated? 1Bed rest with bathroom privileges only 2Bed rest keeping the affected extremity flat 3Bed rest with elevation of the affected extremity 4Bed rest with the affected extremity in a dependent position
correct answer: 3Bed rest with elevation of the affected extremity Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated, and bed rest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. The positions in the remaining options are incorrect.
The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the primary health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? 1Mental status 2Urinary output 3Respirations and blood pressure 4Temperature and blood pressure
correct answer: 3Respirations and blood pressure Rationale: Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client who experienced an MI. Although monitoring mental status is a component of the nurse's assessment, it is not the priority following administration of morphine sulfate. The nurse should monitor the client's respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature is also not associated with the use of this medication.
A client is receiving supplemental therapy with folic acid. The nurse evaluates the effectiveness of this therapy by monitoring the results of which laboratory study? 1Blood glucose 2Blood urea nitrogen 3Alkaline phosphatase 4Complete blood count
correct answer: 4.Complete blood count Rationale: Folic acid is necessary for red blood cell production and is classified as a vitamin and an antianemic agent. The effectiveness of therapy can be measured by monitoring the results of periodic complete blood count levels, noting particularly the hematocrit level. Blood glucose, Blood urea nitrogen, and alkaline phosphatase are not associated with the use of this medication.
In order to assess the dorsalis pedis pulse of a client diagnosed with arterial vascular disease, the nurse palpates which anatomical location? Refer to figure. 1A 2B 3C 4D
correct answer: 4.D Rationale: The dorsalis pedis pulse is located on the dorsum (top) of the foot. The carotid artery is located in the neck region. The radial artery is located in the wrist. The posterior tibial artery is located at the medial aspect of the ankle.
The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? 1.Provide the client with a walker. 2.Remove the telemetry equipment 3.Encourage the client to cough and deep breathe. 4.Premedicate the client with an analgesic before ambulating.
correct answer: 4.Premedicate the client with an analgesic before ambulating. Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.
A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? 1Intake and output 2Height and weight 3Peripheral pulse rates 4Prior reaction to contrast media
correct answer: 4.Prior reaction to contrast media Rationale: This procedure requires a signed informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. Although intake and output, height and weight, and presence of peripheral pulses may be components of data collection, they are not the most critical items.
The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse would plan to maintain bed rest for this client in which position? 1High-Fowler's position 2Supine with no head elevation 3Left lateral (side-lying) position 4Supine with head elevation no greater than 30 degrees
correct answer: 4.Supine with head elevation no greater than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period to prevent arterial occlusion or bleeding and hematoma. With a femoral approach, the client's affected extremity is kept straight and the head elevated no more than 30 degrees (some cardiologists prefer a lower head position or the flat position) until hemostasis is adequately achieved. The client may turn from side to side. Bathroom privileges are not allowed during the immediate postcatheterization period. High-Fowler's (90-degree elevation), flat, and side lying on the puncture site are not effective in preventing complications or allowing for client comfort.
When preparing a client for a pericardiocentesis, in which position does the nurse place the client? 1Supine with slight lowering of the head 2Lying on the right side with a pillow under the head 3Lying on the left side with a pillow under the chest wall 4Supine with the head of bed elevated at a 45- to 60-degree angle
correct answer: 4.Supine with the head of bed elevated at a 45- to 60-degree angle Rationale: The client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60-degree angle. This places the heart in proximity to the chest wall for easier insertion of the needle into the pericardial sac. The remaining options are incorrect positions for this procedure.
A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. Which interpretation would the nurse make of these findings? 1The boot has not yet dried. 2The boot is controlling leg edema. 3The boot is impairing venous return. 4The boot has been applied too tightly.
correct answer: 4.The boot has been applied too tightly. Rationale: An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.
The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? 1Midsternum equal with the nipple line 2At the midaxillary line on the left side of the chest 3At the midline of the chest just below the xiphoid process 4At the midclavicular line at the fifth left intercostal space
correct answer: 4At the midclavicular line at the fifth left intercostal space Rationale: The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex.