Cardiovascular & Cardio Med NCLEX book
A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?
Monitor for signs of bleeding.
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 should check the client's medical history for which item?
Smoking history
The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?
Status of airway
The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching?
"I will take enteric-coated aspirin for my headaches because it is coated."
The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (9.95 mmol/L). The client is taking cholestyramine. Which statement made by the client indicates the need for further teaching?
"I'll continue my nicotinic acid from the health food store."
A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?
"Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing."
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?
"Moving to a warmer climate should help."
Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level?
Activated partial thromboplastin time (aPTT) of 55 seconds
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?
Crackles
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?
Acute kidney injury
The nurse 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 nurse immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply.
Administering oxygen Inserting a Foley catheter Administering furosemide Administering morphine sulfate intravenously
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 should do which action first?
Check the client status and lead placement.
A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse take? Select all that apply.
Check the client's pain level. Check the client's blood pressure. Administer a second nitroglycerin, 0.4 mg, sublingually.
The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition?
Dependent edema
The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication?
Hypokalemia, hyperglycemia, sulfa allergy
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?
Limiting movement and abduction of the right arm
A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia?
Low blood glucose level
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 should make which determination about the client's neurovascular status?
Normal, caused by increased blood flow through the leg
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
Premedicate the client with an analgesic before ambulating.
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?
Pulmonary embolism
The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position?
Supine with head elevation no greater than 30 degrees
Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client?
Take the medication with food.
The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipate? Select all that apply.
The client should be placed on a cardiac monitor. Rhythm strips should be obtained before, during, and after the procedure. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.
The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication associated with propranolol?
The development of audible expiratory wheezes
A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? Select all that apply.
Visual disturbances Nausea and vomiting Serum digoxin level of 2.3 ng/mL (2.93 nmol/L)
