Cardiovascular ATI targeted 2016

A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?

"I can't get rid of these hiccups." Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation. "I feel dizzy when I stand." incorrect Dizziness is not a complication of the insertion procedure and is expected initially as the client adjusts to the pacemaker. "My incision site stings." Pain or stinging at the incision site is not a complication of the insertion procedure. However, the client should monitor the pacemaker insertion site for manifestations of infection. "I have a headache."Headache is not a complication of the insertion procedure. However, it might be related to other disease processes.

A nurse providing teaching for a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in teaching? -"You might no longer be able to feel chest pain." -"Your level of activity intolerance will not change." -"After 6 months, you will no longer need to restrict your sodium intake." -"You will be able to stop taking immunosuppressants after 12 months."

-You may no longer be able to feel chest pain. Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart. The client's activity tolerance should gradually improve as the healing process progresses. The client will need to permanently maintain a diet that is restricted in sodium and fat. The client will remain on immunosuppressants for the remainder of his life to help prevent rejection of the heart.

A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? 1. A client who has hypothyroidism 2. A client who has diabetes mellitus 3. A client whose daily caloric intake consists of 25% fat 4. A client who consumes two 12-oz bottles of beer a day

A client who has diabetes mellitus which places the client at risk for microvascular damage and progressive peripheral arterial disease. Hypothyroidism is not a risk factor for developing peripheral arterial disease. Twenty-five percent is within the recommended range for daily fat intake, and Two 12-oz bottles of beer a day is considered moderate alcohol intake diet does not place the client at risk for development of peripheral arterial disease.

A nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade?

Blood pressure 140/82 mm Hg on inspiration and 154/90 mm Hg on expiration

A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect? Confusion Friction rub Hypertension Dry skin

Confusion. Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status. hear a friction rub during cardiac auscultation on a client who has pericarditis. monitor a client who has a bradydysrhythmia for hypotension. monitor a client who has a bradydysrhythmia for diaphoresis.

A nurse is caring for a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? Hemoglobin 14 g/dL Minimal bruising of extremities Decreased blood pressure INR 2.5

INR 2.5 The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke. the followings are not evidence of effective warfarin therapy such as a hemoglobin level of 14 g/dL is within the expected reference range. minimal bruising or no bruising is desired. decreased blood pressure is a manifestation of bleeding, which is an adverse effect of warfarin.

A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse.

Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the APICAL pulse or point of maximal impulse. The point of maximal impulse is located at the LEFT FIFTH intercostal space in the midclavicular line.

A nurse is caring for a client who has dilated cardiomyopathy. The client reports increasing difficulty completing her daily 1-mile walks. The nurse should recognize that this is a finding of which of the following?

Left ventricular failure

A nurse caring for a client who is being treated for heart failure and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications? Shortness of breath Lightheadedness Dry cough Metallic taste

Lightheadedness Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness. Furosemide is used to manage shortness of breath secondary to heart failure. This is not an adverse reaction to this medication. The other two are not adverse reaction to furosemide.

A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? Apply the new patch to the same site as the previous patch. Place the patch on an area of skin away from skin folds and joints. Keep the patch on 24 hr per day. Replace the patch at the onset of angina.

Place the patch on an area of skin away from skin folds and joints. The client should apply the patch to an area of intact skin that has ENOUGH room for the patch to fit smoothly.

A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? Hemoglobin 14.4 g/dL History of peripheral arterial disease Urine output 200 mL/4 hr Previous allergic reaction to shellfish

Previous allergic reaction to shellfish. The contrast medium used is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine. A hemoglobin level of 14.4 g/dL is within the expected reference range. An output of 200 mL in 4 hr is within the expected reference range. This procedure involves access through large arteries or veins into the heart and is not affected by peripheral arterial disease.

A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of deep-vein thrombosis. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96 seconds?

Stop the heparin infusion. The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

A nurse is caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client?

Urine output

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? Ventricular depolarization Guillain-Barré syndrome Myelodysplastic syndrome Valvular disease

Valvular disease. Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium. Ventricular depolarization occurs during a normal cardiac cycle and is not a potential complication of endocarditis. Guillain-Barré syndrome is associated with certain bacterial and viral infections but is not a potential complication of endocarditis. Myelodysplastic syndrome is a disorder of the bone marrow

A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?

Weak peripheral pulses

A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find? a. Increased abdominal girth b. Weak peripheral pulses c. Jugular venous neck distention. d. dependent edema

b. Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. Increased abdominal girth is a finding related to systemic congestion resulting from right-sided heart failure. Jugular venous neck distention is a finding related to systemic congestion resulting from right-sided heart failure. Dependent edema is a finding related to systemic congestion resulting from right-sided heart failure.

A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values? a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL b. Cholesterol of 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL c. Cholesterol 190 mg/dL, HDL 25 mg/ dL, LDL 160 mg/dL d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL

c. The expected reference range of cholesterol is less than 200 mg/dL, HDL above 40 mg/dL, and LDL less than 100 mg/dL.

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? -Dyspnea on exertion -Tracheal deviation -Pericardial rub -Weight loss

correct is Dyspnea on exertion, which is as an expected manifestation of dilated cardiomyopathy and due to ventricular compromise and reduced cardiac output. The nurse should identify that tracheal deviation is an expected manifestation of a tension pneumothorax. The nurse should identify that a pericardial rub is an expected manifestation of pericarditis. The nurse should identify that weight GAIN is an expected manifestation of dilated cardiomyopathy. Weight gain is due to ventricular compromise and fluid retention.

A nurse is caring for a client who has a history of angina and is scheduled for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? "I'm still hungry after the bowl of cereal I ate at 7 a.m." "I didn't take my heart pills this morning because the doctor told me not to." "I have had chest pain a couple of times since I saw my doctor in the office last week." "I smoked a cigarette this morning to calm my nerves about having this procedure."

"I smoked a cigarette this morning to calm my nerves about having this procedure." Smoking prior to this test can CHANGE the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test. It is not necessary for the client to be NPO prior to this procedure. The provider might withhold cardiovascular medications prior to this procedure to effectively monitor cardiovascular response to stress. Episodes of chest pain are not a contraindication to this test.

A nurse is assessing a client who has pulmonary edema related to HF, which is the following findings indicates effective treatment of the client's condition? 1. Absence of adventitious breath sounds 2. Presence of a nonproductive cough 3.Decrease in respiratory rate at rest 4. SaO2 86% on room air

1. correct Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving. 2. A moist, productive cough usually accompanies pulmonary edema. However, the presence of a nonproductive cough does not indicate that the problem is resolving. 3. The respiratory rate usually decreases while at rest. It is not an indicator of effective treatment. 4. This value is below the expected reference range. It is not an indicator of effective treatment.

A nurse is caring for a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? 1. Hemoglobin 14 g/dLb. 2. Minimal bruising of extremities. 3.Reduced circumference of affected extremity. 4. INR 2.5

4. INR 2.5 The nurse should determine that an INR of 2,5 is within the desired therapeutic range and is the best evidence of effective warfarin therapy.

A nurse in the emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week postoperative open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? -Administering IV morphine sulfate -Administering oxygen at 2 L/min via nasal cannula -Helping the client to the bedside commode -Assisting with thrombolytic therapy

Assisting with thrombolytic therapy. The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy. The nurse should administer IV morphine to the client to relieve pain and reduce myocardial oxygen demand. The nurse should administer supplemental oxygen to the client to increase myocardial tissue perfusion. Using a bedside commode is less stressful than using a bedpan, and most clients are allowed to use a commode following a myocardial infarction.

A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. Which of the following client findings should the nurse report to the provider? Mediastinal drainage 100 mL/hr Blood pressure 160/80 mm Hg Temperature 37.1° C (98.8° F) Potassium 4.0 mEq/L

Blood pressure 160/80 mm Hg. The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites. Mediastinal drainage of up to 150 mL/hr is expected during this time. A body temperature within the expected reference range is desired following a CABG. A potassium level of 4.0 mEq/L is the desired goal in the postoperative period after CABG.

A nurse is caring for a client who was admitted for tx of left-sided HF with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular HR. which of the following actions should the nurse take first? -Obtain client's current weight. -Review serum electrolyte values. -Determine the time of the last digoxin dose. -Check the client's urine output.

Correction is Review serum electrolyte values. Because that Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the K level, because the client is at RISK for dysrhythmias from hypokalemia. The nurse should obtain the client's current weight to determine fluid loss from diuretic therapy. The nurse should determine the time of the last digoxin dose in order to evaluate when the next dose is due. The nurse should check the client's urine output to determine fluid loss from diuretic therapy. However, the nurse should take another action first.

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction (MI)? Myoglobin C-reactive protein Creatine kinase-MB Homocysteine

Creatine kinase-MB. Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury. Homocysteine is always present in the blood. An increased level might indicate a risk factor for the development of cardiovascular disease. C-reactive protein increases soon after the beginning of an inflammatory process, such as rheumatoid arthritis, and is not specific to cardiac muscle. Myoglobin is elevated following an MI. However, it is not specific to the cardiac muscle and is elevated with skeletal muscle injury.

A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Identify the area of the strip the nurse should examine to observe for atrial depolarization.

Image: (The first box) The nurse should examine this area, the P wave, of the rhythm strip to evaluate for Atrial Depolarization. the QRS complex, of the rhythm strip to evaluate for Ventricular depolarization. the T wave, of the rhythm strip to evaluate for ventricular repolarization.

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous status ulcer?

Inquire about the presence or absence of claudication. Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.

A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include? (Select all that apply.) Limited alcohol intake Regular exercise program Decreased magnesium intake Reduced potassium intake Tobacco cessation

Limited alcohol intake. Regular exercise program. Smoking cessation Clients who have hypertension should limit alcohol intake. A regular exercise program will help reduce blood pressure. Tobacco use exacerbates hypertension.

A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about the adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following? Tendon pain Persistent cough Frequent urination Constipation

Persistent cough. A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication. Tendonitis is an adverse effect of fluoroquinolone antibiotics. Frequent urination is an expected outcome of this medication. Constipation is an adverse effect of ACE inhibitors. However, the client does not need to discontinue use or report this to the provider.

A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for FURTHER clarification by the nurse? 1. "My arthritis is really bothering me because I haven't taken my aspirin in a week." 2. "My blood pressure shouldn't be high because I took my blood pressure medication this morning." 3. "I took my warfarin last night according to my usual schedule." 4. "I will check my blood sugar because I took a reduced dose of insulin this morning."

"I took my warfarin last night according to my usual schedule." Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding. 1. The provider might have the client discontinue over-the-counter medications, such as aspirin, prior to surgery to reduce the risk of bleeding. Thus, My arthritis is really bothering me because I haven't taken my aspirin in a week." 2. The provider might instruct the client to administer medications to treat high blood pressure to reduce the risk of hypertension. 4. The provider might instruct a client who takes insulin to take a reduced dose in the morning of surgery to regulate blood glucose.

A nurse is caring for a client who presents to the emergency department with a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in hypertensive crisis. Which of the following actions should the nurse take first? Initiate seizure precautions. Tell the client to report vision changes. Elevate the head of the client's bed. Start a peripheral IV.

Place the head of the bed at 45°. The GREATEST risk to this client is ORGAN injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to REDUCE blood pressure and promote oxygenation. The nurse should initiate seizure precautions because the client is at risk for seizures. The nurse should tell the client to report vision changes because the client is at risk for blurred vision. The nurse should initiate an IV to provide access for medication administration to reduce the client's blood pressure. However, these are not the first action the nurse should take.

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately? -Slurred speech -Irregular pulse -Dependent edema -Persistent fatigue

Slurred speech. The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately. An irregular pulse is an expected finding for a client who has atrial fibrillation and indicates the client is at risk for inadequate cardiac output. Dependent edema is an expected finding for a client who has heart failure and indicates the client is at risk for inadequate circulation. Fatigue is an expected finding for a client who has heart failure and indicates the client is at risk for inadequate cardiac output. However, another finding is the priority.

A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a heart rate of 200 to 210/min and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions? Delivery of a precordial thump Vagal stimulation Administration of atropine IV Defibrillation

Vagal stimulation The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole. atropine is used to treat bradydysrhythmias. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia. A cardioversion, rather than defibrillation, is used to treat supraventricular tachycardia. a precordial thump is used for witnessed ventricular tachycardia if a defibrillator is unavailable.

A nurse is proving discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings to the provider? -Weight gain of 0.9 kg (2 lb) in 24 hr -Increase of 10 mm Hg in systolic blood pressure -Dyspnea with exertion -Dizziness when rising quickly

Weight gain of 0.9 kg (2 lb) in 24 hr. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? Serosanguineous drainage on dressing Severe pain with coughing Urine output of 20 mL/hr Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F)

correct is Urine output of 20 ml/hr. Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture. This temperature is within the expected reference range and is not a manifestation of shock. Coughing is painful after an aortic aneurysm repair. However, it is not a manifestation of shock. Serosanguineous drainage 1 hr postoperative is expected and is not a manifestation of shock. Serosanguineous drainage should decrease over the FIRST few days and discontinue after day 5.