Cardiovascular Disorders Passpoint

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A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown. At 1030, the client has sharp mid-chest pain after having a bowel movement. What should the nurse do first? 1. Assess the client's vital signs. 2. Administer pain medication as prescribed. 3. Assess the client's neurologic status. 4. Contact the health care provider (HCP).

Correct response: Client has a persistent cough. Explanation: A persistent cough is a side effect of the ACE inhibitor that may warrant a change to another antihypertensive medication.BP and potassium are within normal limits. The nurse assesses when the drug is taken and changes to an earlier time of administration.

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems? 1. Monitor skin integrity. 2. Provide a self-care program for the client and family. 3. Promote arterial and venous circulation. 4. Relieve pain caused by decreased circulation.

Correct response: Promote arterial and venous circulation. Explanation: Maslow's hierarchy defines priorities with physiological needs as the highest priority. In the case of a client with peripheral vascular disease, the highest priority would be tissue perfusion. Once this is established, the nurse can address the problems of pain and skin integrity. It is also important to educate the client and provide a self-care program. However, the client's physiological needs must be met first.

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of 1. cardiogenic shock. 2. pneumonia. 3. acute pulmonary edema. 4. right-sided heart failure.

Correct response: acute pulmonary edema. Explanation: Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.

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? 1. defibrillating the client 2. assessing the client 3. calling the resuscitation team 4. delivering a precordial thump

Correct response: assessing the client Explanation: The priority action of the nurse would be to assess the client to determine if the client is having a loss of consciousness with cessation of respiration or pulse. The electrodes may have lost connection with the client's skin. The other choices would be inappropriate actions until an assessment has been performed.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should administer oxygen. place the client in high Fowler's position. have the client take deep breaths and cough. perform chest physiotherapy.

Correct response: diabetic neuropathy Explanation: A common complication of diabetes is diabetic neuropathy. Diabetic neuropathy results from the metabolic and vascular factors related to hyperglycemia. Damage leads to sensory deficits and peripheral pain. Muscle atrophy can result from disuse, but it is not a direct consequence of diabetes. Raynaud's disease is associated with vasospasms in the hands and feet. Transient ischemic attacks involve the cerebrum.

The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor? 1. contraction 2. atrophy 3. gangrene 4. rubor

Correct response: gangrene Explanation: The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.

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? 1. thrombin clotting time, 10 to 15 seconds 2. partial thromboplastin time, 1.5 to 2.5 times the normal control 3. International Normalized Ratio, 2 to 3 seconds 4. prothrombin time, 1.5 to 2.5 times the normal control

Correct response: partial thromboplastin time, 1.5 to 2.5 times the normal control Explanation: The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of warfarin, oral anticoagulation therapy. The thrombin clotting time is used to confirm disseminated intravascular coagulation.

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. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1. Document the effectiveness of the treatment given. 2. Check vital signs, particularly blood pressure. 3. Report findings to the physician. 4. Administer sublingual nitroglycerin. 5. Evaluate the effectiveness of the treatment given.

Correct response: 2. Check vital signs, particularly blood pressure. 4. Administer sublingual nitroglycerin. 5. Evaluate the effectiveness of the treatment given. 1. Document the effectiveness of the treatment given. 3. Report findings to the physician. Explanation: Oxygen administered at 2 to 4 L/minute via nasal cannula is a first-line treatment for myocardial oxygen deficit, which is evidenced by the client's chest pain. The nurse should then check vital signs, particularly blood pressure, before administering sublingual nitroglycerin. The nurse should then evaluate the effectiveness of the treatment given, document it, and report it to the physician.

Which symptom should the nurse teach the client with unstable angina to report immediately to the health care provider (HCP)? 1. pain during sexual activity 2. pain during an argument 3. pain during or after a physical activity 4. a change in the pattern of the chest pain

Correct response: a change in the pattern of the chest pain Explanation: The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.

The nurse is planning the care for a client with risk factors for atherosclerosis. What should the nurse include in the teaching plan for this client as modifiable risk factors? Select all that apply. 1. gender 2. e-cigarette use 3. stress 4. hypertension 5. genetics

Correct response: e-cigarette use hypertension stress Explanation: Nicotine use (e-cigarettes), hypertension, and stress are modifiable risk factors for atherosclerosis. Gender and genetics are nonmodifiable risk factors for atherosclerosis.

The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client who is inquiring about the purpose of the new diet? 1. to address the fluctuation in blood sugar 2. to reduce the metabolic workload of digestion 3. to reduce the amount of fecal elimination 4. to improve the gastric acidity of the stomach

Correct response: to reduce the metabolic workload of digestion Explanation: Acute care of the client with an MI is aimed at reducing the cardiac workload. Clear liquids are easily digested to help reduce this workload. Sympathetic nervous system involvement causes decreased peristalsis and gastric secretion, so limiting food intake helps prevent gastric distension and cardiac workload. A clear diet will not reduce gastric acidity or blood glucose, and fecal elimination will still occur, so these are incorrect choices.

The nurse is caring for a client during the postsurgical period after having a right femoral-popliteal bypass graft. The nurse enters the room to conduct a nursing assessment and care. Order the nurse's actions according to priority. All options must be used. 1. Assess lung fields. 2. Offer clear fluids. 3. Assess incision site. 4. Assess pain/obtain medication. 5. Assess peripheral pulses. 6. Instruct on client positioning.

Correct response: Assess peripheral pulses. Assess incision site. Assess lung fields. Assess pain/obtain medication. Instruct on client positioning. Offer clear fluids. Explanation: Following a femoral-popliteal bypass, it is most important to assess circulation to the lower extremity by assessing the quality of the right pedal (peripheral) pulse. By assessing a strong pulse, the nurse knows that the graft is functioning. Next, the nurse assesses the incision site noting any bleeding. Lung sounds are assessed because the client had anesthesia. Lastly, the nurse assesses the client's pain level and obtains medication as appropriate. Before leaving the room, the nurse positions the client and then obtains fluids.

A clinically obese client with moderately painful varicose veins chooses self-care options for managing the varicosities. The nurse should coach the client to follow which health care practices? Select all that apply. 1. Elevate the legs. 2. Lose weight. 3. Apply lotion to the veins. 4. Wear compression stockings. 5. Sleep with pillows under the knees.

Correct response: The client reports increasing severe back pain. Explanation: Increased severe back pain and increased irritation to nerves are indicative of a potential rupture of an aneurysm. The client would be hypertensive and present with tachycardia, so the other choices are not correct. Nausea, although possible, or a missed dose of medication, do not indicate potential rupture.

A client with third-degree atrioventricular heart block with a rate of 28 is admitted to the coronary care unit. Which intervention takes priority? 1. teaching the client to take the pulse 2. teaching the client about a temporary pacemaker 3. applying an apnea monitor 4. reviewing information regarding advanced directives

Correct response: teaching the client about a temporary pacemaker Explanation: Third degree A-V heart block is manifested by profound bradycardia and may be accompanied by confusion, dizziness, and syncope. This type of heart block will require pacemaker insertion. Applying an apnea monitor is not appropriate for this client. Reviewing advanced directives are not necessary at this time. Teaching the client to take the pulse is important but also not a priority.

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? 1. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. 2. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. 3. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the health care provider. 4. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs.

Correct response: Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Explanation: Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client? 1. Keep the legs elevated when sitting or lying down. 2. Avoid walking to reduce the discomfort. 3. Contact a surgeon to perform a femoral-popliteal bypass graft. 4. Sclerotherapy can be used for cosmetic improvement.

Correct response: Keep the legs elevated when sitting or lying down. Explanation: The nurse instructs the client to elevate the legs to improve venous return and alleviate discomfort. Walking is encouraged to increase venous return. Sclerotherapy or laser treatment is done for cosmetic reasons, but it does not improve circulation. Surgery may be performed for severe venous insufficiency or recurrent thrombophlebitis in the varicosities. Femoral-popliteal bypass graft is a surgical intervention for arterial disease.

The nurse on the previous night shift documented that the lungs of a client with lung cancer were CTA (clear to auscultation) in all fields. While doing the shift assessment, the day shift nurse noticed decreased breath sounds, especially in the right lower lobe. Which action is the nurse's best choice? 1. Notify the physician of the change in client status. 2. Report the findings to the charge nurse for documentation follow up with the previous shift's nurse. 3. Document the findings as the only action, as this is expected in clients with lung cancer. 4. Call radiology for an X-ray to confirm findings.

Correct response: Notify the physician of the change in client status. Explanation: Pleural effusion is a common complication of lung cancer. Fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Documentation of abnormal findings without any follow-up is an error in the nursing process. Ordering an X-ray is not an independent nursing action.

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization? 1. Observe neurologic function every 15 minutes. 2. Monitor skin warmth and turgor. 3. Observe the puncture site for swelling and bleeding. 4. Monitor the laboratory values.

Correct response: Observe the puncture site for swelling and bleeding. Explanation: Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

What is the nurse's priority action for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention? 1. Reposition the client so the lower legs dangle off the bed. 2. Administer furosemide 40 mg I.V. as ordered. 3. Apply supplemental oxygen at 4 L/min. 4. Notify the attending physician.

Correct response: Reposition the client so the lower legs dangle off the bed. Explanation: The client's presentation suggests congestive heart failure. Cardiac output is compromised. Dangling the legs will cause pooling of blood in the lower extremities, allowing some relief to the overloaded heart. Oxygenation will improve with improved cardiac output. Furosemide will decrease the fluid, but will take some time to work. Notifying the attending should occur after the client is rescued.

The nurse is evaluating the therapeutic goal of a client with history of cardiac dysrhythmias and newly completed radiofrequency catheter ablation. Which client-centered goal is most appropriate? 1. The client will have a lowered blood pressure from the dilation of arterial vessels. 2. The client will have no fainting from overstimulation of the heart. 3. The client will experience reperfusion of ischemic heart tissue. 4. The client will have a regular heart rhythm from destruction of errant tissue of the heart.

Correct response: The client will have a regular heart rhythm from destruction of errant tissue of the heart. Explanation: The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue in hopes of allowing impulse conduction to travel over appropriate pathways. The goal does not include dilation of blood vessels or reperfusion of heart tissue. There is no stimulation of the heart.

A client who is receiving multiple medications for a myocardial infarction reports severe nausea. Assessments reveal that the heartbeat is irregular and slow. The nurse should recognize these symptoms as toxic effects of which medication? 1. aminosalicylic acid (ASA) 2. meperidine hydrochloride 3. digoxin 4. morphine sulfate

Correct response: digoxin Explanation: Signs of digitalis toxicity include cardiac dysrhythmias, anorexia, nausea, vomiting, and visual disturbances. Cardiac dysrhythmias result from the inhibition, by digitalis, of myocardial Na+ and K+. Extra cardiac effects may be caused by central nervous system or local disturbances. The common side effect associated with aminosalicylic acid (ASA) is tinnitus. A common side effect of morphine is of a respiratory depression, and meperidine causes hypotension.

A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume? 1. supine 2. leaning forward while sitting 3. semi-Fowler's 4. prone

Correct response: leaning forward while sitting Explanation: The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis.

A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem? myocarditis renal failure liver failure myocardial infarction

Correct response: myocarditis Explanation: Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection. The T lymphocytes respond to the viral infection by secreting cytokines to kill the virus, but they also kill the virus-infected myocardium. Myocardial infarction, renal failure, and liver failure are not direct consequences of a viral or parasitic infection.

An older adult is receiving morphine to manage pain after abdominal surgery. The nurse should observe the client for which side effect of this drug? 1. seizures 2. constipation 3. respiratory depression 4. dysrhythmias

Correct response: respiratory depression Explanation: It is especially important for the nurse to carefully assess the elderly client for respiratory depression after administering a dose of meperidine. It may be necessary to reduce the dosage to prevent respiratory depression. Dysrhythmias, constipation, and seizures are all potential adverse effects of meperidine, but respiratory depression is most significant in the elderly.

The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply. s1. erum troponin 2. serum myoglobin 3. 24-hour creatinine clearance 4. electroencephalogram 5. urinalysis 6. serum bilirubin

Correct response: serum troponin serum myoglobin Explanation: Troponin and myoglobin are enzymes that are released when cardiac muscle is damaged. Serum troponin levels increase within 2 to 4 hours after MI. Serum myoglobin levels increase within ½ hour to 2 hours after MI. Serum bilirubin evaluates liver function and is not altered with cardiac damage. Urinalysis and 24-hour creatinine clearance reflect kidney—not cardiac—function. An electroencephalogram evaluates the electrical activity of the brain.

Which client has a need for prophylactic antibiotic therapy prior to dental manipulations? 1. the client who had a TKR (total knee replacement) one year ago 2. the client who had an aortic valve replacement 5 years ago 3. the client who had an in ICD (implantable cardiac defibrillator) 2 weeks ago 4. the client who had a left THR (total hip replacement) 3 months ago

Correct response: the client who had an aortic valve replacement 5 years ago Explanation: A heart valve prosthesis such as an aortic valve replacement is a major risk factor for the development of infective endocarditis. Preventative measures include antibiotic prophylaxis prior to dental work. Other implanted devices (hip, knee, ICD) can increase the risk of infection, but the client with the greatest risk is the one with the valve replacement.

A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Immediately following surgery, what should the nurse do as a priority to prevent infection? 1. Monitor the radial pulse in the right arm. 2. Protect the extremity from cold. 3. Assess the temperature in the right arm. 4. Avoid using the arm for a venipuncture.

Correct response: Avoid using the arm for a venipuncture. Explanation: If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.

The nurse is monitoring a client with a pacemaker. Which finding shows that the client's pacemaker is functioning correctly? The nurse palpates bilateral radial pulses. The client reported no pacemaker problems with medical history information. The generator is observed on the chest wall of the client. The nurse observed a spike on the electrocardiogram (EKG) with pacing initiated.

Correct response: The nurse observed a spike on the electrocardiogram (EKG) with pacing initiated. Explanation: The client should have a spike on the EKG when pacing is initiated; this would come before the P wave if the pacemaker is initiating atrial contraction and before the QRS if the pacemaker initiates ventricular contraction instead. Finding the generator would be an indication of having a pacemaker, but not that it was working. The client should report any pacemaker problems, but it would not be an indication of the pacemaker's function at present. Having bilateral radial pulses does indicate heart function but does not specifically address pacemaker function.

The nurse is assessing a client with peripheral arterial disease who had a femoral-popliteal bypass. Which finding indicates improved arterial blood supply to the lower extremity? absence of pulse using a Doppler ultrasound decrease in muscle pain when walking reduction in pitting edema dependent rubor

Correct response: decrease in muscle pain when walking Explanation: With increased blood supply to the leg there should be less or absent claudication (cramping pain in leg with walking). Pulses should be palpable with improved blood supply. Edema is associated with venous disease. Pallor with elevation and dependent rubor are symptoms of peripheral arterial disease.

Which signs and symptoms accompany a diagnosis of pericarditis? 1. pitting edema, chest discomfort, and nonspecific ST-segment elevation 2. lethargy, anorexia, and heart failure 3. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) 4. low urine output secondary to left ventricular dysfunction

Correct response: fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) Explanation: The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction lethargy, anorexia, heart failure and pitting edema do not result from acute renal failure.

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.) 1. pain in extremity. 2. nail bed color. 3. fluid intake. 4. skin temperature. 5. nausea.

Correct response: nail bed color. skin temperature. pain in extremity. Explanation: Maintaining circulation is critical in individuals with peripheral vascular disease. Skin and nail bed color and temperature will reveal the degree to which the extremity is receiving blood flow. Clients with peripheral vascular disease also usually have a certain amount of pain, especially when the oxygen demand becomes greater than oxygen supply, such as with walking or exercising. Fluid intake and nausea are unrelated to peripheral circulation.

The nurse is assessing a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. What should the nurse do immediately? 1. Assess vital signs. 2. Apply a tourniquet. 3. Call the health care provider (HCP). 4. Elevate the involved extremity with a large pillow.

Correct response: Assess vital signs. Explanation: The client should be evaluated for hemodynamic stability and extent of bleeding prior to calling the HCP. Direct pressure can be used prior to applying a tourniquet if there is significant bleeding. To avoid flexion contractures, which can delay rehabilitation, elevation of the surgical limb is contraindicated.

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal? C-reactive protein (CRP) platelet count potassium B-type natriuretic peptide (BNP)

Correct response: B-type natriuretic peptide (BNP) Explanation: The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.

A client with heart failure has assessment findings of jugular vein distension (JVD) when lying flat in bed. What is the best nursing intervention? 1. Notify the healthcare provider. 2. Elevate the head of the bed to 30 to 45 degrees and reassess JVD. 3. Document the finding as the only action. 4. Obtain orthostatic blood pressure readings.

Correct response: Elevate the head of the bed to 30 to 45 degrees and reassess JVD. Explanation: Jugular vein distension should be measured when the head of the client's bed is at 30 to 45 degrees. The healthcare provider may or may not need to be notified, based on the assessment findings with the head of the bed elevated. Further assessment should be performed, but this further assessment does not include obtaining orthostatic blood pressure readings, since these readings do not affect JVD.

The nurse has received the change-of-shift report on the clients. Who should the nurse assess first? 1. a client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating 2. a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due 3. a client with atrial fibrillation who is scheduled to go the cardiac catheterization lab at 10 am (1000) for an ablation 4. a client who had a temporary pacemaker inserted 2 hours ago, who is now pacing 1:1 with a heart rate of 70

Correct response: a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due Explanation: The firing of the ICD suggests that the client's ventricles are irritable. The nurse's priority is to assess the client and administer the amiodarone to prevent further dysrhythmias. The client with reports of dizziness should be kept in bed until the nurse is available to perform further assessment. Other clients can be seen after the medication is administered.

The nurse is administering adenosine to a client with supraventricular tachycardia. What is the expected therapeutic response? 1. a brief episode of ventricular tachycardia 2. an increase in blood pressure 3. a short period of asystole 4. A brief feeling of numbness and tingling of extremities

Correct response: a short period of asystole Explanation: The expected response to this medication is a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain followed by a return to normal sinus rhythm. It is used to convert dysrhythmias to normal sinus rhythm and should not cause ventricular tachycardia. Numbness and tingling of extremities is not an expected side effect.

A client with Raynaud's phenomenon is prescribed diltiazem. The nurse should assess the client for which intended outcome of this drug? 1. increased heart rate 2. lower serum calcium levels 3. less pain in extremities f4. ewer episodes of numbness in the fingers

Correct response: fewer episodes of numbness in the fingers Explanation: Calcium channel blockers are first-line drug therapy for the treatment of vasospasms with Raynaud's phenomenon when other therapies are ineffective. Diltiazem relaxes smooth muscles and improves peripheral perfusion, thereby reducing finger numbness. Diltiazem reduces the heart rate; it does not increase it. Diltiazem does not directly reduce pain, but it does improve circulation. The intended outcome of diltiazem is not to decrease calcium levels.

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. How should the nurse document these findings? 1. heart rate irregular with S3 2. heart rate irregular with S4 3. heart rate irregular with mitral stenosis 4. heart rate irregular with aortic regurgitation

Correct response: heart rate irregular with S3 Explanation: An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex, and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.

The nurse instructs a client prescribed digoxin about the signs and symptoms of toxicity. Which client statement indicates that teaching was effective? 1. "A dry mouth and urine retention is to be expected when taking this medication." 2. "Having to void during the night and trouble sleeping are expected effects of the medication." 3. "I should contact the healthcare provider if I notice a change in my vision such as flashing lights or different colors." 4. "I can expect my ability to taste and smell to change because of the medication."

Correct response: "I should contact the healthcare provider if I notice a change in my vision such as flashing lights or different colors." Explanation: Digoxin toxicity may cause visual disturbances such as flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata. Alteration in taste and smell are not associated with digoxin toxicity. Dry mouth and urine retention typically occur with anticholinergic agents and not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide and not digoxin.

A nurse is monitoring a client on the telemetry unit. The electrocardiogram tracing shows a PR interval of 0.22 seconds. What is the appropriate action of the nurse? Administer epinephrine. Document the findings and continue to monitor the client. Administer oxygen via nasal cannula. Contact the healthcare provider.

Correct response: Document the findings and continue to monitor the client. Explanation: The PR interval normally ranges from 0.12 to 0.20 seconds. A reading of 0.22 seconds is first-degree heart block. The nurse should monitor the client and document the findings. The other interventions are not necessary at this time.

The nurse is developing a discharge plan with a client who is receiving chemotherapy to treat lymphoma. What should the nurse include in the plan? Select all that apply. 1. Decrease the protein in your diet. 2. Wear a mask if leaving the house. 3. Rest as needed. 4. Contact the health care provider (HCP) if a fever develops. 5. Avoid people with colds or flu.

Correct response: Rest as needed. Avoid people with colds or flu. Contact the health care provider (HCP) if a fever develops. Explanation: The nurse should teach the client to obtain as much rest as need, to avoid people who have a cold or the flu, and to report a fever to the HCP. It is not necessary for the client to wear a mask when going out of the house, but the client should avoid large crowds where there may be people with contagious diseases. It is not necessary to decrease the protein in the diet, but rather, the client should eat a well-balanced diet. The client may need to change some foods if the client has side effects of the chemotherapy and may need to obtain more calories.

The most common site of aneurysm formation is in the abdominal aorta, just below the renal arteries. descending aorta, beyond the subclavian arteries. ascending aorta, around the aortic arch. aortic arch, around the ascending and descending aorta.

Correct response: abdominal aorta, just below the renal arteries. Explanation: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? 1. Bed rest with the affected extremity elevated 2. bed rest with the affected extremity flat 3. bed rest with all normal activities as long as there no increased pain on the affected site 4. bed rest with the affected extremity in the dependent position

Correct response: Bed rest with the affected extremity elevated Explanation: Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.

A nurse is evaluating the labs of a client with heart failure. Which lab values are expected findings? Select all that apply. 1. serum potassium 4.0 mEq/L 2. Serum sodium 130 mEq/L 3. Serum creatinine 1.0 mg/dL 4. hemoglobin 14.2 g/dL, hematocrit (Hct) 32.8% 5. microalbuminuria and proteinuria

Correct response: hemoglobin 14.2 g/dL, hematocrit (Hct) 32.8% Serum sodium 130 mEq/L microalbuminuria and proteinuria Explanation: Fluid volume overload present with heart failure causes the hematocrit to be low indicating a dilutional ratio of red blood cells to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. Serum potassium and creatinine are within normal limits.

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and orders sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, which instruction should the nurse provide? 1. "A burning sensation after administration indicates that the nitroglycerin tablets are potent." 2. "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." 3. "Replace leftover sublingual nitroglycerin tablets every 9 months to make sure your pills are fresh." 4. "You may take a sublingual nitroglycerin tablet every 30 minutes, if needed. You may take as many as four doses."

Correct response: "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Explanation: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 3 to 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina and may repeat the dose every 5 minutes for up to three doses; if this intervention doesn't bring relief, the client should seek immediate medical attention.

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? 1. Apply the external pacemaker. 2. Defibrillate the client. 3. Begin cardiopulmonary resuscitation (CPR). 4. Assess the client's airway, breathing, pulses, and level of conciseness.

Correct response: Assess the client's airway, breathing, pulses, and level of conciseness. Explanation: If the client is experiencing ventricular tachycardia, the priority for the nurse is to assess the client's airway, breathing, and level of consciousness before any further action is taken.

During a shift report for a client with heart failure, the nurse going off shift reports that the client had sinus bradycardia during the shift and a creatinine of 3.5 mg/dL. Which action does the nurse perform when administering digoxin to this client? 1. Measure the urine output. 2. Monitor the radial pulse. 3. Assess the digoxin level. 4. Evaluate the B-type natriuretic peptide level (BNP).

Correct response: Assess the digoxin level. Explanation: After digoxin is metabolized, the kidneys eliminate the remaining digoxin. Kidney disease will prevent elimination of digoxin causing potential toxicity; measuring the digoxin level, especially in the presence of bradycardia, a side effect of digoxin, is indicated. The nurse monitors the apical pulse when administering digoxin, as atrial fibrillation or other dysrhythmia that causes a pulse deficit may lead the nurse to hold the medication when the true pulse is above 60 beats/min. Renal impairment does not always decrease urine output; therefore, monitoring for toxicity is the priority. Although the BNP level will correlate to the client's heart failure, the most important assessment is for digoxin toxicity.

A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. 1. Monitor the mediastinal chest tube drainage. 2. Check the postoperative CBC, INR, PTT, and platelet levels. 3. Administer warfarin. 4. Confirm availability of blood products. 5. Start a dopamine drip for a systolic BP less than 100 mm Hg.

Correct response: Check the postoperative CBC, INR, PTT, and platelet levels. Confirm availability of blood products. Monitor the mediastinal chest tube drainage. Explanation: The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding; therefore, availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should not be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.

A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply. 1. Monitor the mediastinal chest tube drainage. 2. Administer warfarin. 3. Start a dopamine drip for a systolic BP less than 100 mm Hg. 4. Check the postoperative CBC, INR, PTT, and platelet levels. 5. Confirm availability of blood products.

The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which actions should the nurse implement? Select all that apply. 1. Discontinue administration of digoxin. 2. Administer low flow oxygen. 3. Determine serum digoxin and electrolyte levels. 4. Insert nasogastric tube. 5. Begin continuous electrocardiographic monitoring.

Correct response: Discontinue administration of digoxin. Begin continuous electrocardiographic monitoring. Determine serum digoxin and electrolyte levels. Explanation: Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting. If digoxin toxicity is suspected, the steps the nurse should implement include discontinue administration of drug; begin continuous electrocardiographic monitoring for cardiac dysrhythmias; administer any appropriate antidysrhythmic drugs as ordered; determine serum digoxin and electrolyte levels; administer potassium supplements for hypokalemia if indicated, as ordered; institute supportive therapy for gastrointestinal symptoms (nausea, vomiting, or diarrhea); and administer digoxin antidote (digoxin immune fab) if indicated, as ordered. Inserting a nasogastric tube or administering oxygen is not appropriate for digoxin toxicity.

A client with congestive heart failure is admitted to the hospital. Which interventions should the nurse include in the plan of care to prevent skin breakdown? Select all that apply. 1. Apply heel protectors when lying in bed. 2. Encourage the client to ambulate three times a day. 3. Monitor vital signs every 4 hours. 4. Apply 2 liters of oxygen per nasal cannula if SaO2 < 93%. 5. Weigh the client daily at the same time in the morning.

Correct response: Encourage the client to ambulate three times a day. Apply heel protectors when lying in bed. Explanation: The client with congestive heart failure has fluid volume excess and is at risk for skin breakdown due to edema. Ambulating and wearing heel protectors will help prevent skin breakdown. While daily weights and vital signs are aspects to monitor with heart failure, it will not have a direct impact on the prevention of skin breakdown. Oxygen may be required if the client has fluid volume excess that has affected the respiratory status, but it is not an intervention to prevent skin breakdown.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize? 1. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. 2. Restrict alcohol intake to two drinks per day. 3. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses. 4. Store the drug in a cool, well-lit place.

Correct response: Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Explanation: Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

During a home visit, the nurse assesses a client who is taking hydrochlorothiazide and lisinopril for the treatment of hypertension. Which finding would indicate the nurse should inform the health care provider of a possible need to change medication therapy? 1. Blood pressure is 132/80 mm Hg. 2. Client has a persistent cough. 3. Potassium level is 4.1 mEq/L. 4. Client is experiencing nocturia.

Correct response: Lose weight. Wear compression stockings. Elevate the legs. Explanation: To manage varicose veins the nurse should coach the client to lose weight to relieve pressure on the veins, wear compression stockings to promote circulation and elevate the legs when sitting or lying down. Applying lotion to the veins will keep the skin moist, but does not promote venous circulation. Pillows under the knees will obstruct circulation.

The nurse reviews the morning laboratory results from a client admitted with a deep vein thrombosis. The client is receiving intravenous heparin. Based on the client's current laboratory values, what should the nurse do? 1. Notify the health care provider (HCP) about the increased liver enzymes. 2. Maintain the current rate of the heparin infusion. 3. Monitor oxygen saturation levels every 4 hours. E4. ncourage the client to drink 3,500 mL of fluids daily.

Correct response: Maintain the current rate of the heparin infusion. Explanation: An aPTT of 65 seconds is considered therapeutic with a control of 30. Therapeutic levels for heparin are 1.5 to 2.5 times the control, which would make therapeutic level between 45 seconds and 75 seconds. The nurse should continue the infusion at the current rate and continue to monitor the client. The liver enzymes (AST, ALT) are within normal range; it is not necessary to notify the HCP. The BUN and creatinine are within normal limits; the client does not need to increase fluid intake beyond 3,000 mL. The hemoglobin and hematocrit are within normal limits; it is not necessary to obtain frequent oxygen saturation levels.

What is the most important goal of nursing care for a client who is in shock? 1. Manage vasoconstriction of vascular beds. 2. Manage inadequate tissue perfusion. 3. Manage increased cardiac output. 4. Manage fluid overload.

Correct response: Manage inadequate tissue perfusion. Explanation: Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

While managing a client's immediate post-cardiac catheterization period, which interventions are priorities? Select all that apply. 1. Assess for any signs of hematoma formation. 2. Assess the catheter insertion site every 30 minutes for 4 hours. 3. Monitor vital signs every 15 minutes for the first hour. 4. Restrict the client to bed rest for 2 to 6 hours. 5. Note any limb discoloration and reported numbness. 6. Assess all peripheral pulses frequently.

Correct response: Monitor vital signs every 15 minutes for the first hour. Restrict the client to bed rest for 2 to 6 hours. Assess the catheter insertion site every 30 minutes for 4 hours. Note any limb discoloration and reported numbness. Assess for any signs of hematoma formation. Explanation: The key word is "immediate," indicating that care may be different throughout the recovery period. In the immediate period, the client's vital signs are typically monitored every 15 minutes for the first hour, then every 30 minutes for 2 hours or until vital signs are stable, and then every 4 hours or according to facility policy. All peripheral pulses do not require frequent assessment. (Always reflect on the word "all" in the selection.) The pulses in the affected extremity are usually assessed with every vital signs check. Clients typically remain in bed for 2 to 6 hours unless a special closure is used. The insertion site extremity is kept straight following the procedure, with neurological checks of color, warmth, and circulation. Bleeding at the insertion site and hematoma formation indicating internal bleeding are also assessed.

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. What should the nurse do first? 1. Notify the health care provider (HCP). 2. Increase the oxygen concentration to 4 L/min. 3. Increase the IV infusion rate 150 mL per hour. 4. Administer a prescribed analgesic.

Correct response: Notify the health care provider (HCP). Explanation: PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the HCP should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first? 1. Check the second client's identification and administer the remaining medication to him. 2. Alert the charge nurse that they made a medication error. 3. Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. 4. Document the medication error and completion of the variance report in the client's chart and notify the physician.

Correct response: Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed. Explanation: The nurse should return to the room to check the client's identification against the medication administration record. If there was an error, the nurse should then complete a variance report in accordance with facility policy and check the remaining medication before administering it to the second client. The client record shouldn't include documentation of a completed variance report. The nurse should inform the charge nurse of the error after confirming that an error has been made.

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? 1. a urinary output of 50 mL in the past 3 hours 2. vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60 3. a Sa02 reading of 92% 4. a white blood cell count of 19,000/mm3

Correct response: a urinary output of 50 mL in the past 3 hours Explanation: Sepsis can cause the release of myoglobin from the cells which will directly block the renal tubules, causing decreased urinary output. If it is not treated with hydration and antibiotics, the client could develop renal failure. A high white blood cell count is expected with sepsis. Temperature can be elevated or below normal in clients with sepsis. The elevated pulse and respirations are normal in the presence of infection and should be monitored. The saturated oxygen level is within normal limits as is the blood pressure.

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse? 1. vital signs T 38° C (100.4° F), P 104, R 26, and B/P 100/60 2. a Sa02 reading of 92% 3. a urinary output of 50 mL in the past 3 hours 4. a white blood cell count of 19,000/mm3

A nurse is preparing a teaching plan for a male client newly prescribed atenolol. Which information is important for the nurse to teach this client? 1. control of excessive flatus 2. causes and treatments for erectile dysfunction 3. prevention of constipation 4. management of incontinence

Correct response: causes and treatments for erectile dysfunction Explanation: Erectile dysfunction is a potential adverse effect of beta blockers. The other symptoms are not side effects of this drug.

A nurse is teaching a client with a new prescription for amiodarone. The nurse determines teaching has been effective when the client correctly identifies which adverse effects for amiodarone? Select all that apply. 1. blue-gray coloring of the skin 2. low blood pressure 3. increased heart rate 4. constipation 5. headache

Correct response: constipation headache blue-gray coloring of the skin low blood pressure Explanation: Adverse effects of amiodarone including pulmonary toxicity, thyroid disorders, bradycardia, hypotension, SA node dysfunction, QT prolongation, blue-gray coloring of the skin (face, arms, neck), constipation, and headache. An increased heart rate is not a side effect of amiodarone.

Which client is at risk for pulmonary embolism? A client with: 1. varicose veins. 2. a small abdominal aneurysms. 3. deep vein thrombosis (DVT). 4. arteriosclerosis.

Correct response: deep vein thrombosis (DVT). Explanation: DVT is commonly associated with venous stasis in the legs when there is a lack of the skeletal muscle pump that enhances venous return to the heart. When a client is confined to bed rest, venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site. DVT increases the risk that a displaced plaque will become a pulmonary embolus.Arteriosclerosis is hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen, tortuous veins. These are not generally considered risk factors for pulmonary embolism.

The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which condition? 1. a hypoglycemic reaction 2. development of congestive heart failure 3. acute renal failure 4. cardiogenic shock associated with heart block

Correct response: development of congestive heart failure Explanation: Crackles probably signify pulmonary edema, which occurs when there is left-sided congestive heart failure. The client is very dyspneic, and the heart appears to be compensating (increased rate because of respiratory congestion). Initiation of measures to help strengthen the heartbeat is a very important priority. Signs and symptoms do not indicate hypoglycemic reaction or renal failure. Heart block would be indicated by bradycardia.

An older adult is admitted to the hospital with nausea and vomiting. The client has a history of heart failure and is being treated with digoxin. The client has been nauseated for a week and began vomiting 2 days ago. Laboratory values indicate hypokalemia. Because of these clinical findings, the nurse should assess the client carefully for: 1. digoxin toxicity. 2. chronic renal failure. 3. metabolic acidosis. .4 exacerbation of heart failure.

Correct response: digoxin toxicity. Explanation: Nausea and vomiting, along with hypokalemia, are likely indicators of digoxin toxicity. Hypokalemia is a common cause of digoxin toxicity; therefore, serum potassium levels should be carefully monitored if the client is taking digoxin. The earliest clinical signs of digoxin toxicity are anorexia, nausea, and vomiting. Bradycardia, other dysrhythmias, and visual disturbances are also common signs. Chronic renal failure usually causes hyperkalemia. With persistent vomiting, the client is more likely to develop metabolic alkalosis than metabolic acidosis.

The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? 1. furosemide 2. metoprolol 3. dopamine 4. enalapril

Correct response: dopamine Explanation: Cardiogenic shock is when the heart has been significantly damaged and is unable to supply enough blood to the organs of the body. Dopamine, a sympathomimetic drug, improves myocardial contractility and blood flow through vital organs by increasing perfusion pressure. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and does not have a direct effect on contractility or tissue perfusion. Metoprolol is a adrenergic blocker that slows heart rate and lowers blood pressure; neither is a desired effect in the treatment of cardiogenic shock.

A client returns from a left heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client? 1. anterior to the right tibia 2. right mid-inguinal area 3. dorsal surface of the right foot 4. posterior to the right knee

Correct response: dorsal surface of the right foot Explanation: To best monitor that the client's circulation remains intact, the dorsal surface of the right foot should be palpated. When the left-side of the heart is catheterized, the cannula enters via an artery. In this instance, the right femoral artery was accessed. While all options assess arterial points of the right leg, the dorsal surface of the right foot (the pedal pulse) is the most distal. If this pulse point is present and unchanged from before the procedure, the other pulse points should also be intact.

A client returns from a left heart catheterization. The right groin was used for catheter access. In which location should the nurse palpate the distal pulse on this client? 1. posterior to the right knee 2. anterior to the right tibia 3. dorsal surface of the right foot 4. right mid-inguinal area

A fourth heart sound (S4) indicates a 1. dilated aorta. 2. normally functioning heart. 3. decreased myocardial contractility. 4. failure of the ventricle to eject all blood during systole.

Correct response: failure of the ventricle to eject all blood during systole. Explanation: An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. A nurse doesn't hear an S4 in a normally functioning heart.

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. How should the nurse document these findings? 1. heart rate irregular with S4 2. heart rate irregular with S3 3. heart rate irregular with aortic regurgitation 4. heart rate irregular with mitral stenosis

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. How should the nurse document these findings? heart rate irregular with mitral stenosis heart rate irregular with S4 heart rate irregular with aortic regurgitation heart rate irregular with S3

A nurse is caring for a client recovering from cardiac revascularization surgery of 3 days ago. Upon analysis of lab reports, the nurse notes the client's platelet count decreased from 230,000 to 5,000 ml (5,000 mmol/L). Which condition is suspected? pancytopenia heparin induced thrombocytopenia (HIT) idiopathic thrombocytopenic purpura (ITP) disseminated intravascular coagulation (DIC)

Correct response: heparin induced thrombocytopenia (HIT) Explanation: HIT may occur after a cardiac revascularization procedure because of heparin use during surgery. HIT is caused by antibodies that bind to complexes of heparin and platelet factor 4, activating the platelets and promoting a prothrombotic state. Pancytopenia is a reduction in all blood cells. Although ITP and DIC cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery.

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm? 1. The client reports feeling nauseated. 2. The client has been taking an antihypertensive for the past 3 years but forgot to take it today. 3. The client reports increasing severe back pain. 4. The blood pressure and pulse are within normal limits, but the client's skin color is pale and slightly diaphoretic.

Correct response: place the client in high Fowler's position. Explanation: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

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? 1. severe staphylococcal infection 2. croup r3. heumatic fever 4. medullary sponge kidney

Correct response: rheumatic fever Explanation: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.

Which position is best for a client with heart failure who has orthopnea? 1. lying on the back with the head lowered (Trendelenburg position) and legs elevated 2. sitting upright (high Fowler's position) with legs resting on the mattress 3. lying on the right side (Sims' position) with a pillow between the legs 4. semi-sitting (low Fowler's position) with legs elevated on pillows

Correct response: sitting upright (high Fowler's position) with legs resting on the mattress Explanation: Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg position.

When caring for a client with a newly diagnosed cardiac dysrhythmia, which laboratory values are the priority for the nurse to monitor? Select all that apply. 1. potassium of 3.1 mEq/L 2. hemoglobin of 14 g/dL 3. prothrombin time of 12 seconds with INR of 1 4. sodium of 124 mEq/L 5. hematocrit of 40% 6. calcium of 8.5 mEq/L 7. blood urea nitrogen (BUN) of 20 mg/dL

Correct response: sodium of 124 mEq/L potassium of 3.1 mEq/L calcium of 8.5 mEq/L Explanation: Because abnormalities in electrolytes are likely to affect depolarization and repolarization of cardiac cells, it is most important for the nurse to monitor sodium, potassium, and calcium levels. The blood urea nitrogen is within normal range. Hemoglobin and hematocrit are not generally associated with cardiac dysrhythmias; the hemoglobin is within normal range. The prothrombin time and INR would be monitored closely on a client taking warfarin, not necessarily a client with cardiac dysrhythmia; the PT and INR are within normal range.

The client asks the nurse, "Why won't the health care provider tell me exactly how much of my leg he is going to take off? Don't you think I should know that?" On which information should the nurse base the response? 1. the need to remove as much of the leg as possible 2. the ease with which a prosthesis can be fitted 4. the adequacy of the blood supply to the tissues 5. the client's ability to walk with a prosthesis

Correct response: the adequacy of the blood supply to the tissues Explanation: The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply, the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.

The nurse is preparing the client with a cerebrovascular accident for discharge to home. Which will influence the client's continuing progress in rehabilitation at home? 1. the family's ability to provide support to the client 2. the client's ability to ambulate 3. availability of a home health aide to care for the client f4. requency of follow-up visits with the health care provider

Correct response: the family's ability to provide support to the client Explanation: The strong support of family members is frequently identified as an important factor that influences a cerebrovascular accident client's continuing progress in rehabilitation after discharge. Discharge planning should prepare the client and family for the many changes necessary when the client returns home.Continuing progress in rehabilitation is not dependent upon the client's ability to ambulate.A client's continuing progress in rehabilitation is more dependent on the client and family support than the home health aide.Follow-up visits with the health care provider are important but are not the greatest influence on the client's progress with rehabilitation.

A client is receiving captopril for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals dry cough. postural hypotension. peripheral edema. skin rash.

Correct response: peripheral edema. Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

When assessing a client with heart failure, the nurse should immediately report which findings to the health care provider (HCP)? Select all that apply. 1. O2 saturation 94% on room air 2. 2-pound (0.9- Kg) weight gain in 5 days 3. confusion 4. urine output 20 mL/hr 5. blood pressure 108/62 mm Hg, heart rate 88 beats per minute bibasilar crackles

Correct response: urine output 20 mL/hr confusion Explanation: The nurse reports signs of decreased tissue perfusion to the HCP; these include a decrease in urine output and confusion. Crackles, edema, and weight gain are monitored closely, but are not as high a priority as decreasing tissue perfusion. Vital signs and oxygen saturation are within normal limits.

The nurse is caring for a client who has just returned from having a percutaneous transluminal balloon angioplasty. In which order, from first to last, should the nurse obtain information about the client? All options must be used. 1. pedal and radial pulses 2. vital signs and oxygen saturation 3. catheterization site 4. color and sensation of extremity

Correct response: vital signs and oxygen saturation pedal and radial pulses catheterization site color and sensation of extremity Explanation: When a client returns from having a transluminal balloon angioplasty, it is important to establish a baseline vital signs as this will allow the health care provider (HCP) to know if the client is experiencing complications such as bleeding or decreased perfusion. Assessing pedal pulse is important to establish a baseline and to determine if this client is receiving adequate peripheral tissue perfusion. Assessing the catheterization site and discharge teaching are important nursing activities, but are not a high priority at this time.

A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action? 1. crackles in lower lung fields during inspiration 2. weight gain of 2.5 kg (5.5 lb) in 24 hours 3. blood pressure 110/90 mm Hg 4. apical heart sounds 2 cm to the left of midclavicular line

Correct response: weight gain of 2.5 kg (5.5 lb) in 24 hours Explanation: Aortic stenosis leads to left ventricular enlargement and eventually to heart failure. Signs of heart failure include rapid weight gain, a shift of the apical pulse to the left of the midclavicular line, narrowed pulse pressure, and adventitious lung sounds. The nurse must intervene for rapid weight gain of more than 1 kg in 24 hours, which indicates fluid retention from worsening heart failure.

A client with chest pain doesn't respond to nitroglycerin. When the client is admitted to the emergency department, the healthcare team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? 1. within 24 to 48 hours 2. within 12 hours 3. within 5 to 7 days 4. within 6 hours

Correct response: within 6 hours Explanation: For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

What is the expected outcome of thrombolytic drug therapy for stroke? 1. prevention of hemorrhage 2. vasoconstriction 3. increased vascular permeability 4. dissolved emboli

Correct response: dissolved emboli Explanation: Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

A client is scheduled for a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory value to the health care provider (HCP) prior to the stress test? 1. cholesterol level 2. erythrocyte sedimentation rate 3. prothrombin time 4. troponin level

Correct response: troponin level Explanation: The elevated troponin level should be reported to the HCP prior to the stress test as this change indicates myocardial damage. Sending the client to walk on a treadmill for stress testing would be contraindicated with evidence of recent myocardial injury and could further extend the damage. The other blood levels are helpful but not critical to this client's welfare at this point in time.

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to safely remove the femoral sheath when the partial thromboplastin time (PTT) is: 1. 100 seconds or less. 2. 50 seconds or less. 3. 75 seconds or less. 4. 125 seconds or less.

Correct response: 50 seconds or less. Explanation: Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 50 seconds or less before the sheath is removed. Removing the sheath before the PTT drops below 50 seconds can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.

A client with heart failure is receiving furosemide, 40 mg I.V. The physician orders [40 mEq (40 mmol/L)] of potassium chloride in 100 ml of dextrose 5% in water to infuse over 4 hours. The client's most recent serum potassium level is [3.0 mEq/L (3.0 mmol/L)]. At what infusion rate should the nurse set the I.V. pump? 50 ml/hour 25 ml/hour 10 ml/hour 100 ml/hour

Correct response: 25 ml/hour Explanation: The nurse should use the following formula to determine the infusion rate:ml/hour = (total volume (in ml) to be infused/total time of infusion in hours)ml/hour = (100 ml/4 hours) ml/hour = 25

A nurse knows that the major clinical use of dobutamine is to 1. prevent sinus bradycardia. 2. treat hypotension. 3. increase cardiac output. 4. treat hypertension.

Correct response: increase cardiac output. Explanation: Dobutamine, a catecholamine agent, increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension, but this is not a primary indication for administration of dobutamine. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.

A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having which procedure? 1. tooth extraction 2. an IV line inserted 3. blood drawn 4. an X-ray examination

Correct response: tooth extraction Explanation: The client with a synthetic graft may need to be treated with prophylactic antibiotics before undergoing major dental work and should notify the HCP before any such procedure. Prophylactic antibiotic treatment reduces the danger of systemic infection caused by bacteria from the oral cavity. Venous access for drawing blood, IV line insertion, and X-rays do not contribute to the risk of infection.

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include? 1. "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours." 2. "Client will verbalize the intention to stop smoking." 3. "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol." 4. "Client will verbalize the intention to avoid exercise."

Correct response: "Client will verbalize the intention to stop smoking." Explanation: A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).

The nurse is evaluating the cardiac function of a client with history of left ventricular hypertrophy and new diltiazem administration. Which client statements indicate therapeutic use of diltiazem leading to adequate cardiac functioning? Select all that apply. 1. "In the morning, I notice 2 plus edema in my ankles." 2. "I am sleeping well in the second floor bedroom." 3. "My lab results reveal a serum potassium of 3.5 mEq/L (3.5 mmol/L.)" 4. "I am tolerating my new low fat diet." 5. "I am completing all of my activities of daily living independently." 6. "My blood pressure has been consistently in the 130/70 range."

Correct response: "I am sleeping well in the second floor bedroom." "My blood pressure has been consistently in the 130/70 range." "I am completing all of my activities of daily living independently." Explanation: When evaluating cardiac functioning, assess for client statements indicating normal client activities being completed successfully. Positive activities include sleeping well even after traveling upstairs, the blood pressure within normal limits and completing activities of daily living independently. It is good that the client is tolerating the low fat diet and has a normal serum potassium level but that is not related to adequate cardiac functioning. Pitting edema in the morning is a sign of cardiac compromise.

A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained? 1. "The physician will make a small incision in my chest wall and place the generator there." 2. "A wire from the generator will be attached to my heart." 3. "This implanted defibrillator will protect me against some of those bad rhythms my heart goes into." 4. "I wonder if there is any other way to prevent these bad rhythms."

Correct response: "I wonder if there is any other way to prevent these bad rhythms." Explanation: The client wondering if there is another way to prevent the abnormal rhythms indicates that other treatment options weren't discussed with the client. Before participating in a clinical trial, the client must be informed of all other available treatment options. The other statements about implantable cardioverter-defibrillators are all true.

When assessing a client with left-sided heart failure, the nurse expects to note 1. ascites. 2. air hunger. 3. jugular vein distention. 4. pitting edema of the legs.

Correct response: air hunger. Explanation: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.

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? 1. Auscultate heart sounds. 2. Begin telemetry monitoring. 3. Obtain a health history. 4. Evaluate the client's pain.

Correct response: Begin telemetry monitoring. Explanation: Telemetry monitoring should be started as soon as possible. Life-threatening arrhythmias are the leading cause of death in the first hours after MI. The other options are secondary in importance to assessing abnormal, life-threatening rhythms.

Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of: 1. I.M. injection. 2. cerebral bleeding. 3. myocardial necrosis. 4. skeletal muscle damage due to a recent fall.

Correct response: myocardial necrosis. Explanation: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

An obese diabetic client has bilateral leg aching is to start a cardiac rehabilitation with an exercise program. Using which exercise equipment will be most helpful to the client? 1. treadmill 2. stair climber 3. elliptical trainer 4. stationary bicycle

Correct response: stationary bicycle Explanation: The stationary bicycle is the most appropriate training modality because it is a non-weight-bearing exercise. The time that the individual exercises on the stationary bicycle is increased with improved functional capacity. The other exercise equipment requires exercising while standing.

The nurse is developing a discharge plan for a client who has had a myocardial infarction and been in the cardiac care unit for 2 days. The client will be transferred to a telemetry unit tomorrow. When can the client begin cardiac rehabilitation? 1. today, with a gradual increase of daily activities 2. when transferred to the telemetry unit 3. after an EKG shows 2 days of normal sinus rhythm 4. when discharged from the hospital

Correct response: today, with a gradual increase of daily activities Explanation: A basic principle of rehabilitation, including cardiac rehabilitation, is that rehabilitation begins on hospital admission and the client should increase activities as tolerated each day. It is not necessary to wait until the client is moved to a telemetry unit as the client will have EKG monitoring in both units. It is not necessary for the client to have normal sinus rhythm to increase activity; monitoring will detect potentially dangerous dysrhythmias. Delaying rehabilitation activities is associated with poorer client outcomes.

Which orders would the nurse anticipate initially in a client admitted with unrelieved chest pain? Select all that apply. 1. morphine sulfate 4 mg intramuscularly as needed for chest pain 2. cardiac diet 3. bed rest 4. troponin level now 5. computerized tomography scan of chest 6. electrocardiogram in 72 hours

Correct response: troponin level now cardiac diet bed rest Explanation: The nurse would expect troponin levels, cardiac diet, as well as bed rest. The other orders would not be anticipated for this client.

A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process? 1. "There is never contact between the donor's family and the recipient." 2. "The recipient is allowed to ask questions about the donor and have them answered." 3. "It is important that the recipient knows how to reach the family of the donor if health problems arise after the transplant." 4. "I will have the transplant coordinator speak with you to answer your questions."

Correct response: "I will have the transplant coordinator speak with you to answer your questions." Explanation: The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation processes, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.

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