Cardiovascular EAQ

A pregnant client who has a history of cardiac disease asks how she can relieve her occasional heartburn. The nurse should instruct the client to avoid antacids containing which ingredient?

Sodium

A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the health care provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse?

"It is important to take your medications daily to achieve optimal results."

A healthcare provider prescribes an antidysrhythmic to be administered intravenously (IV) at 1000 mcg/min. The directions from the pharmacy state that 500 mg of the drug should be added to 500 mL of D5W. At what rate should the nurse set the volume control device to administer the medication correctly? Record your answer using a whole number. ___ mL/hr

60

A nurse is working in the intensive care unit. Which client will the nurse be prepared to assist with cardioversion?

A client with supraventricular tachycardia

A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition?

A failure of the circulatory pump

A client is brought to the emergency department with chest pain. The client asks why an electrocardiogram (ECG) has been prescribed. The nurse explains that the ECG will do what?

Aid in detecting heart damage

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (Bumex) and digoxin (Lanoxin). What does the nurse determine is the cause of the depletion?

Diuretic therapy

What medication does a nurse expect to administer to control bleeding in a child with hemophilia A?

Factor VIII concentrate

After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next?

Interrupt the infusion and notify the primary healthcare provider of the aPTT result.

A nurse is determining whether or not a client's atrial rhythm is regular when reviewing the ECG rhythm strip. Which consistency of spacing will the nurse use to determine regularity?

P waves

What dietary choices should the nurse instruct the client taking spironolactone to avoid increasing? Select all that apply.

Potatoes Cantaloupe

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?

Sinus tachycardia

A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply, which may be diminished further by what?

Smoking cigarettes

A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days?

Taking the apical pulse before drug administration and teaching the client how to count the pulse.

A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction?

This prevents further fluid accumulation, which increases the workload of the heart.

A client is receiving continuous ECG monitoring while intravenous medication is being administered for premature ventricular complexes (PVC). Which dysrhythmia does the nurse conclude that the client is experiencing when the following rhythm appears on the ECG monitor?

Ventricular tachycardia

A healthcare provider prescribes morphine for a client who had a myocardial infarction. What clinical response will be reduced if the client experiences the intended therapeutic effect of morphine?

Workload of the heart

A nurse is providing discharge instructions about digoxin. Which response should a nurse include as a reason for a client to withhold the digoxin?

Blurred vision

What is the most common warning symptom of myocardial infarction in women?

Fatigue

A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain?

Fluid retention

Which process involves replacing dead and decomposed tissue with fresh collagen tissue?

Granulation

A client with heart failure is receiving digoxin and hydrochlorothiazide. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply.

Nausea Yellow vision Irregular pulse

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication?

Tachycardia and petechiae over the chest

What is the most objective way that a nurse can assess the extent of edema in a client?

Weighing the client

A client is receiving heparin sodium intravenously at 1500 units/hour. The concentration in the bag is 25,000 units/500 milliliters. The nurse determines that how many milliliters will infuse during the nurse's 8-hour shift? Record your answer using a whole number.

240mL

Which older adult is at an increased risk of inflammation due to gerontological changes?

An older adult with changes in his or her natural defense mechanism

A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. What is the nurse's best response?

"Coffee has caffeine, which can affect your heart. It should be avoided."

A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level?

Cannula

What should the nurse include in a teaching plan to help reduce the side effects associated with diltiazem (Cardizem)?

Change positions slowly.

A client's echocardiogram report indicates decreased cardiac output. Which nursing intervention is most appropriate for this client?

Restricting activity to avoid fatigue

The nurse provides medication discharge instructions to a client who received a prescription for digoxin (Lanoxin) following the client's myocardial infarction. The nurse concludes that the teaching was effective when the client says what?

"I should check my radial pulse rate daily."

A nurse is to administer 5000 units of heparin to a prenatal client on prolonged bed rest. The label indicates that there are 20,000 units of heparin in each milliliter of solution. How much solution should the nurse give the client? Record your answer using two decimal places and include a leading zero if applicable. ___ mL

0.25

Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client?

1 to 3 minutes

A client's cardiac monitor indicates multiple multifocal premature ventricular complexes (PVCs). The nurse expects that the treatment plan will include a prescription for which medication?

Amiodarone

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of?

Cardiac irritability

The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected?

Cardiopulmonary

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all the cholesterol in my body so it isn't a problem?" Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question?

Cellular membranes

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first?

Cervical

The nurse observes a client collapse while walking down the hallway. The nurse rushes to the client and determines that the client is in cardiopulmonary arrest. What will the nurse do first?

Check for a carotid pulse

What client response must the nurse monitor to determine the effectiveness of amiodarone?

Decrease in cardiac dysrhythmias

The nurse is caring for a client who is scheduled for an electrophysiology study (EPS) because of persistent ventricular tachycardia. Before the procedure the client is to receive a beta-blocker. What client's response during the procedure best indicates that the beta-blocker is working effectively?

Decreased heart rate

A nurse is evaluating the results of treatment with erythropoietin. Which assessment finding indicates an improvement in the underlying condition being treated?

Decreased pallor

A client experiences angina and is admitted to the telemetry unit for observation. Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain. Which instruction should the nurse include when teaching the client about the correct use of sublingual nitroglycerine?

Hold the tablet under the tongue until it is dissolved

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes?

Hypokalemia

The healthcare provider prescribes atenolol for a client with angina. What potential side effect will the nurse mention when instructing the client about this medication?

Hypotension

A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I watch my diet and stress levels carefully?" What is the most appropriate initial response by the nurse?

Identifying the concerns and helping the client explore feelings

A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority?

Immediate defibrillation

A client is admitted with a higher than expected red blood cell (RBC) count. What physiological alteration does the nurse expect will result from this clinical finding?

Increased blood viscosity

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect?

Increased contractile force of the myocardium

What are the clinical manifestations of myocardial infarction in women? Select all that apply.

Indigestion Unusual fatigue Sleep disturbances

A client develops ventricular fibrillation in a coronary care unit. Which action is a priority?

Initiate defibrillation

During chest physiotherapy (CPT), a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next?

Interrupt the therapy

Valsartan, an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? Select all that apply.

Irregular pulse rate Orthostatic hypotension

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response is based on which principle of bed rest?

It decreases the potential for further dislodgment of emboli

A client admitted to the hospital for chest pain is diagnosed with angina. What should the nurse teach the client that the most common characteristic of anginal pain is?

It is relieved by rest

The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, what should the client be instructed to do?

Keep a diary of activities

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, what should the nurse include?

Maintaining the supine position for a minimum of 4 hours

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply.

Palpitations Tachycardia Nervousness

A nurse teaches a client about warfarin (Coumadin). Which information is essential for the nurse to include in the education plan?

Periodic blood testing is necessary.

The nurse encourages a client with Raynaud's disease to stop smoking because it causes what?

Peripheral vasoconstriction

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take?

Place the client in the supine position and take the vital signs

Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias?

Potassium of 7.02 mEq/L (7.02 mmol/L)

Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate?

Protamine sulfate to parenteral heparin

A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?

Pulmonary embolism

Digoxin (Lanoxin) and furosemide (Lasix) are prescribed for a client with a diagnosis of pulmonary edema. What client response to digoxin is unrelated to toxicity?

Pulse of 64

A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. How does the nurse expect the client to describe the chest pain?

Severe, intense

After surgery a client's fever does not respond to antipyretics. The health care provider prescribes that the client be placed on a hypothermia blanket. What is a response to hypothermia therapy that the nurse should prevent?

Shivering

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary?

Spinach salad

While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority?

Stop the transfusion and administer normal saline

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?

Troponin T (cTnT)

A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is which type?

Type A or O negative

A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60. The nurse should assess the client for what early sign of decreased arterial pressure?

Weak radial pulses

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

Weight Smoking

A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates an understanding?

"Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? Select all that apply.

Iced tea Chocolate pudding Hot cocoa

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client?

Increase oxygen concentration to heart cells

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client?

Serum potassium of 7.2 mEq/L (7.2 mmol/L)

A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required?

"I have to take his blood pressure every day in the arm with the fistula."

A client is hospitalized with chest pain. The client's spouse voices concern about how pale the client is. What is the best response by the nurse?

"You must be frightened by this."

A client has elevated triglycerides and cholesterol. The client appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." Which is the nurse's most appropriate response?

"You need some fat to supply the necessary fatty acids, so you mainly just need to cut down on the amount of fat you consume."

A client who is diagnosed as having a myocardial infarction is admitted to the coronary care unit with prescriptions for bed rest and medication for chest pain. Within an hour after admission, the nurse finds the client walking around the unit. What is the nurse's best initial response?

"You need to rest. You should get back into bed."

After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse?

"You will be able to run progressively longer distances before tiring."

An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid and the serum electrolyte value demonstrates hyponatremia. What does the nurse conclude that the element that most likely contributed to the hyponatremia is?

Fluid intake

A client with a partial occlusion of the left common carotid artery is to be discharged while still receiving warfarin (Coumadin). Which clinical adverse effect should the nurse identify as a reason for the client to seek medical consultation?

Presence of blood in urine

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery?

Promoting physical and emotional rest

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client two days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what?

Tissue necrosis

A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client as the major purpose for catheterization?

To visualize the disease process in the coronary arteries

Which modifiable risk factors for coronary artery disease (CAD) should the nurse include in a teaching session for a Native American patient? Select all that apply.

Tobacco Hypertension Diabetes mellitus (DM)

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply.

Unusual fatigue Dependent edema Nocturnal dyspnea

When performing a physical assessment, the nurse identifies bilateral varicose veins. What does the nurse expect the client to report about the legs?

Worsening ankle edema as the day progresses

The healthcare provider prescribes nitroglycerin ointment for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment?

"I may experience a headache."

Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor?

"The monitor will record any abnormal heart rhythms while I go about my usual activities."

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse?

"This test will reflect any heart damage."

A client hospitalized with a severe myocardial infarction tells the nurse, "My life is over. I may as well just give up." What is the best response by the nurse?

"You feel your life is over?"

A nurse is monitoring a child for toxicity precipitated by digoxin. For what sign of digoxin toxicity will the nurse assess the child?

Vomiting

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process?

A pulse rate irregularity

A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. The behavior that demonstrates an increase in client autonomy is when the client does what?

Actively participates in providing self-care

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective?

An activated partial thromboplastin (APTT) twice the usual value

A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client?

Ankle edema

A client has a pulse deficit. Which documentation by the nurse supports this finding?

Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8.

A client is admitted to the hospital with a large leg ulcer, and a femoral angiogram is performed. What should the nurse do after this procedure?

Apply pressure to the catheter insertion site

A health care provider prescribes ophthalmic drops for a client. What should a nurse include in the instructions for a client learning to self-administer eye drops?

Apply pressure to the nasolacrimal duct after instillation.

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication?

Aspirin (ASA)

The nurse providing postprocedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first?

Assess the catheterization site

A client undergoes cardiac catheterization via the femoral artery. What is the most important nursing action after the procedure?

Assess the groin for bleeding

A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take?

Assess the pulses distal to the dressing

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what?

Attempts to minimize the illness

A nurse is teaching a client who had a myocardial infarction about the prescribed 1500-calorie, 2-gram-sodium, weight-reducing diet. Which low-sodium, low-calorie nutrients should the nurse recommend that the client include in the diet? Select all that apply.

Baked chicken Mashed potatoes

A client returns from a cardiac catheterization procedure and is to remain in the supine position for four hours with the affected leg straight. The nurse explains that these measures are to prevent what?

Bleeding at the arterial puncture site

A beta-blocker, atenolol (Tenormin), is prescribed for a client with moderate hypertension. What information should the nurse include when teaching the client about this medication? Select all that apply.

Change positions slowly Count the pulse before taking the medication Mild weakness and fatigue are common side effects

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check for a pulse

A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit the client's vital signs remained stable for one hour, with blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first?

Check the dressing on the incision

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do?

Keep a record of the day's activities

Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the patient with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin?

Common side effects include headache and low blood pressure

After undergoing a cardiac catheterization, the client complains of tingling sensations in the affected leg. What should the nurse do to determine the cause of the tingling?

Compare femoral, popliteal, and pedal pulses in both legs

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium (Coumadin) daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do?

Contact the health care provider to determine what anticoagulant therapy should be prescribed for this client

A client with cardiac dysrhythmia on medication for it. During a follow-up visit, the primary health-care provider learns that the client is experiencing fatigue, anorexia, headache, and visual disturbances. Which medication is likely responsible for the client's condition?

Digoxin

A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse understands that these signs and symptoms are toxic effects of which medication?

Digoxin (Lanoxin)

A client with heart failure is digitalized (given a loading dose of digoxin) and placed on a maintenance dose of digoxin 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved?

Diuresis and decreased pulse rate

While being prepared for surgery for a ruptured spleen, a client complains of feeling light-headed. The client's color is pale and the pulse is rapid. What should the nurse conclude about the client's condition?

Going into shock

The nurse in the intensive care unit is monitoring a client who had an aortic valve replacement. What can a slow pulse rate during the early postoperative period after open heart surgery indicate?

Heart block

While receiving a blood transfusion, a client develops flank pain, chills, fever, and hematuria. What type of transfusion reaction does the nurse conclude that the client probably is experiencing?

Hemolytic

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list?

Heredity

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?

How long the client was anoxic

The primary health-care provider suggests that a low-income 40-year-old client with cardiovascular disease, hypertension, and cerebrovascular accident access long-term care services. Which system would financially support the client to access the services?

Medicaid

A client is admitted to the emergency department with chest pain and shortness of breath. An electrocardiogram indicates that the client is experiencing a myocardial infarction. An emergency cardiac catheterization is scheduled. What information should the nurse include in the pre-procedure teaching?

Mild sedation is maintained during the procedure.

A nurse is auscultating a client's heart sounds. Which valves close when the first heart sounds are produced?

Mitral and tricuspid

A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention?

Monitor the vital signs every 15 minutes

A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure?

Monitoring the site for bleeding

A client who recently had a myocardial infarction is admitted to the cardiac care unit. How can the nurse best determine the effectiveness of the client's ventricular contractions?

Monitoring urinary output hourly

A client who is complaining of severe midsternal pain is brought to the emergency department. The client is diagnosed with a myocardial infarction. Which drug can the nurse expect to be prescribed to control this client's pain?

Morphine sulfate (MS Contin)

A client with a history of heart failure on daily weights has a 2-pound (0.9 kilogram) weight gain and pitting edema in lower extremities bilaterally. Which action should the nurse take next?

Perform a head-to-toe assessment, including vital signs

A home care nurse makes an initial visit to a 60-year-old female client with heart failure. The client lives with her daughter who is addicted to drugs and a single parent of seven children. When the nurse enters the home, the client is feeding a 6-month-old granddaughter and preparing dinner for the rest of the family. A 14-year-old grandson, disabled and in a wheelchair, states his mother is sleeping. What should the nurse do?

Question the client to determine whether there is a private place to take a health history and perform an examination

A client is admitted to the coronary care unit complaining of "viselike" chest pain radiating to the neck. Assessment reveals a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis. Cardiac monitoring is instituted, and morphine sulfate 4 mg intravenous (IV) push stat is prescribed. What is the priority nursing care for this client?

Relief of pain

A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first?

Remove any medication patches

A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition?

Report signs of bleeding no matter how slight

One week after admission to the cardiac care unit, a client displays an outburst of anger and tells the nurse to get out of the room. Which is the most appropriate nursing action?

Return when the client has calmed down

A thallium scan is scheduled for a client who had a myocardial infarction. What should the nurse explain to the client regarding the reason the scan has been prescribed?

That it establishes the viability of myocardial muscle

A client in the emergency department is diagnosed with atrial fibrillation. Initially the primary healthcare provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm?

The vagus nerve is stimulated.

Discharge teaching for a client with hypercholesterolemia includes nutritional instructions for a diet low in saturated fat. Which items included by the client on a list of foods to avoid supports the nurse's conclusion that teaching has been effective?

Whole milk and hard cheeses

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to follow up?

Whole milk with oatmeal

A client whose total cholesterol level is found to be 210 mg/dL at a screening session at a health fair asks the nurse what to do in light of this result. How does the nurse respond?

Your level is elevated slightly and a diet low in saturated fats should be followed."

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role?

"I will take clients' vital signs after their procedures are over."

The parents of a school-age child with leukemia ask the nurse why irradiation of the spine and skull is necessary. What is the most accurate response by the nurse?

"Leukemic cells may invade the nervous system, but the usual drugs are ineffective in the brain."

A client with type 1 diabetes asks what causes the several brown spots that have been noted on the skin. What is the nurse's best response?

"The brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

A client with angina pectoris is scheduled for a stress echocardiogram. What should the nurse tell the client that an echocardiogram is?

A noninvasive approach to assess cardiovascular status

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114 mm Hg. What should the nurse do first?

Elevate the head of the bed, provide reassurance, and reassess the blood pressure.

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?

Emboli associated with atrial fibrillation

A client with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client?

Decreased white blood cells

Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider?

Difficulty breathing

A primary health care provider decides to omit a treatment that was part of a course of chemotherapy for a client because the client demonstrates myelosuppression. What information would be appropriate for the nurse to give to the client regarding myelosuppression?

Eating a balanced diet, resting, and trying to avoid bleeding and infections are appropriate at this time

A client with a history of angina is scheduled for a cardiac catheterization. Catheter entry will be through the femoral artery. What should the nurse tell the client to expect?

Experience a feeling of warmth during the procedure

A client with a cardiovascular disorder reports exhaustion and activity intolerance. What does the nurse document in the assessment report?

Fatigue

A nurse teaches a client with varicose veins about prevention of a thromboembolus. Which statement regarding preventive measures indicates that the client requires further teaching?

I will massage my legs twice a day."

The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. The teaching includes that the client will be what?

In the supine position with the affected leg extended for several hours postprocedure.

A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do?

Notify the health care provider

A client is taking administering warfarin (Coumadin). The nurse recalls that the antidote for this medication is what?

Vitamin K