CHA 1 Exam #4

An 84-year-old client with heart failure presents to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning to the nurse? a. Digoxin (Lanoxin) therapy daily. b. Daily metoprolol (Lopressor). c. Furosemide (Lasix) twice daily. d. Currently taking an antacid for upset stomach.

A Confusion, blurry vision, and upset stomach are symptoms of Digoxin toxicity, which is common in older adults and requires immediate treatment. The other answers are important assessment data but do not indicate an immediate connection to the client's presentation.

Non-modifiable risk factors for CAD

Age Gender Ethnicity Family history Genetic predisposition

A client with chronic heart failure presents to the ED with a new onset of atrial fibrillation. Which of the following medications would the nurse question? a. Lasix (furosemide) b. Toprol XL (metoprolol succinate) c. Cardizem (diltiazem) d. Corlanor (ivabradine)

D Ivabradine is contraindicated in the presence of atrial fibrillation and should be stopped.

Parameters for: Prehypertension?

Systolic: 120 to 139 mm Hg Diastolic: 80 to 89 mm Hg

Determine which patient to see first at the start of shift: Daily assignment a. 60 yo F BP 210/90 with history of CAD b. 28 yo M BP 200/100, no personal cardiac history c. 50 yo M BP 160/99, c/o chest discomfort d. 45 yo F BP 180/80, creatinine of 1.4 mg/dL

c. 50 yo M BP 160/99, c/o chest discomfort

Which effects of aging on the cardiovascular system should the nurse anticipate when providing care for older adults (select all that apply)? a. Systolic murmur b. Diminished pedal pulses c. Increased maximal heart rate d. Decreased maximal heart rate e. Increased recovery time from activity

a. Systolic murmur b. Diminished pedal pulses d. Decreased maximal heart rate e. Increased recovery time from activity

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? a. blood pressure b. Airway patency c. Oxygen flow rate d. level of consciousness

b. Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs, level of consciousness, and dysrhythmia detection.

Modifiable risk factors for CAD

Elevated serum lipids Hypertension Tobacco use Physical inactivity Obesity

Parameters for: Stage 1 Hypertension?

Systolic: 140 to 159 mm Hg Diastolic: 90 to 99 mm Hg

A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. which medication would need to be with how for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglidine 4. Regular insulin

2. Metformin Metformin has to be withheld 24 hours before and for 48 hours after the cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney functions, with metformin in the system the client would be at an increased risk for lactic acidosis. The other medications in the remaining options do not need it withheld before and after cardiac catheterization.

A client is being discharged home following 5 days of acute care for treatment of a deep vein thrombosis. Which statement made by the client indicates a need for further teaching? a. "I will be going home on oral Heparin and warfarin." b. "I have an appointment for follow up care with my primary care provider." c. "I will avoid dark green leafy vegetables while taking warfarin." d. "I will report any signs of bleeding to my primary care provider."

A Heparin is not an oral drug and a patient will not go home on both Heparin and Coumadin. These medications are overlapped in the hospital for at least 5 days because they work differently from anticoagulants. A follow-up appointment is appropriate following hospitalization and labs will most likely be assessed for warfarin maintenance. Dark green leafy vegetables contain Vitamin K which is the antidote for warfarin. Avoidance is appropriate. Following DVT, all patients will be discharged on anticoagulant therapy. All anticoagulants present a risk for bleeding. Prompt recognition and reporting of bleeding is an appropriate action.

A client diagnosed with atherosclerosis and hypertension has been newly prescribed a combination drug of amlodipine and atorvastatin (Caduet). Which statement by the client indicates a need for further teaching? a. "I will continue to take my amlodipine with the new medication." b. "I'll follow up with my nurse practitioner on a regular basis." c. "I need to quit smoking as soon as I possibly can." d. "I shouldn't drink grapefruit juice while on this drug."

A The patient should not be taking amlodipine (Norvasc) and Caduet. Caduet is a combination drug that contains a statin as well as amlodipine (Norvasc). All other options are correct statements.

A nurse assesses a patient who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction

A, B, C Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

A client is prescribed lisinopril (Zestril) for control of hypertension. What health teaching will the nurse provide to this patient? (Select all that apply.) a. "This medication can cause increased potassium levels." b. "It is important to change positions slowly when you start this medication." c. "This medication may cause you to develop a persistent, non-productive cough." d. "To achieve maximum benefit of Zestril, your diet should include foods high in sodium." e. "Be sure to monitor your BP regularly while taking this medication."

A, B, C, E Lisinopril (Zestril) is an ACE inhibitor which is known to cause orthostatic hypotension associated with vasodilation; thus changing positions slowly is important. Persistent, nagging cough is also common in this drug category. Because this medication is being used to modify BP, regular monitoring is important to assess effectiveness. Hyperkalemia is also associated with ACE Inhibitors especially for clients with diabetes mellitus and renal dysfunction. A high sodium diet is inappropriate for a client with hypertension and would adversely affect BP

A client is diagnosed with right-sided heart failure. Which assessment findings will the nurse expect the client to have? (Select all that apply.) a. Peripheral edema b. Crackles in both lungs c. Increased abdominal girth d. Ascites e. Tachypnea

A, C, D, E Peripheral edema, increased abdominal girth, ascites, and tachypnea are all symptoms associated with right-sided heart failure due to the back up into the peripheral system. Crackles in the lungs are associated with left-sided heart failure.

The nurse is admitting a client with an ulcer on the right foot. Which statement made by the client indicates venous insufficiency? (Select all that apply.) a. "My ankles swell up all the time." b. "My leg hurts after I walk about a block." c. "My feet are always really cold." d. "My veins really stick out in my legs." e. "My ankles have been discolored for years."

A, D, E Symptoms of venous insufficiency include ankle and leg swelling, ankle discoloration, and full veins with dependent positioning of the legs (Chart 36-4). Pain with ambulation would signal claudication and cold extremities would indicate poor arterial perfusion.

Which action does flecainide have on the heart? a. Decreases conduction b. Decreases automaticity c. Accelerates repolarization d. Reduces myocardial contractility

A. Flecainide is a class IC sodium channel blocker; it decreases impulse conduction in the heart. Mexiletine is a class IB sodium channel blocker that accelerates repolarization. β-adrenergic blockers like esmolol decrease the automaticity of the sinoatrial node. Myocardial contractility is reduced with diltiazem, a calcium channel blocker.

During routine suctioning of a client with a tracheostomy, the client becomes diaphoretic, nauseous, and the heart rate decreases to 39 beats/minute. What is the nurse's best action at this time? a. Continue to clear the airway b. Stop suctioning the patient c. Administer atropine d. Call the heath care provider immediately

B Removing the noxious stimuli causing the vagal response would be the first action. If this does not resolve the bradycardia, second action would be to administer atropine and call provider. Continuing to suction is not appropriate as this is the cause of the vagal episode.

The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? a. Incisional pain with decreased urine output b. Muffled heart sounds with the presence of JVD c. Sternal wound drainage with nausea d. Increased blood pressure and decreased heart rate

B Symptoms are part of Beck's Triad which are indicative of tamponade. Incisional pain is expected. While sternal wound drainage is a problem, it is not an indicator of cardiac tamponade. With tamponade, blood pressure will decrease and the heart rate will increase.

Which statement made by the client on the way to the catheterization lab requires an immediate action by the nurse? a. "My allergies are bothering me so I took some Benadryl last night before bed." b. "I was nervous last night but I still remembered to take my warfarin last night." c. "I sure am hungry. I haven't had anything to eat since I went to bed last night." d. "I don't know what I will do if they find a blockage in my heart."

B Warfarin should be held prior to the procedure to avoid the risk of excessive bleeding. The nurse will need to call the provider immediately to determine if the cardiac catheterization will need to be rescheduled. Benadryl prior to the procedure is not contraindicated. This statement requires no action by the nurse. The statement in option C informs the nurse that the client has been NPO which is required prior to the heart catheterization. This statement in option D indicates mild anxiety associated with the medical procedure. Emotional support from the nurse is an appropriate response.

While performing an admission assessment on a client, the nurse assesses which of the following as risk factors for cardiovascular disease? (Select all that apply.) a. BMI of 22. b. Well-controlled diabetes mellitus. c. Exposure to second-hand cigarette smoke. d. BP of 128/54. e. History of repeated streptococcal tonsillitis. f. Family history of cardiovascular disease. g. Total cholesterol level is 140 mg/dl.

B, C, E, F Diabetes mellitus is a risk factor even if it is well controlled. The client's wife exposes him to second-hand smoke which is a risk for CVD. Recurrent streptococcal infections are associated with valvular disease and place the client at risk for CVD. A primary relative with the disease is a major risk factor. A BMI of 22 is normal, as is a BP of 128/54, and a cholesterol level of 140 mg/dl.

A 48-year-old female client having an annual physical asks the nurse about her risk for developing a myocardial infarction (MI). The nurse discusses risk factors with the client. Which modifiable risk factors will the nurse assess to guide the client's teaching plan? (Select all that apply.) a. Older age b. Tobacco use c. Female d. High-fat diet e. Family history f. Obesity

B, D, F Tobacco use, diet, and obesity are all considered modifiable risk factors and should be included in the plan of care.

A client who recently had a heart valve replacement is preparing for discharge. What statement by the client indicates that the nurse will need to do additional health teaching? a. "I need to brush my teeth at least twice daily and rinse with water." b. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." c. "I need to take a full course of antibiotics prior to my colonoscopy." d. "I will take my blood pressure every day and call if it is too high or low."

C Antibiotics are only required prior to dental procedures. Good oral hygiene is the best prevention for endocarditis. The statement in option A is correct and shows the patient understands the need for oral hygiene. The patient with a mechanical valve will be on warfarin (Coumadin); thus, foods high in Vitamin K should be avoided. This statement is in option B is correct and shows the patient understands foods that are LOW in Vitamin K. This statement in option D is also correct and shows that the patient understands the importance of regular BP assessment as well as when to call the provider based on the assessment.

The health care provider prescribes warfarin (Coumadin) for a client with atrial fibrillation. Which statement made by the client indicates additional education is needed? a. "I need to go to the clinical once a week to have my blood level checked." b. "If my stools turn black, I will be sure to call my healthcare provider" c. "I'm glad I do not need to change my diet. Salads are my favorite food." d. "I need to stop taking my herbal supplement"

C Patients on Coumadin therapy need to avoid foods high in Vitamin K including green leafy vegetables; INR needs to be measured frequently; black stools are a sign of bleeding and should be reported; herbal medications interfere with functioning of coumadin.

The nurse is teaching a client with a newly diagnosed cardiovascular disorder. Which statement made by the client demonstrates health promotion? a. "My heart disease will go away when I cut down to one cigarette a day." b. "I'm glad I don't have to change my diet and continue to eat whatever I want." c. "I need to get at least 150 minutes of moderate exercise a week." d. "I finally have my blood pressure to a normal level of 150/85."

C The statement in answer C shows that the client demonstrates health promotion. Answer A - This client needs additional education regarding smoking cessation. Certainly, decreasing cigarette smoking is helpful. However, any amount of smoking increases cardiovascular risk. A decrease in smoking will not cause heart disease to go away. Answer B - This patient requires further teaching regarding a healthy heart diet that is low in fat and sodium. Answer D - This client requires further teaching regarding normal blood pressure values.

The nurse is assessing a client with chest pain. Which symptoms assessed by the nurse would be most indicative of myocardial infarction? (Select all that apply.) a. Substernal chest discomfort associated with exertion b. Chest pain that is relieved with rest c. Chest pain associated with ECG changes d. Chest pain relieved with nitroglycerin. Chest pain relieved only by opioids f. Chest pain associated with shortness of breath g. Chest pain that lasts less than 10 minutes

C, E, F Refer to chart 38-2. Pain associated with myocardial infarction is associated with ECG changes (dysrhythmias and ST elevation), is often only relieved by opioids and has associated symptoms such as shortness of breath and nausea. The options are associated with angina pain.

The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact? a. Disabled automaticity b. Electrodes in the wrong lead c. Too much hair under the electrodes d. Stimulation of the vagus nerve fibers

C. Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.

A patient has recently started taking oral digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for control of heart failure. Which assessment finding by the home health nurse is most important to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Liver is palpable 2 cm below the ribs on the right side. c. Serum potassium level is 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

C. Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which also can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

A client in the telemetry unit is on a cardiac monitor. The monitor technician notices there are no ECG complexes and the alarm sounds. What is the first action by the nurse? a. Suspend the alarm. b. Call the emergency response team. c. Press the record button to get an ECG strip. d. Assess the client and check lead placement.

D ALWAYS check the patient first. Cardiac monitors are a tool for assessment but they do not replace hands-on nursing assessment.

The nurse is caring for a client with intermittent claudication pain related to peripheral arterial disease. Which statement made by the client indicates understanding of proper self-management? a. "I need to reduce the number of cigarettes that I smoke each day." b. "I will elevate my legs above the level of my heart." c. "I will use a heating pad to promote circulation." d. "I will start to exercise gradually, stopping when I have pain."

D Gradual exercise can improve collateral circulation and decrease pain associated with intermittent claudication. Teach the client to walk until they have pain, then to stop and rest, only to resume walking again. This promotes collateral development. Complete abstinence from smoking is essential to prevent vasoconstriction. While maintaining warmth is good to promote vasodilation, use of a heating pad is not safe due to the decreased sensation that can occur. Elevation of the extremities may be beneficial to reduce swelling; however, they should not be elevated above the heart level.

When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors? a. Male gender b. Marfan syndrome c. Abdominal trauma history d. Uncontrolled hypertension

D. We don't want the abdominal aortic aneurysm to rupture

Contributing modifiable risk factors for CAD

DM Metabolic Syndrome Chronic stress Homocysteine Substance abuse (meth and cocaine)

What is intermittent claudication?

Impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest. The perceived level of pain from claudication can be mild to extremely severe. Claudication is most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms. MC caused by PAD.

Parameters for: Stage 2 Hypertension?

Systolic: Greater than 160 mm Hg Diastolic: Greater than 100 mm Hg

Parameters for: Normal Blood Pressure?

Systolic: less than 120 mm Hg Diastolic: less than 80 mm Hg

The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should assess the client for which associated signs and or symptoms? Select all that apply. a. Syncope b. Dizziness c. palpitations d. Hypertension e. flat neck veins

a, b, c The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats per minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Hypertension and flat neck veins are not associated with the loss of cardiac output.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority intervention? Select all that apply a. Administering oxygen b. inserting a Foley catheter c. administering Furosemide d. administering morphine sulfate intravenously e. transporting the client to the coronary Care Unit f. placing the client in a little flower sideline position

a, b, c, d Extreme dyspnea, tachycardia, and crackles in a client with heart failure indicate acute pulmonary edema, a life-threatening event. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, the client is placed in high Fowler's position to ease of work of breathing. Furosemide, a rapid-acting diuretic, will measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact this may not be necessary at all if the client response to treatment is successful.

The nurse is obtaining a health history from a patient with hypertension. Nonmodifiable risk factors for the development of hypertension include which of these? Select all that apply. a. Age 65 years b. Excessive dietary sodium c. African-American ethnicity d. Excessive alcohol consumption e. A family history of hypertension

a, c, e

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mmHg. What should the nurse do next? a. Assess the patient's adherence to therapy b. Ask the patient to make an exercise plan c. Instruct the patient to use the dietary approaches to stop hypertension (DASH) diet d. Request a prescription for a thiazide diuretic

a. A long-acting calcium-channel blocker, such as nifedipine, causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance (SVR) and arterial blood pressure (BP) and related side effects. The nurse needs to assess the patient's adherence to therapy. The patient's blood pressure is elevated still and must be addressed. Asking the patient to make an exercise plan or use the DASH diet is not addressing the blood pressure. It is not necessary to request another medication without assessing if the patient actually is taking the medication prescribed.

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? a. Arousal, sinus rhythm, blood pressure 116/72 b. non arousal, sinus rhythm, BP 88/60 c. arousal, marked bradycardia, BP 86/54 d. non routable, supraventricular tachycardia, BP 122/60

a. After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during the ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardio pulmonary complications. Arousal status, adequate BP, and a sinus rhythm indicates successful response to defibrillation.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How should the nurse interpret the clients neurovascular status? a. The neurovascular status is normal because of increased blood flow through the leg. b. The neurovascular status is moderately impaired, and the surgeon should be called. c. The neurovascular status is slightly deteriorating and should be monitored for another hour. d. The neurovascular status shows adequate arterial flow, but penis complications are already arising.

a. An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Remaining options are incorrect interpretations.

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of esmolol (Brevibloc). The nurse should withhold the dose and consult the prescribing health care provider for which vital sign taken just before administration? a. Pulse 48 b. Respirations 24 c. Blood pressure 118/74 d. Oxygen saturation 93%

a. Because esmolol is a β1 -adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse-rate limits

A client electrocardiogram strip shows an atrial and ventricular rate of 110 beats per minute. the PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse interpret this rhythm? a. Sinus tachycardia b. sinus bradycardia c. sinus dysrhythmia d. normal sinus rhythm

a. Sinus tachycardia has the characteristics of a normal sinus rhythm, including a regular PP interval and normal with PR and QRS interval; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats per minute

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? a. It can develop into ventricular fibrillation at any time. b. it is almost impossible to convert to a normal rhythm. c. It is uncomfortable for the client, giving a sense of impending doom. d. it produces a high cardiac output with cerebral and myocardial ischemia.

a. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as a pacemaker for the heart. Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. Clients frequently experience a feeling of impending doom. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion, or defibrillation.

The nurse is providing care for a patient who has decreased cardiac output related to heart failure. What should the nurse recognize cardiac output? a. Calculated by multiplying the patient's stroke volume by the heart rate b. The average amount of blood ejected during one complete cardiac cycle c. Determined by measuring the electrical activity of the heart and the patient's heart rate d. The patient's average resting heart rate multiplied by the patient's mean arterial blood pressure

a. Calculated by multiplying the patient's stroke volume by the heart rate

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? a. Pulsus paradoxus b. Ventricular dysrhythmias c. Rising diastolic blood pressure d. falling central venous pressure

b. Dysrhythmias commonly occur as a result of decreased oxygen and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Pulsus Paradoxus is a finding associated with cardiac tamponade.

A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? a. Glipizide b. Metformin c. repaglinide d. regular insulin

b. Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If contrast medium affects kidney function, with metformin in the system the client would be at an increased risk for lactic acidosis. Medications in the remaining options do not need to be withheld before and after cardiac catheterization.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? a. Stridor b. Crackles c. scattered rhonchi d. diminished breath sounds

b. Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngeal spasm or edema of the upper Airway.

A client is wearing a continuous cardiac monitor, which begins to sound it's alarm. The nurse sees no electrocardiographic complex is on the screen. Which is the priority nursing action? a. call a code b. check the client's status c. call the health care provider d. document the lack of complexes

b. Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client is necessary to determine the cause and identify the appropriate intervention. Remaining options are secondary to client assessment.

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 ml /hour for 2 hours. The client received a single bolus of 500 mL of IV fluid. Urine output for the subsequent hour was 25 ml. Daily lab results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? a. Hypovolemia b. acute kidney injury c. glomerulonephritis d. urinary tract infection

b. The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urinary urea nitrogen and creatinine levels. Normal reference levels are bun, 10 to 20 mg/dL and creatinine 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg /dL for females. The client may need medication to increase renal perfusion and possibly could need peritoneal dialysis over hemodialysis. No data in the question indicates the presence of hypovolemia, glomerulonephritis, or UTI.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? a. anxiety level of the client and family b. activation status and settings of the device c. presence of a Medic Alert card for the client to carry d. knowledge of restrictions on post-discharge physical activity

b. The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cut off above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Complaint of left calf pain b. New onset shortness of breath c. Red skin color of left lower leg d. Temperature of 100.4° F (38° C)

b. New onset shortness of breath

Auscultation of a patient's heart reveals the presence of a murmur. What is this assessment finding a result of? a. Increased viscosity of the patient's blood b. Turbulent blood flow across a heart valve c. Friction between the heart and the myocardium d. A deficit in heart conductivity that impairs normal contractility

b. Turbulent blood flow across a heart valve

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women? Select all that apply. a. Lose weight b. Limit nuts and seeds c. Limit sodium and fat intake d. Increase fruits and vegetables e. Exercise 30 minutes most days

c, d, e Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in blood pressure (BP). Along with exercise for 30 minutes on most days, the dietary approaches to stop hypertension (DASH) eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Weight loss may or may not be necessary for the individual. Nuts and seeds and dried beans are used for protein intake.

A client with atrial fibrillation is receiving a continuous Heparin infusion at 1000 units per hour. The nurse determines that the client is receiving a therapeutic effect based on which result? a. Prothrombin time of 12.5 seconds b. activated partial thromboplastin time 28 seconds c. activated partial thromboplastin time of 60 Seconds d. activated partial thromboplastin time longer than 120 seconds

c. Common laboratory ranges for aptt are 30 to 40 seconds. Because the aptt should be 1.5 2.5 times the normal value, the clients aptt would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? a. Muffled heart sounds b. client reports dyspnea c. a rise in blood pressure d. jugular vein distention

c. Following pericardiocentesis, the client usually expresses immediate-relief. Heart sounds are no longer muffled or distance and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.

Which item on the patient's dinner tray should not be taken in large quantities by the patient prescribed furosemide (Lasix) for hypertension? a. Coffee b. Ice cream d. Grapefruit juice e. Chicken noodle soup

c. Furosemide , a diuretic, causes fluid loss to decrease blood pressure. Chicken noodle soup is high in sodium and may cause increased fluid retention, negating the effects of the medication and increasing the blood pressure. Ice cream, grapefruit juice, and coffee will not decrease the effectiveness of furosemide.

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse use to explain it? a. Blocks β-adrenergic effects b. Relaxes arterial and venous smooth muscle c. Inhibits conversion of angiotensin I to angiotensin II d. Reduces sympathetic outflow from the central nervous system (CNS)

c. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. Beta blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the CNS to produce vasodilation and decreased systemic vascular resistance (SVR) and blood pressure (BP).

The nurse is reviewing an electrocardiogram rhythm strip. The p waves and QRS complexes are regular. The PR interval is 0.16 seconds, and the QRS complex is measured 0.06 seconds. The overall heart rate of 64 beats per minute. Which action should the nurse take? a. Check vital signs b. check lab test results c. monitor for any rhythm change d. notify the primary health care provider

c. Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats per minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or lab results or to notify the primary healthcare provider. Therefore, the nurse would continue to monitor the client for any rhythm change

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? a. Cause of factors, such as caffeine b. sensation of fluttering or palpitations c. blood pressure and oxygen saturations d. precipitating factors, such as infection

c. Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, any number of physiological stressors, such as infection, illness, surgery, or trauma, and intake of caffeine, nicotine, or alcohol.

A client is being treated with Procainamide for cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? a. Obtain 12-lead electrocardiogram b. check the client's fingerstick glucose level c. auscultate a client's apical pulse and blood pressure d. measure the QRS interval duration on the Rhythm strip

c. Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although measuring the QRS duration on the Rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, they should be done after the vital signs are taken and before assessing for other possible issues, like hypoglycemia

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. the clients Rhythm suddenly changes to one with no p waves, no definable QRS complex, and coarse wavy lines of varying amplitude. How should the nurse interpret this rhythm? a. Asystole b. atrial fibrillation c. ventricular fibrillation d. ventricular tachycardia

c. Ventricular fibrillation is characterized by regular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible p waves or QRS complexes and results from electrical chaos in the ventricles

The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no p waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? a. Sinus tachycardia b. ventricular fibrillation c. ventricular tachycardia d. premature ventricular contractions

c. Ventricular tachycardia is characterized by the absence of p waves, wide QRS complexes, and typically a rate between 140 and 180 and pulses per minute. The rhythm is regular.

When looking at the electrocardiogram (ECG) of the patient, the nurse knows that the QRS complex recorded on the ECG represents which part of the heart's beat? a. Depolarization of the atria b. Repolarization of the ventricles c. Depolarization from AV node throughout ventricles d. The length of time it takes for the impulse to travel from the atria to the ventricles

c. Depolarization from AV node throughout ventricles

While assessing the cardiovascular status of a patient, the nurse performs auscultation. Which intervention should the nurse implement in the assessment during auscultation? a. Position the patient supine. b. Ask the patient to hold his or her breath. c. Palpate the radial pulse while auscultating the apical pulse. d. Use the bell of the stethoscope when auscultating S1 and S2.

c. Palpate the radial pulse while auscultating the apical pulse.

The nurse provides discharge instructions to a client with atrial fibrillation who is taking Warfarin sodium. Which statement, by the client, reflects the need for further teaching? a. I will avoid alcohol consumption b. I will take my pills every day at the same time c. I have already called my family to pick up a Medic Alert bracelet d. I will take coated aspirin for my headaches because it will coat my stomach

d. Aspirin containing products should be avoided when I client is taking this medication. Alcohol consumption should be avoided by a client taking Warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The Medic Alert bracelet provides Healthcare personnel with emergency information.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 ml per hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90 ml/hr, 50 ml/hr, and 28 ml/hr (most recent). The client's BUN levels 35 mg/dL, and the serum creatinine level is 1.8 mg/dL, as of this morning. Which nursing action is the priority? a. check the serum albumin level b. check the urine specific gravity c. continue monitoring urine output d. call the primary health care provider

d. Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during their surgery and, depending on the injuries and location, the renal arteries may be hyperperfused for a short period during surgery. Number reference levels are bun 10 to 20 mg/dL and creatinine 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. Continuing to monitor urine output or checking other parameters can wait. An output lower than 30 ml per hour is reported to the PHCP for urgent treatment.

A client with sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60, reports dizziness. Which intervention should the nurse anticipate will be prescribed? a. Administer digoxin b. defibrillate the client c. continue to monitor the client d. prepare for transcutaneous pacing

d. Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This Rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for the treatment of pulseless V-tach and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.

A client and ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level for the first delivery? a. 50 J b. 120 J c. 200 J d. 360 J

d. The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.

a client who is receiving digoxin daily has a serum potassium level of 3 mEq/L and reports anorexia. The HCP prescribes a serum digoxin level be done. The nurse checks the results and should recognize which level is abnormal? a. 0.5 ng/mL b. 0.8 ng/mL c. 0.9 ng/mL d. 2.2 ng/mL

d. The optimal therapeutic range for digoxin is 0.5 to 2.0. If the client is experiencing symptoms such as anorexia and is experiencing hypokalemia as evidenced by a low potassium level, then digoxin toxicity is a concern. Therefore, option d correct because it is outside of the therapeutic level.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads on the client's chest and before discharging the device, which intervention is a priority? a. ensure that the client has been intubated b. set the defibrillator to the synchronize mode c. administer a amiodarone bolus intravenously d. confirm that the rhythm is ventricular fibrillation

d. Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads are also checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize.

A client with variant angina is scheduled to receive an oral calcium channel blocker twice-daily. Which statement by the client indicates the need for further teaching? a. I should notify my cardiologist if my feet are like start to swell b. I'm supposed to report to my cardiologist if my pulse rate decreases below 60 c. avoiding grapefruit juice will definitely be a challenge for me since I usually drink it every morning with breakfast d. myself told me that since I have developed this problem, we are going to stop walking in the mall every morning

d. Variant angina, or Prinzmetal angina, is prolonged, severe and occurs at the same time each day, often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice should be avoided with calcium channel blockers. If bradycardia occurs, the client should contact the primary health care provider a cardiologist. The client should also be taught to change position slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina, therefore, the client should be able to continue morning walks with their spouse.