CHAPTER 23 Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders
The nurse is caring for a client who underwent valve replacement surgery 1 hr ago. Which of the following interventions should the nurse implement?
Communicate using simple terms and closed-ended questions.
The nurse is teaching a group of clients about risk factors for pericarditis. Which of the following should the nurse include in the teaching? Select all that apply.
Infections Medications Systemic lupus erythematosus (SLE) Kidney disease
The nurse is caring for a client with infective endocarditis (IE). Which clinical manifestations can the nurse expect to find? Select all that apply
Petechiae Aching muscles Fever
The nurse is caring for a client with infective endocarditis (IE). Which clinical manifestations can the nurse expect to find? Select all that apply.
Petechiae Aching muscles Fever
The nurse is caring for a client with myocarditis. Which of the following is an early clinical manifestation of this condition?
Pharyngitis
The nurse is caring for a client receiving heparin sodium who begins bleeding. Which medication is an antidote to heparin?
Protamine sulfate
Where does pulmonary circulation begin?
Right ventricle which pumps deoxygenated blood towards the lungs for gas exchange in the alveoli.
The nurse is caring for a client with aortic regurgitation. Which of the following interventions should the nurse implement?
Schedule periods of rest between activities.
What is the term for a normal heartbeat?
Sinus rhythm
The nurse is caring for a client with aortic regurgitation. Which of the following clinical manifestations should the nurse expect to find?
Forceful heartbeat when lying down
he nurse is caring for a client with aortic regurgitation. Which of the following clinical manifestations should the nurse expect to find?
Forceful heartbeat when lying down
The nurse is teaching a client about enoxaparin. Which statement made by the client indicates the need for further teaching?
"I need to get the air bubble out of the syringe."
The nurse is providing teaching for a client with mitral valve prolapse. Which of the following statements made by the client indicates an understanding of the teaching?
"I should follow a healthy diet."
The nurse is providing teaching to a client with strep throat about preventing rheumatic fever. Which statement made by the client indicates an understanding of the teaching?
"I will be given penicillin to treat the strep throat." -Using antibiotics to treat streptococcal infections can prevent rheumatic fever. Most common in ages 5-15 but can occur in at any age.
The nurse is providing teaching for a client with thrombophlebitis. Which of the following statements made by the client indicates an understanding of the teaching?
"I will elevate my legs to promote circulation and reduce edema."
The nurse is caring for a client with suspected cardiomyopathy. Which statement made by the client requires correction by the nurse?
"Restrictive cardiomyopathy is the most common type." -Dilated cardiomyopathy is the most common type.
The nurse is caring for a client with mitral regurgitation. The client asks the nurse what this means. Which response by the nurse is best?
"Your mitral valve leaflets do not close all the way. This allows backflow of blood into the left atrium every time the left ventricle contracts."
The nurse is reviewing the prothrombin time (PT) of a client receiving warfarin. The PT is 64 seconds. Which action should the nurse take first?
. Notify the health-care provider (HCP). the blood is too thin-normal
The nurse is caring for a client on warfarin. A normal prothrombin time (PT) range is 9 to 12 seconds. Calculate the therapeutic range. Enter the numeral only.
13.5-24
The nurse is caring for a group of clients. Which client is at highest risk for mitral valve prolapse (MVP)?
A 20-year-old female client -MVP is common in clients who are women age 15 to 30.-
The nurse is caring for a group of clients. Which client does the nurse identify as a high risk for developing dilated cardiomyopathy?
A client who recently received chemotherapy
The nurse is caring for a group of clients. Which client should the nurse see first?
A client with deep vein thrombosis (DVT) who reports dyspnea- may be experiencing a pulmonary embolism.
The nurse is caring for a group of clients. Which client does the nurse identify as high risk for developing infective endocarditis (IE)? Select all that apply.
A client with human immunodeficiency virus (HIV) A client who reports using intravenous (IV) drugs A client with gingival gum disease A client with an artificial heart valve
The nurse is caring for group of clients. Which client is at highest risk for developing deep vein thrombosis (DVT)?
A truck driver
The nurse is caring for a client receiving tissue plasminogen activator (tPA). Which of the following orders should the nurse question?
Administer acetylsalicylic acid (aspirin) as ordered. -Aspirin should be avoided because it can increase the risk of bleeding.
The nurse is caring for a client with myocarditis. Which of the following interventions should the nurse implement?
Administer lisinopril as ordered. -The nurse should administer ACE inhibitors or beta blockers.
The nurse is caring for a client with thrombophlebitis. Which of the following interventions should the nurse implement?
Administer nonsteroidal anti-inflammatory drugs (NSAIDS) as ordered
The nurse is caring for a client with mitral valve prolapse (MVP). Which of the following clinical manifestations can the nurse expect to find? Select all that apply.
Anxiety Dyspnea Murmur Fatigue
The nurse is caring for a client with a deep vein thrombosis (DVT). Which interventions should the nurse implement? Select all that apply.
Apply compression stockings. Instruct the client to quit smoking. Encourage ambulation as tolerated. Administer warfarin as ordered. Turn the client every 2 hr.
The nurse is caring for a client with mild mitral regurgitation. Which clinical manifestations can the nurse expect to find?
Asymptomatic
The nurse is caring for a client with pericarditis. Which clinical manifestation can the nurse expect to find?
Chest pain radiating to the clavicle
The nurse is assessing a client with a suspected deep vein thrombosis (DVT) of the left leg. Which clinical manifestations can the nurse expect to find? Select all that apply.
Edema Pain Calf tenderness Venous distention Warm skin
The nurse is teaching a group of clients about preventing infective endocarditis (IE). Which of the following should the nurse include in the teaching?
Emphasize importance of regular dental care.
The nurse is caring for a client with aortic stenosis. Which of the following interventions should the nurse implement?
Encourage the client to use the call light when getting up -Dizziness and syncope are symptoms of aortic stenosis; the nurse should encourage the client to call when getting up.
Where does systemic circulation begin?
Left ventricle -it pumps oxygenated blood into the aorta, the many branches of which eventually give rise to capillaries within the tissues.
The nurse is caring for a client receiving anticoagulant therapy for a deep vein thrombosis (DVT) of the left leg. How will the nurse know that therapy has been effective?
Measurement of the effected calf has shown a decrease in size.
Which of the following are valves of the heart?
Mitral Tricuspid Pulmonic Aortic
The nurse is caring for a client with cardiomyopathy. The client suddenly develops orthopnea, extreme fatigue, and chest pain. Which action should the nurse take first?
Notify the health-care provider. The client is exhibiting symptoms of heart failure
The nurse is caring for a client with pericarditis. Which of the following is a clinical manifestation the nurse can expect to find?
Pericardial friction rub
The nurse is caring for a client with pericarditis who develops cardiac tamponade. For which treatment should the nurse prepare the client?
Pericardiocentesis -process of puncturing the pericardium with a needle and draining excess fluid from the pericardial sac.-
Rheumatic fever is a rare complication of which condition?
Strep throat
The nurse is assessing a client with aortic stenosis. Which of the following should concern the nurse the most?
Wet lung sounds -can be indicative of heart failure or pulmonary edema.
The nurse is caring for a client receiving warfarin who begins to bleed. Which medication is the antidote for warfarin?
Vitamin K
normal therapeutic range of warfarin is
normal therapeutic range of warfarin is 13.5 to 24 seconds.
