Circulation and Perfusion
A new nurse is learning how to set up telemetry monitoring for a new admission. Put the steps in the correct order. 1. Expose the client's chest and shave the hair if dense. 2. Connect the lead wires to the transmitter. 3. Clean the client's skin with an alcohol pad. 4. Remove the electrode backing. 5. Insert a new battery into the transmitter. 6. Attach the lead wires to the electrodes. 7. Turn on the transmitter. 8. Apply the electrodes to the sites. 9. Place the transmitter in the pouch and the pouch strings around the client's neck. 10. Secure the monitoring equipment.
Answer: 1. Insert a new battery into the transmitter and turn it on. 2. Connect the lead wires to the transmitter. 3. Exposes the client's chest and shaves the hair if it is thick or dense. 4. Cleans the client's skin with an alcohol pad 5. Removes the electrode backing 6. Attaches the lead wires to the electrodes 7. Apply the electrodes to the sites 9. Secures the monitoring equipment 10. Place the transmitter in the pouch and the pouch strings around the client's neck.
A community health nurse is teaching CPR for a single rescuer of an adult victim collapse. Put the steps in order. Start CPR. Obtain an AED. Call 911. Establish responsiveness. Push hard and fast on the center of the chest. Administer one shock per AED. Continue CPR until help arrives. When the AED arrives, turn on and apply pads.
Answer: Establish Responsiveness Call 911 Obtain AED Start CPR Push hard and fast on the center of the chest When the AED arrives, turn on and apply pads Administer one shock per AED Continue CPR until helps arrives Correct Feedback: First, the rescuer should stablish responsiveness. If needed, call 911. Obtain an AED. Then, the rescuer should start CPR. The rescuer should push hard and fast on the center of the chest. When the ED arrives, they will turn on and apply pads and administer one shock per AED. The rescuer should continue CPR until help arrives.
The nurse is interviewing a client who presents to the clinic and reports a history of peripheral arterial disease. The client states the pain has gotten worse. Which question is the most important for the nurse to ask the client to obtain more information? 1. "Do you currently smoke?" 2. "How old will you be this year?" 3. "Do you have any pitting edema?" 4. "How often do you have chest pain?"
Answer: "Do you currently smoke?" Option 1: Smoking further restricts blood supply to the lower extremities and worsens peripheral arterial disease. Option 2: The client's age is not the most important information to obtain, as it does not affect peripheral arterial disease. Option 3: Pitting edema is noted most often in peripheral venous disease, not arterial. Option 4: The presence of chest pain would be important, but it is not related to peripheral arterial disease.
A client is learning about anticoagulant therapy. Which statement indicates that the client understands this therapy? 1. "There are no antidotes for heparin or Coumadin." 2. "I will need weekly blood tests if I take apixaban." 3. "If I am taking Coumadin, I will avoid green, leafy vegetables." 4. "I can use a regular razor to shave my face."
Answer: "If I am taking Coumadin, I will avoid green, leafy vegetables." Option 1: There are antidotes for heparin and Coumadin. Heparin is protamine sulfate and the antidote for Coumadin is vitamin K. Option 2: There are no weekly blood tests for dabigatran, apixaban, or rivaroxaban, and there are no antidotes. Option 3: Green leafy vegetables like kale, spinach, Brussels sprouts, parsley, collard greens, mustard greens, chard, and green tea contain vitamin K and should be avoided so as to not interfere with Coumadin. Option 4: Clients should be instructed to use an electric razor in order to prevent risk of cuts and bleeding.
A client was admitted to the hospital and started on heparin therapy. The client asks the nurse why the health-care provider prescribed heparin. What is the nurse's best response? 1. "I will discuss this prescription with your health-care provider." 2. "What concerns you the most about receiving this medication?" 3. "The health-care provider prescribes this medication for everyone." 4. "Since you are not moving around as much, this prevents blood clots."
Answer: "Since you are not moving around as much, this prevents blood clots." Option 1: This statement does not provide information to the client and is not the best response. Option 2: This response does not provide the client information as to why he or she is receiving the medication. Option 3: This is not the best response for the client, as it does not provide information. Option 4: Anticoagulants such as heparin are administered to hospitalized clients to prevent blood clots caused by decreased activity.
The nurse is administering morning medications including a once-a-day aspirin to a client with cardiovascular disease and diabetes mellitus. The client asks the nurse why the health-care provider prescribed an aspirin when he or she has no pain. What is the nurse's best response? 1. "The aspirin is used to prevent any pain from occurring." 2. "We will hold the medication until I receive clarification." 3. "This is a small dose of aspirin that I would not worry about it." 4. "Your risk for heart attacks and strokes can be decreased by taking aspirin every day."
Answer: "Your risk for heart attacks and strokes can be decreased by taking aspirin every day." Option 1: If the health-care provider was using aspirin as a pain reliever, it would be prescribed PRN instead of once a day. Option 2: The nurse would not need to hold the medication because the nurse could explain why the medication was administered. Option 3: This statement dismisses the client's concerns and does not answer the question. Option 4: The client has cardiovascular disease and diabetes mellitus. This places the client at a high risk for heart attacks and strokes. An aspirin a day can decrease the client's risk.
Which symptoms would the nurse expect to find in a female client experiencing a heart attack? Select all that apply. 1. Nausea 2. Jaw pain 3. Shortness of breath 4. Radiating left arm pain 5. Disappearance of chest pain with exhalation
Answer: 1,2,3 Option 1: Many women experience nausea during a heart attack. Option 2: Jaw pain is a frequent finding in women who are suffering a heart attack. Option 3: Women having a heart attack develop shortness of breath. Option 4: Men experiencing a heart attack experience radiating left arm pain. This does not happen in women. Option 5: Cardiac pain does not change with inhalation or exhalation.
Which interventions should the nurse include in the plan of care for a client with peripheral venous insufficiency? Select all that apply. 1. Elevate the lower extremities. 2. Apply compression stockings. 3. Ambulate the hallways frequently. 4. Assess for intermittent claudication. 5. Refrain from range of motion exercises.
Answer: 1,2,3 Option 1: The nurse would elevate the client's lower extremities to promote venous return and decrease edema. Option 2: Compression stockings help decrease edema and promote venous blood return. Option 3: The nurse should encourage the client to ambulate the hallways frequently to promote venous return. Option 4: Intermittent claudication occurs in clients with peripheral arterial disease. It causes pain with ambulation due to restricted blood supply. Option 5: Range of motion exercises will help move the lower extremities and improve venous blood return.
Which diagnostic tests would the nurse expect the health-care provider to prescribe to determine a client's risk for cardiovascular disease? Select all that apply. 1. Lipid panel 2. Cholesterol level 3. Arterial blood gas 4. C-reactive protein 5. Basic metabolic panel
Answer: 1,2,4 Option 1: A lipid panel is used to determine a client's cardiovascular risk. Option 2: The heath-care provider would prescribe a cholesterol level for a client to determine cardiovascular risk. Option 3: Arterial blood gases are prescribed to determine oxygenation. It does not assess risk factors. Option 4: A C-reactive protein test assesses for the presence of arterial inflammation and is used to determine cardiovascular risk. Option 5: A basic metabolic panel measures electrolytes, renal function, and glucose level. It does not measure a person's cardiovascular risk.
A nurse is assessing a client with cardiac pain. What is the difference between cardiac pain and pleuritic pain? Select all that apply. 1. Pleuritic pain is unrelieved with nitrates. 2. Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety. 3. Pleuritic pain is the result of a pulmonary emboli. 4. Cardiac pain typically does not change with inhalation or exhalation. 5. Pleuritic pain is diagnosed with cholesterol, lipid panel, C-reactive protein, and glucose testing.
Answer: 1,2,4 Option 1: Pleuritic pain may present as cardiac pain but is usually well localized in the chest wall, without radiation and with dyspnea on exertion. There may be evidence of inflammation and intercostal retractions. Option 2: Classic signs of cardiac pain occur in the center/left side of the chest, and the pain radiates to the left arm and lasts several minutes. It may subside and return. Option 3: A pulmonary emboli (PE) does not present with pleuritic pain. A PE presents with sudden chest pain, tachycardia, tachypnea, and hemoptysis. A complete assessment will differentiate this diagnosis. Option 4: A nursing assessment includes location, duration, frequency, radiation, and quantity. When the heart muscle is infarcted, it will be constant and not change with respirations. Option 5: A cardiovascular assessment includes cholesterol, lipid panel, C-reactive protein (CRP), and glucose lab testing. The CRP is the most reliable marker for arterial inflammation.
A nurse is teaching a client who is started on digoxin before discharge. Which statements by the client indicate correct understanding of the teaching? Select all that apply. "I will take my pulse before every dose and contact my health-care provider for a pulse of less than 50." 2. "I will notify my health-care provider if I have blurred, yellow vision." 3. "I don't have to worry about my potassium level when taking digoxin." 4. "My blood levels of digoxin should be between 0.2 and 0.5." 5. "My blood levels will have to be checked every month."
Answer: 1,2,5 Option 1: Clients and family members should be taught how to take a radial pulse for 1 minute and when to contact the health-care provider if below 50 beats/min. Option 2: This is a classic sign of digoxin toxicity and must be reported immediately to the health-care provider. Option 3: Potassium levels should also be monitored, as a level below 3.5 mEq/L may precipitate digoxin toxicity. Option 4: The therapeutic blood level for digoxin is 0.8 to 2.0 ng/mL. Option 5: Blood levels must be monitored closely to prevent ctoxicity. Levels greater than 2.0 are toxic.
Which questions should the nurse ask the client when assessing for peripheral vascular deficits? Select all that apply. 1. "Do you have numbness in your hands and feet?" 2. "Are there any sores on your legs that never heal?" 3. "Do you experience any chest pain upon exertion?" 4. "Do you feel dizzy when you change positions too fast?" 5. "What makes the pain worse, elevating your legs or dangling them?"
Answer: 1,2,5 Option 1: The presence of numbness in the hands and feet indicates the presence of peripheral vascular deficits. Option 2: Sores that never heal can occur with peripheral vascular deficits. Option 3: Chest pain is an example of impaired coronary circulation, not peripheral vascular circulation. Option 4: Dizziness that happens when changing positions too fast is orthostatic hypotension. This is central circulation, not peripheral circulation. Option 5: Arterial vascular disease can make the pain worse with elevating the legs; dangling the legs worsens the pain of venous vascular disease.
A nurse is teaching a client how to promote venous circulation. Which statements by the client indicates understanding of the teaching? Select all that apply. 1. "I will keep my legs elevated when I am sitting in the recliner." 2. "I will take a walk around the block in the morning and afternoon." 3. "I will only be able to perform range-of-motion exercises once per week" 4. "It's ok if I sit with my legs crossed in the car." 5. "I will drink at least six 8-ounce glasses of water every day." 6. "I will attend a smoking cessation class at the YMCA."
Answer: 1,2,5,6 Option 1: The client should have the legs raised above the level of the heart. Gravity promotes venous return from the feet and legs. Option 2: Walking is encouraged to contract the leg muscles and to move venous blood upward against gravity. Option 3: Range-of-motion exercises should be done every day, not just once a week. Option 4: Clients should be taught not to cross their legs, as it interferes with blood flow back to the heart. Option 5: Adequate hydration keeps the blood from becoming viscous, as viscous blood can lead to clots more easily. Clients should be encouraged to consume approximately 2,000 mL per day unless contraindicated. Option 6: Nicotine increases the risk of clots because it constricts the blood vessels.
What would the nurse assess for in a client with stable angina? Select all that apply. 1. Chest pain relieved by rest 2. Chest pain unrelieved by medication 3. Chest pain caused by cigarette smoking 4. Chest pain that gets worse without relief 5. Chest pain that leads to a myocardial infarction
Answer: 1,3 Option 1: Chest pain that is relieved by rest is stable angina. Option 2: Chest pain that is not relieved by medication is considered unstable angina. Option 3: Cigarette smoking that leads to chest pain in considered stable angina. Option 4: A client who develops chest pain that gets worse without any relief is unstable angina. Option 5: Chest pain that leads to a myocardial infarction is unstable angina.
Which interventions can the nurse include in the plan of care to prevent deep vein thrombosis (DVT) formation related to intravenous (IV) therapy? Select all that apply. 1. Ensure proper dilution of IV solutions. 2. Provide 2,000 mL of fluid intake per day. 3. Maintain aseptic technique during IV insertions. 4. Make sure the client changes positions frequently. 5. Assess the client's pedal pulses every 4 hours.
Answer: 1,3 Option 1: When IV solutions are too concentrated, this can cause chemical irritation to the veins. Option 2: Even though the nurse should ensure the client takes in 2,000 mL of fluid every 24 hours to prevent DVT formation, this does not prevent clots from forming at the IV site. Option 3: It is essential to maintain aseptic technique to prevent infection. Infectious pathogens can cause venous irritation and cause thrombi to form. Option 4: The nurse should make sure the client changes positions frequently to prevent lower extremity blood clots from forming; however, this would not cause DVTs to form from IV therapy. Option 5: The nurse would assess the client's pedal pulses to determine peripheral circulation. However, this would not prevent DVT formation from IV therapy.
The nurse is educating a client regarding the cardiovascular effects of chronic alcohol abuse. Which information should the nurse include? Select all that apply. 1. Leads to congestive heart failure 2. Causes endocarditis of the heart 3. Forms thrombi in the coronary arteries 4. Produces hepatic encephalopathy of the brain 5. Depresses cardiovascular centers of the brain
Answer: 1,3,5 Option 1: Congestive heart failure occurs from fluid volume overload and heart enlargement. This can occur from chronic alcohol abuse. Option 2: Endocarditis occurs from drug abuse, not alcohol. Option 3: Chronic alcohol abuse can lead to thrombi formation in the coronary arteries. Option 4: Hepatic encephalopathy occurs from chronic alcohol use, but it affects the brain, not the cardiovascular system. Option 5: Alcohol abuse affects the brain by depressing the cardiovascular centers of the brain.
A client with a diagnosis of dysrhythmias questions the nurse about the need for so many medications. The nurse explains the need for an antiarrhythmic to regulate the heart rate and rhythm. Which complications should the nurse explain to the client that can occur with untreated dysrhythmias? Select all that apply. 1. Amplified risk of stroke 2. Increased cardiac output 3. Narrowed valves in the heart 4. Decreased tissue oxygenation 5. Noted audible cardiac murmur
Answer: 1,4 Option 1: Dysrhythmias that are untreated can place a client at an increased risk for strokes. Option 2: Untreated dysrhythmias can cause a decrease, not an increase, in cardiac output. Option 3: Heart valves are narrowed due to congenital damage or acquired damage. This is not related to untreated dysrhythmias. Option 4: Tissue oxygenation decreases in clients with untreated dysrhythmias. Option 5: The nurse would notice an audible cardiac murmur in a client with heart valve abnormalities.
A nurse is teaching a group of clients about different cardiovascular medications. Which cardiac medications are considered vasodilators? Select all that apply. 1. ACE inhibitors 2. Diuretics 3. Beta-adrenergic blockers 4. Angiotensin II receptor blockers 5. Nitrates 6. Statins
Answer: 1,4,5 Option 1: ACE inhibitors cause vessel dilation. Such medications include captopril, lisinopril, and enalapril. Option 2: Diuretics remove sodium and water from the body via urine. Diuretics include HCTZ, furosemide, and spironolactone. Option 3: Beta-adrenergic blockers block the stimulation of beta receptors, which are located in the heart, to decrease heart rate, slow conduction of the AV node, and reduce myocardial contractility. Medications include metoprolol and propranolol. Option 4: Angiotensin II receptor blockers (ARBS) relax blood vessels, decrease blood pressure, and ease workload of the heart. Medications include losartan and valsartan. Option 5: Nitrates dilate the vessels during an episode of chest pain. Nitrates include nitroglycerin and Isordil. Option 6: Statins are a class of drugs that protect against coronary artery disease by lowering triglycerides and reduce the production of cholesterol by the liver.
Which conditions do beta blockers treat? Select all that apply. 1. Angina 2. Bradycardia 3. Lower cholesterol levels 4. Congestive heart failure 5. Acute myocardial infarction
Answer: 1,4,5 Option 1: Beta blockers are used to treat angina. Option 2: Bradycardia is a side effect of beta blockers. They are not used to treat bradycardia. Option 3: Statins, not beta blockers, are a classification of medications used to lower cholesterol levels. Option 4: Beta blockers are used in the treatment of congestive heart failure. Option 5: Beta blockers are used to treat acute myocardial infarctions because they decrease myocardial oxygen demand.
The nurse is examining a client who reports a history of peripheral venous abnormalities. What would the nurse expect to find during the examination? Select all that apply. 1. Cool skin 2. Stasis ulcers 3. Poor capillary refill 4. Lower extremity edema 5. Brown skin discoloration
Answer: 2,4,5 Option 1: A client with peripheral arterial disease would present with cool skin due to insufficient oxygenation to the extremities. Option 2: Due to fluid leaking from capillaries, the client will have tissues that weep and cause venous stasis ulcers. Option 3: Poor capillary refill is an assessment finding in a client with peripheral arterial disease. Option 4: A client with venous vascular disease would have lower extremity edema due to an increase in oncotic pressure that causes fluid to leak from capillaries. Option 5: Due to vascular congestion, a client with peripheral venous disease would have a brown skin discoloration in the lower extremities.
Which anticoagulants do not require blood testing to monitor blood levels? Select all that apply. 1. Heparin 2. Warfarin 3. Apixaban 4. Dabigatran 5. Rivaroxaban
Answer: 3,4,5 Option 1: Heparin administration requires blood monitoring of partial thromboplastin times. Option 2: Warfarin requires frequent blood testing for prothrombin times and international normalized ratios. Option 3: Apixaban does not require blood testing. Option 4: Dabigatran is a newer anticoagulant that does not require blood testing to monitor levels. Option 5: Rivaroxaban is an anticoagulant that does not require blood monitoring.
Which factors can decrease cardiac tissue perfusion? Select all that apply. 1. Pregnancy 2. Hypovolemia 3. Hyperlipidemia 4. Substance abuse 5. Birth control pills
Answer: 3,4,5 Option 1: Pregnancy increases cardiac output. It does not decrease cardiac tissue perfusion. Option 2: Hypovolemia can place a client at risk for shock and affect blood flow to the peripheral tissues. It does not alter cardiac tissue perfusion. Option 3: Hyperlipidemia can cause decreased cardiac tissue perfusion, as it narrows cardiac arteries. Option 4: Abusing drugs can decrease cardiac tissue perfusion. Option 5: The use of birth control pills can cause blood clots, which can affect both peripheral and cardiac tissue perfusion.
The nurse is preparing to interview a client with an extensive cardiac history. Which questions would the nurse ask of a client in a focused assessment of the family history? Select all that apply. 1. "How often do you experience chest pain?" 2. "Did your parents smoke? If so, at what age?" 3. "At what age did you begin to smoke cigarettes?" 4. "Have any of your siblings experienced a heart attack or stroke?" 5. "Who on your father's side of the family has heart disease?"
Answer: 4,5 Option 1: The nurse would ask the client about chest pain during the focused cardiovascular assessment. This does not fall under the family history. Option 2: Whether the client's parents smoke is not relevant family history. Those are modifiable risk factors and not genetic-related. Option 3: The client's smoking history does not relate to the client's family history. Option 4: Sibling cardiovascular health is relevant family history that the nurse should ask the client. Option 5: The nurse would ask the client about the parental history of cardiovascular disease in the family history.
A nurse is learning about coronary artery disease. What is coronary artery disease? 1. A narrowing of blood through a constricted heart valve 2. A condition when the heart becomes an inefficient pump and is unable to meet the body's demands 3. A heart disorder that results in heart enlargement and impairs cardiac contractility 4. A condition where plaque builds up in the arteries that is a leading cause of cardiac ischemia
Answer: A condition where plaque builds up in the arteries that is a leading cause of cardiac ischemia Option 1: A valve stenosis increases the workload of the heart and leads to hypertrophy (an enlarged heart muscle). Option 2: Heart failure can be on the right or left side. Blood is oxygenated by the lungs but is not circulated well through the tissues and organs. Option 3: Cardiomyopathy can be primary as a result of genetic causes, or it can be secondary, from another cardiovascular event. Option 4: Coronary artery disease (CAD) is caused by plaque that narrows the arteries, reduces blood flow to the heart muscle, and makes it more likely that clots will form and block the arteries fully.
A client is in the emergency room with complaints of chest pain and dyspnea. What would be the most important assessment data to report to the physician? 1. A blood pressure of 168/94 in left arm 2. A pulse oximetry reading of 91% on room air 3. A heart rate of 112 beats/min 4. An oral temperature of 98.9°F
Answer: A pulse oximetry reading of 91% on room air Option 1: A normal blood pressure is < 120/< 80. If this client is having a cardiac event, the blood pressure would be elevated. This is a circulation problem. Option 2: A normal pulse oximetry reading should be 95 to 100% on room air. This is the most important data to report because it is an oxygenation problem and needs to be treated immediately. Option 3: A normal heart rate is 60 to 100 beats/min. This client's heart rate is elevated due to complaints but is not dangerously high. Option 4: This temperature is within the normal range and does not require any treatment.
The nurse is reviewing the structures of the heart. Which part is the pericardium? 1. Two thin-walled muscles that receive blood into the heart 2. A sac of connective tissue that encases the heart 3. Two thick-walled muscles that pump blood out of the heart 4. The nerve tissue that acts as the pacemaker
Answer: A sac of connective tissue that encases the heart Option 1: The thin-walled muscles that receive blood into the heart are called atria. Option 2: The pericardium is located inside the chest cavity and encloses the heart. Option 3: The thick-walled muscles that pump blood out of the heart are called ventricles. Option 4: The SA node is called the pacemaker.
A nurse is reviewing lab data on a client with a BMI of 30.2 (obesity). What lab value would be most concerning? 1. A potassium level of 3.7 mEq/L 2. A total cholesterol level of 189 mg/dL 3. An HDL level of 47 mg/dL 4. An LDL level of 122 mg/dL
Answer: A total cholesterol level of 189 mg/dL Option 1: A normal potassium level is between 3.5 and 5.1 mEq/L. This potassium level is normal. Option 2: A total cholesterol level should be less than 200 mg/dL. Option 3: An acceptable HDL level is greater than 45 mg/dL. Option 4: An acceptable LDL level is less than 130 mm/dL.
Which statement is accurate regarding electrocardiography (ECG)? 1. An ECG includes placing two electrodes on the chest. 2. An ECG monitors the mechanical activity of the heart. 3. An ECG reflects what the nerves tell the heart muscle to do. 4. An ECG is used in screening to determine the risk factors for cardiac disease.
Answer: An ECG reflects what the nerves tell the heart muscle to do Option 1: An ECG involves placing three to five electrodes on the chest. Option 2: The ECG monitors the electrical, not mechanical, activity of the heart. Option 3: The ECG is demonstrating what the nerves are telling the heart muscle to do. Option 4: Current evidence states that ECGs should not be used to determine cardiac disease risk factors.
A client with a pulmonary effusion reports difficulty breathing and is short of breath. The pulse oximetry reading for the client is 97% on room air and has no circumoral cyanosis or any other symptoms. What should the nurse do next? 1. Assess the anxiety level. 2. Call a rapid response. 3. Give oxygen via nasal cannula. 4. Notify the health-care provider.
Answer: Assess the anxiety level Option 1: The nurse should assess the client's anxiety level, as this could make a client short of breath. Option 2: The nurse need not call a rapid response, as the client has good oxygenation. Option 3: The client has an oxygen saturation of 97%. Therefore, the client does not need supplemental oxygen. Option 4: The nurse has other things to do prior to notifying the health-care provider.
A nurse is caring for a woman who has been diagnosed with a myocardial infarction and does not want her family to know. The nurse states that she will not tell her family. What ethical principle is the nurse upholding? 1. Paternalism 2. Autonomy 3. Justice 4. Beneficence
Answer: Autonomy Option 1: Paternalism is when health-care professionals make decisions about diagnosis, therapy, and prognosis for the client. Based upon the health-care professional's belief about what is in the best interest of the client, he or she chooses to reveal or withhold client information in these three important arenas. Option 2: Autonomy is an agreement to respect another's right to determine a course of action; it supports independent decision making. Option 3: The justice principle refers to an equal and fair distribution of resources based on analysis of benefits and burdens of decision. Justice implies that all citizens have an equal right to the goods distributed, regardless of what they have contributed or who they are. Option 4: This refers to having compassion, taking positive action to help others, and desiring to do good. It is the core principle of client advocacy.
A nurse is assessing an older client for orthostatic hypotension. What receptors would respond to a client's lowering blood pressures? 1. Chemoreceptors 2. Thermoreceptors 3. Baroreceptors 4. Photoreceptors
Answer: Baroreceptors Option 1: Chemoreceptors are located in the aortic arch and carotid arteries and are sensitive to chemicals in the blood pH, oxygen, and carbon dioxide. Option 2: Thermoreceptors are located in the skin (external) and the hypothalamus (internal). Option 3: Baroreceptors are located in the walls of the heart and blood vessels and are sensitive to pressure changes. Option 4: Photoreceptors are located in the eyes (rod and cone cells).
A nurse is reviewing clinical data on a client with a history of type 2 diabetes mellitus, hypertension, and tobacco use. What data is the most concerning? 1. Blood pressure of 156/86 in left arm 2. Fasting serum glucose of 168 mg/dL 3. C-reactive protein of 3.2 mg/dL 4. Total cholesterol of 205 mg/dL
Answer: C-reactive protein of 3.2 mg/dL Option 1: Although this blood pressure is elevated, it is not the most significant finding. Option 2: For a client with type 2 diabetes mellitus, this fasting blood sugar is not ideal but is not the most significant finding. Option 3: A c-reactive protein of 3.2 mg/dL indicates a high-risk level for cardiovascular disease. CRP measures the amount of inflammation in the body and ideally should be less than 1.0 mg/dL. Option 4: Total cholesterol should be less than 200 mg/dL. Cholesterol levels can be managed with diet, exercise, or statins.
Anemia is a serious condition when the blood is unable to carry adequate amounts of oxygen to the tissues. What is the most common cause of anemia? 1. Carbon monoxide poisoning 2. Venous abnormalities 3. Arterial abnormalities 4. Valve incompetence
Answer: Carbon monoxide poisoning Option 1: Carbon monoxide is a colorless, odorless gas produced by the combustion of flammable materials or fuels. When inhaled, it binds tightly to hemoglobin at the oxygen receptor sites, which makes it impossible for hemoglobin to carry oxygen. Option 2: Venous abnormalities disrupt blood return from the heart and present with edema and brown skin discoloration. They are not caused by anemia. Option 3: Arterial abnormalities disrupt flow of oxygenated blood to tissues. Signs and symptoms of compromised arterial blood flow include pallor, pain, weak or absent pulses, slow capillary refill, and cool skin. Option 4: Valve incompetence does not cause anemia. Incomplete closure of a valve results in regurgitation of blood back to the chamber it originated from.
The nurse is preparing to give the first dose of sotalol, an antiarrhythmic, to a client. Besides taking vital signs, what else should the nurse assess for prior to administering the medication? 1. Cardiac rhythm strip 2. Pedal pulses 3. Bilateral lung sounds 4. Lower extremity edema
Answer: Cardiac rhythm strip Option 1: The nurse should print a cardiac rhythm strip prior to and after giving an antiarrhythmic medication. This allows the nurse to evaluate the effectiveness of the medication. Option 2: The nurse would assess for the presence of pedal pulses to determine perfusion to the lower extremities. The pedal pulses do not need be assessed for sotalol. Option 3: The nurse would assess bilateral lung sounds prior to administering a bronchodilator, not an antiarrhythmic. Option 4: The nurse would assess for lower extremity edema prior to administering a diuretic, not an antiarrhythmic.
A nurse is assessing lab values for a client admitted to rule out myocardial infarction. What is the most sensitive test that measures damage in the heart muscle? 1. Troponin 2. Myoglobin 3. Hemoglobin 4. Creatinine kinase-MB (CK-MB)
Answer: Creatinine kinase-MB (CK-MB) Option 1: Troponin measures a complex of proteins used to detect an MI. Troponin levels peak at 18 to 24 hours. Option 2: Myoglobin levels peak at approximately 2 to 4 hours and is a nonspecific marker for an MI. Option 3: Hemoglobin levels are not used to detect damage to the heart muscle. Hemoglobin carries oxygen. Option 4: The MB isoenzyme is only present in the heart muscle. A serum measurement of the MB band is used to detect an MI. Levels rise with an acute MI within 4 to 8 hours.
A nurse is admitting a client with a myocardial infarction. Which nursing diagnosis is the highest priority? 1. Activity intolerance 2. Decreased cardiac output 3. Risk for ineffective renal perfusion 4. Anxiety
Answer: Decreased cardiac output Option 1: This diagnosis is important but is not the highest priority on admission. Option 2: This is an actual physiological problem, and the client needs to be stabilized and to return to homeostasis. Option 3: At-risk-for diagnoses are not priority and would be lower on the list of diagnoses. Option 4: Anxiety is psychosocial and would be addressed once the decreased cardiac output interventions have been implemented.
Which classification of medications removes excess fluid from body tissues? 1. Diuretics 2. Calcium channel blockers 3. Positive inotropic agents 4. Beta-adrenergic blockers
Answer: Diuretics Option 1: Diuretics remove excess fluid from body tissues. Option 2: Calcium channel blockers treat arrhythmias and control hypertension. Option 3: Positive inotropic agents improve the heart's ability to effectively pump blood. Option 4: Beta-adrenergic blockers work to reduce the heart's workload and control arrhythmias.
The nurse is assessing a client with a potential deep vein thrombosis (DVT). What sign does the nurse use by dorsiflexing the toes? 1. Homan's sign 2. Pratt's sign 3. Kernig's sign 4. Brudzinski's sign
Answer: Homan's sign Option 1: The Homan's sign is elicited when the provider dorsiflexes the toes/foot of the affected leg. If there is pain on dorsiflexion, this is considered a positive Homan's sign. Option 2: The Pratt's sign is similar to the Homan's sign, but it is elicited by squeezing the calf of the affected leg to produce pain on the clot. Option 3: The Kernig's sign is a diagnostic sign for meningitis marked by a loss of the ability of a supine client to completely straighten the leg when it is fully flexed at the knee and hip. Pain in the lower back and resistance to straightening the leg constitutes a positive Kernig's sign. Option 4: The Brudzinski's sign is an involuntary flexion of the hip and knee when the neck is passively flexed. It can occur in clients with meningitis.
Cardiac dysrhythmias have the potential to decrease cardiac output. Which type of dysrhythmia is located in the AV node? 1. Ectopy 2. Supraventricular 3. Ventricular 4. Junctional
Answer: Junctional Option 1: Ectopy occurs when there are extra beats in the cardiac cycle. Option 2: Supraventricular cardiac dysrhythmias occur above the ventricles. Option 3: Ventricular cardiac dysrhythmias occur within the ventricles. Option 4: Junctional dysrhythmias occur within the AV (atrioventricular) node.
In planning care for a client with decreased cardiac output, which is the most important goal? 1. Lung sounds are clear to auscultation. 2. Peripheral pulses are equal bilaterally. 3. Apical pulse is between 60 and 80 beats/min. 4. Capillary refill is less than 2 seconds.
Answer: Lung sounds are clear to auscultation Option 1: Within the ABC prioritization of goals, airway and breathing are the most important before circulation. Option 2: Pulses are important to maintain for perfusion but refer to circulation, so this would be a goal after airway and breathing. Option 3: This is a correct apical pulse rate and would be individualized for that client. Option 4: Capillary refill is assessed in the fingers and toes to non-invasively assess perfusion. Capillary refill in a healthy, perfused client is 1 to 2 seconds.
The vascular system is composed of three types of vessels. What are capillaries? 1. Thick elastic walls that allow them to stretch during cardiac contraction (systole) 2. Thin, muscular, inelastic walls that collapse easily and return deoxygenated blood to the heart 3. Microscopic vessels that connect the arterial and venous systems 4. Vessels that maintain a constant baseline state of tone
Answer: Microscopic vessels that connect the arterial and venous systems Option 1: Arteries have thick elastic walls that allow them to stretch during contraction (systole) and recoil during diastole. Option 2: Veins and venules (the venous system) are the holding tank for fluctuations in blood volume. Option 3: Capillaries are microscopic vessels, created as arterioles branch into smaller and smaller vessels. They are one cell thick and exchange gases, nutrients, and wastes between tissue cells and blood. Option 4: Sympathetic fibers maintain the constant baseline state of partial contraction in the vascular system.
Which part of the ECG complex represents the SA node firing and conducting the impulse through the atria? 1. P wave 2. QRS complex 3. T wave 4. U wave
Answer: P wave Option 1: The P wave represents the firing of the SA node and the impulse moving through the atria. Option 2: The QRS complex reflects ventricular depolarization and causes the ventricles to contract. It is not related to the SA node. Option 3: The T wave occurs when the ventricles return to a resting state. This does not involve the SA node. Option 4: The U wave is usually not detected unless the client has an electrolyte imbalance and is unrelated to the SA node.
Which finding would the nurse expect to note when assessing a client with right-sided heart failure? 1. Peripheral edema 2. Shortness of breath 3. Decreased urinary output 4. Crackles in the lung fields
Answer: Peripheral edema Option 1: A client with right-sided heart failure will experience peripheral edema due to fluid backing up in the extremities. Option 2: Shortness of breath would be noted in a client with left-sided heart failure as blood backs up into the lungs. Option 3: Urinary output decreases in left-sided heart failure due to decreased blood supply to the kidneys. Option 4: The nurse would notice crackles in the lung fields in a client with left-sided heart failure due to inefficient pumping of the left side of the heart. This causes fluid to back up in the lungs, leading to crackles.
The nurse is reviewing the laboratory results for a client and notices a potassium level of 2.6 mEq/L. Based on this finding, which ECG change would the nurse expect to find? 1. Bradydysrhythmia 2. Tachydysrhythmia 3. Presence of U waves 4. Widened QRS complex
Answer: Presence of U waves Option 1: A client does not develop bradydysrhythmias from hypokalemia. These can occur due to scar tissue from previous myocardial infarctions. Option 2: Tachydysrhythmias do not occur from hypokalemia. They can result from fast heart rates. Option 3: U waves are usually not noticed on an ECG unless a client has an electrolyte imbalance such as hypokalemia. Option 4: A widened QRS complex can happen from hyperkalemia, not hypokalemia.
A nurse is reviewing the ECG complex of a client post myocardial infarction (MI). What is the QRS complex? 1. Represents the firing of the SA node and conduction of the impulse through the atria 2. Represents ventricular depolarization and leads to ventricular contraction 3. Represents the return of the ventricles to an electrical resting state so they can be stimulated again 4. Represents an electrolyte imbalance and is not usually seen
Answer: Represents ventricular depolarization and leads to ventricular contraction Option 1: This is the P wave in the cardiac cycle. Option 2: This is QRS complex in the cardiac cycle. Option 3: This is the T wave in the cardiac cycle. Option 4: U waves usually occur in response to certain medications such as digitalis or epinephrine, and an inverted U wave may indicate ischemia.
The NHLBI panel of experts recommended that children between 9 and 11 years be screened for cardiovascular risk factors. What is the most important screening for this age group? 1. Height and weight to calculate BMI 2. Select lipid profile 3. An EKG 4. A chest x-ray
Answer: Select lipid profile Option 1: BMIs are important in this age group but not the most specific indicator for cardiovascular disease. Option 2: A select lipid profile for baseline is recommended in this age group, regardless of family history. Option 3: An EKG is not indicated for this age group unless there is clinical data to support this procedure. Most children do not require an EKG unless there is underlying disease to indicate one. Option 4: A chest x-ray is not necessary as a screening tool for this age group and is not related to cardiovascular disease.
There are various cardiovascular medications that lower cholesterol. Which medication category lowers LDL cholesterol levels? 1. Diuretics 2. Vasodilators 3. Statins 4. Positive inotropes
Answer: Statins Option 1: The purpose of diuretics is to increase the elimination of sodium and water from the body by increasing urinary output. Option 2: The purpose of vasodilators is to dilate the vessels, which eases the work of the heart. Option 3: The purpose of statins is to decrease elevated LDL cholesterol levels. Option 4: The purpose of positive inotropes is to increase cardiac contractility.
The heart is regulated by the autonomic nervous system (ANS) and control centers in the brainstem. Where do the parasympathetic fibers innervate the heart? 1. The baroreceptors 2. The chemoreceptors 3. The trigeminal nerve 4. The vagus nerve
Answer: The vagus nerve Option 1: Baroreceptors are located in the walls of the heart and blood vessels and are sensitive to pressure changes. Option 2: Chemoreceptors are located in the aortic arch and carotid arteries and are sensitive to chemicals in the blood pH, oxygen, and carbon dioxide. Option 3: The trigeminal nerve (cranial nerve V) receives sensation from the face and innervates the muscles of mastication. Option 4: The vagus nerve (cranial nerve X) is both a sensory and motor (mixed) nerve in the heart.
