Exam 2 CARDIO

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A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse used the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as a grade level 1. Which of the following assessment findings correlates with a grade level of 1? A.) Redness at the intravenous access site with pain B.) Red streaks on the affected extremity C.) Palpable venous cord in the affected extremity D.) Purulent drainage at the intravenous site access site

A.) Redness at the intravenous access site with pain

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.

ANS: D Suggest that the health care provider order a basic metabolic panel. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.

DAPT

ASA PLAVIX

The nurse is caring for a patient in atrial fibrillation who is taking Coumadin before administering the dose the nurse reviewed labs and found the following findings K 3.6 mg2.1 ptt 28 pt/inr 22/2.8. What should the nurse do? Asminister the dose Hold it

Administer the dose

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? Anorexia Weight gain Breathlessness Distended abdomen

Breathlessness Manifestations of left-sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion.

A 74-year-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin? A Administer morphine sulfate IV. B Auscultate heart and lung sounds. C Obtain a 12-lead electrocardiogram (ECG). D Assess for coronary artery disease risk factors.

C Obtain a 12-lead electrocardiogram (ECG). If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A: Attach the leads for a 12 lead EKG B: Obtain a blood sample C: Initiate Oxygen Therapy D: Insert the IV Catheter

C. Initiate Oxygen therapy myocardial cell death is reason to prioritize O2 therapy - getting O2 to damaged cells to prevent further injury

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of thefollowing pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm

C. Radial pulse in the left arm Rationale: Palpating the client's pulse distal to the insertion site is essential for evaluating possible thrombophlebitis and vessel occlusion. The left radial pulse should be strong and essentially equal to the right radial pulse.

A nurse at a provider's office receives a phone call from a client who reports unrelieved chest pain after taking a nitroglycerin (Nitrostat) tablet 5 minutes ago. Which of the following is an appropriate response by the nurse?

Call 911

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur. A. is a high-pitched sound due to a narrow valve. B. is an extra sound due to blood entering an inflexible chamber. C. means that there is some inflammation around the heart. D. indicates turbulent blood flow through a valve.

D. indicates turbulent blood flow through a valve.

The nurse understands that aspirin is administered to a patient with a suspected myocardial infarction (MI) for which of the following reasons A. to promote thrombolysis B. to improve oxygenation to the myocardium C. to prevent ventricular dysrhythmias D. to prevent platelet aggregation

D. to prevent platelet aggregation the patient with a suspected MI should receive aspirin immediately, unless allergic to it, to help platelet aggregation

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? Exercise at least three times per week. Take diuretics early in the morning and before bedtime. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week Take naproxen for generalized discomfort.

Exercise at least three times per week. The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? Heart failure Asthma aortic valve regurgitation aortic stenosis

Heart failure Rationale: Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral

a nurse is caring for a patient with chronic atrial fibrillation but is the top priority of nursing care for this patient Cardioversion of Afib to NSR Oxygen status Physical therapy HR control

Heart rate control you can not cardiovert a chronic a fib pt.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? Elevating her feet Massaging her legs Flexing her ankles Ambulating too soon after surgery

Massaging her legs flexing ankles would promote bloodflow

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction(MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? Nitroglycerin Aspirin Oxygen Morphine

Morphine A. Incorrect: Nitroglycerin can help relieve angina pain, but as an acute MI progresses, it is ineffective for managing pain and anxiety. B. Incorrect: Aspirin can help in the immediate treatment of an acute MI, but it is not the medication of choice for managing pain and anxiety. C. Incorrect: Oxygen can help in the immediate treatment of an acute MI, but it is not the medication of choice for managing pain and anxiety. D. Correct: Morphine is the medication of choice for managing the pain and anxiety of an acute MI. By reducing preload and afterload, it decreases the work of the heart.

A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication? Potassium Hemoglobin Creatine BUN

Potassium

A patient with aortic valve stenosis is being admitted for valve replacement surgery. Which assessment finding documented by the nurse is indicative of this condition? Pulse deficit Systolic murmur Distended neck veins Splinter hemorrhages

Systolic murmur The turbulent blood flow across a diseased valve results in a murmur. Aortic stenosis produces a systolic murmur. A pulse deficit indicates a cardiac dysrhythmia, most commonly atrial fibrillation. Distended neck veins may be caused by right-sided heart failure. Splinter hemorrhages occur in patients with infective endocarditis.

Right sided Heart failure results in peripheral edema and jugular vein distention ? TRUE OR FALSE

TRUE Right side Heart failure results in inadequate right ventricle output and systemic congestion (peripheral edema)

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

The P wave is before the QRS complex -The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave. -in normal sinus rhythm, the T wave is upright. -In normal sinus rhythm, the P-R interval has a constant duration between 0.12 and 0.20 seconds. -In normal sinus rhythm, a QRS has a constant duration between 0.04 and 0.10 seconds.

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. which of the following labratory test are used to diagnose a myocardial infarction? Troponin I LDL Troponin T CPK myoglobin

Troponin I, Troponin T, CPK, myoglobin -Troponin I is correct. Troponin I is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. Troponin T is correct. Troponin T is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. Plasma low-density lipoproteins (LDL) is incorrect. Elevation of plasma low-density lipoproteins indicates a client's risk for coronary artery disease. An increase in LDL levels does not diagnose myocardial infarction. CPK is correct. CPK, or creatine phosphokinase, is an enzyme that is elevated in the presence of muscle injury. Although CPK is not specific for myocardial damage, it is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A CPK isoenzyme, CK-MB, is specific to cardiac muscle and a significant elevation in this isoenzyme indicates a myocardial infarction has occurred. Myoglobin is correct. Elevation of myoglobin indicates myocardial injury. Myoglobin levels will significantly increase within approximately 3 hours following myocardial infarction. This test is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction.

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? a. Troponin I b. Lipase c. BNP d. AST

a. Troponin I rule out MI first then BNP for HF

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? MI CAD CHRONIC STABLE ANGINA LEFT-SIDED HF

acute myocardial infarction

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? a. "Cardiac enzymes will identify the location of the MI" b. "These tests help determine the degree of damage to the heart tissues." c. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." d. "These tests will enable the provider to determine the heart structure and mobility of the heart valves."

b. "These tests help determine the degree of damage to the heart tissues."

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG. a. First-degree AV block b. Atrial fibrillation c. Sinus bradycardia d. Sinus tachycardia

b. Atrial fibrillation IRREGULAR PULSE DEFICEIT

The home care nurse visits a patient with chronic heart failure. Which clinical manifestations, assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? a. Fatigue, orthopnea, and dependent edema b. Severe dyspnea and blood-streaked, frothy sputum c. Temperature is 100.4oF and pulse is 102 beats/min d. Respirations 26 breaths/min despite oxygen by nasal cannula

b. Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia? a. Epinephrine b. Magnesium c. Atropine d. Sodium bicarbonate

c. Atropine

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? a. Slow b. Not palpable c. Irregular d. Bounding

c. Irregular With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse. Atrial fibrillation is an abnormal cardiac rhythm in which the atria are unable to effectively contract because of multiple rapid stimuli causing the atria to depolarize in an organized manner. The atrial rate can range from 300 to 600 bpm, with the ventricular rate being 120 to 200 bpm.The heart's contraction is not normal in the client who has atrial fibrillation. The atria quiver rather than contract, and the ventricles contract in a rapid, chaotic fashion. The ventricular response provides the client with a palpable pulse, although it may be difficult to count the rate.With atrial fibrillation, the amplitude of the client's pulse is highly variable. There is a decrease in ventricular filling, resulting in varying stroke volumes.

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? a. The client's EKG tracing shows irregular heart rate without P waves b. The client has an aPTT of 80 seconds c. The client experiences sudden weakness in one arm and leg d. The clients urine output is cloudy and odorless

c. The client experiences sudden weakness in one arm and leg Rationale: a is incorrect, the EKG tracing isn't a priority b is incorrect, the aPTT shows potential of being an issue, but isn't yet c is correct, a stroke could be happening in the brain and it's an actual issue d is incorrect, irrelevant

The nurse is preparing to discharge a patient with acute coronary syndrome what medication would the nurse question beta-blockers antiplatelets diuretics all are fine

diuretics ACS pts do not need to be on diuretics

a nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus? Positive Kernig's sign. Positive Homan's sign. Dull, aching calf pain. Soft, pliable calf muscle

dull aching calf pain (Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf. Kernig's sign indicates meningeal irritation. Homan's sign is unreliable as only a small percentage of clients who have a thrombus develop it, and performing it could mobilize the clot. A thrombus is more likely to cause muscle rigidity than a soft and pliable muscle.)

A nurse is assessing a client who has left sided heart failure which of the following findings should the nurse expect jugular vein dissension abdominal distention dependent edema hacking cough

hacking cough

Manifestation of left sided HF

pink frothy sputum

A patient has a chest tube what is the top nursing priority of this patient prevention of DVT's improved cardiac output prevention of atelectasis blood pressure management

prevention of atelectasis

A nurse is preparing to administer eliquis to a client who has atrial fibrillation the nurse should explain that the purpose of this medication is which of the following to convert atrial fibrillation to sinus rhythm to reduce the risk of stroke in clients who have atrial fibrillation dissolve clots in bloodstream slow the response of the ventricals to the fast atrial impulses

to reduce the risk of stroke in clients who have atrial fibrillation