HESI EAQ 1-6
Which topic will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? Select all that apply. a. need for daily aspirin b. symptoms of infection c. use of pain medications d. wound care for leg incision e. purpose of anticoagulant medications
b, c, e After mitral valve replacement, the nurse would teach the client about symptoms of infection and how to use prescribed pain medications to treat incisional pain. Clients with a mechanical mitral valve will need ongoing anticoagulation. Daily aspirin use would not be prescribed after mitral valve replacement, because there is no indication that this client has coronary artery disease. There is no leg incision with mitral valve replacement.
Which finding would the nurse expect when assessing a client with acute respiratory distress syndrome (ARDS)? a. hypertension b. tenacious sputum c. altered mental status d. slowed rate of breathing
c. altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies ARDS; cognition and level of consciousness are reduced. Hypotension occurs because of cardiac hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing is fast and shallow.
When assigned the care of a client arriving in the emergency department with possible acute coronary syndrome, which prescribed action would the nurse take first? a. obtain a 12 lead electrocardiogram (ECG) b. draw blood for troponin and creatine kinase MB c. ask the client about level of intensity of the chest pain d. notify the cardiac catheterization laboratory about the client
a. obtain a 12 lead electrocardiogram (ECG) Because ECG changes occur within minutes with acute coronary syndrome, an ECG should be obtained and interpreted within 10 minutes of admission for any client with possible acute coronary syndrome. Confirmation of changes indicating myocardial infarction will lead to rapid transfer to the cardiac catheterization laboratory and percutaneous coronary interventions. It is appropriate to obtain troponin and cardiac enzyme levels, but these do not immediately elevate in myocardial infarction and results will not affect immediate care of the client. Intensity of pain is asked of all clients, but is not a good reflection of the size of the ischemic area. Notification of the cardiac catheterization laboratory will be done, but the ECG will need to be done before making decisions about whether to transfer the client for interventions.
Which finding will cause the nurse to suspect cardiac tamponade in a client who has had cardiac surgery? Select all that apply. a. hypertension b. pulsus paradoxus c. muffled heart sounds d. jugular vein distention e. increased urine output
b, c d Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension, not hypertension, and a narrowed pulse pressure. As the cardiac output decreases, there is a decrease in kidney perfusion and a decrease in urine output.
Which nursing action has the highest priority when providing care for a client who has had an acute myocardial infarction (MI)? a. prevent nausea and vomiting b. monitor for cardiac dysrhythmias c. use prescribed medication to lower fever d. teach about the phases of cardiac rehabilitation
b. monitor for cardiac dysrhythmias The most common complication of myocardial infarction is dysrhythmias, including fatal dysrhythmias such as ventricular fibrillation, and the most important action is rapid detection and treatment of dysrhythmias. Clients with acute MI may experience nausea and vomiting secondary to vagal reflexes and these symptoms should be treated quickly, but are not the highest priority. Fever after MI is common because of the normal inflammatory response and may require treatment, but is not life-threatening. Teaching about cardiac rehabilitation is needed, but is not as high a priority as monitoring for dysrhythmias.
Which physiological change in the cardiovascular system is related to the aging process? Select all that apply a. less sensitivity to beta-adrenergic drugs b. tachycardia when changing position c. development of systolic murmurs d. shortening of the PR, QRS, and QT intervals e. increase in systolic blood pressure
a, c, e With age, people might become less sensitive to beta-adrenergic drugs due to a decrease in the number and function of beta-adrenergic receptors in the heart. Valvular fibrosis and calcification occur with aging (especially with the mitral and aortic valves) and can lead to murmurs caused by mitral regurgitation or aortic stenosis. An increase in systolic blood pressure can occur with aging due to arterial stiffening. The normal elevation in heart rate seen when changing position is muted with age, secondary to the sympathetic nervous pathway being affected by fibrous tissue and fatty deposits. With age, there is sometimes a slight lengthening of the PR, QRS, and QT intervals.
When assessing a client with chronic heart failure, which clinical finding would the nurse expect to find? a. dependent edema in the evening b. chest pain that decreases with rest c. palpitations in the chest when resting d. frequent coughing with yellow sputum
a. dependent edema in the evening Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract.
Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin? a. relief of anginal pain b. improved cardiac output c. decreased blood pressure d. ease in respiratory effort
a. relief of anginal pain Cardiac nitrates relax smooth muscles of the coronary arteries; they dilate and deliver more blood to heart muscle, relieving ischemic pain. Although cardiac output may improve because of improved oxygenation of the myocardium, improved cardiac output is not a basis for evaluating the effectiveness of sublingual nitroglycerin. Although dilation of blood vessels and a subsequent drop in blood pressure is a reason why intravenous nitroglycerin may be administered, decreased blood pressure is not the basis for evaluating the effectiveness of sublingual nitroglycerin, which is indicated for pain relief. Ease in respiratory effort is not the basis for evaluating the medication's effectiveness.
Which laboratory value will be important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)? a. troponin T (cTnT) b. c-reactive protein (CRP) c. low-density lipoprotein (LDL) d. b-type natriuretic protein (BNP)
a. troponin T (cTnT) Cardiac troponins are released into circulation within hours after myocardial injury or infarction, and elevation in troponin levels helps determine that the client is experiencing ACS. The other three values will also be monitored but are not markers for ACS or acute myocardial infarction. C-reactive protein is a marker for inflammation and elevated levels can predict cardiac disease. Elevated LDL is a risk factor for atherosclerosis and coronary artery disease. Elevated BNP is diagnostic for heart failure.
When the nurse is auscultating a client's heart, where would S2 be loudest? a. base of the heart b. apex of the heart c. left lateral border d. right lateral border
b. apex of the heart The first heart sound is produced by closure of the mitral and tricuspid valves; it is best heart at the apex of the heart. The base of the heart is where the second heart sound (S2) is best heart; S2 is produced by closure of the aortic and pulmonic valves. Left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. Right lateral border covers a large area; the only auscultatory area near it is the aortic area.
A client develops acute respiratory distress syndrome (ARDS). The nurse assesses the client and notes signs of pulmonary edema and atelectasis. The findings correspond to which phase of ARDS? a. fibrotic b. exudative c. reparative d. proliferative
b. exudative The exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis. The fibrotic phase of ARDS leads to pulmonary hypertension and fibrosis. The reparative (resolution) phase starts about 2 weeks after injury; is it characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death, or chronic disease may result. Proliferative occurs after the exudative (injury) phase, producing more hypoxia.
Which nursing action is most important preoperatively for a client with an abdominal aortic aneurysm? a. administering supplemental oxygen b. maintaining a low blood pressure c. keeping the client is a supine position d. monitoring the femoral and pedal pulses
b. maintaining a low blood pressure Maintaining a low blood pressure reduces the risk of aortic rupture. Administering supplemental oxygen may or may not be necessary. Keeping the client in a supine position may or may not be necessary. Monitoring pulses distal to the aneurysm will help identify whether an aneurysm has ruptured, but it will not prevent rupture
Which topic would be included in discharge teaching for a 22-year-old client who has had mitral valve replacement with a mechanical valve? a. daily aspirin use b. care of leg incisions c. anticoagulation therapy d. low fat and cholesterol diet
c. anticoagulation therapy Because of the risk for thrombus formation on mechanical valves, the client will need to take an anticoagulant such as warfarin on an ongoing basis. A prescription for daily aspirin is common artery coronary artery bypass graft (CABG) surgery for clients with coronary artery disease, but is not needed for a younger client who has mitral valve disease. Clients with mitral valve replacement do not have leg incisions. A 22-year-old client would not need teaching about low fat and low cholesterol.
Which collaborative intervention will the nurse anticipate to treat the dysrhythmia when a client has supraventricular tachycardia that has persisted despite treatment with vagal maneuvers and medications? a. defibrillation b. pacemaker placement c. synchronized cardioversion d. cardiac resynchronization therapy
c. synchronized cardioversion Synchronized cardioversion is the application of a shock that is timed to land on the R wave to depolarize the myocardium and allow the normal cardiac pacemaker in the sinoatrial node to take over normal cardiac stimulation. Defibrillation is not synchronized and might cause fatal dysrhythmias such as ventricular fibrillation if used on a client with supraventricular tachycardia. A pacemaker would be used for slow heart rates such as might occur with atrioventricular blocks. Cardiac resynchronization therapy is used for clients with severe left ventricular failure to synchronize the contraction of the right and left ventricles and improve cardiac output.
Which information about a client who is in cardiac arrest and has been transported by ambulance to the emergency department is most important to communicate to the health care provider? a. the client is male and age is 86 years b. nitroglycerin was taken before cardiac arrest c. the client has a history of coronary artery disease and previous cardiac surgery d. cardiopulmonary resuscitation (CPR) was started 9 minutes after the cardiac arrest
d. cardiopulmonary resuscitation (CPR) was started 9 minutes after the cardiac arrest Successful resuscitation from cardiac arrest usually occurs when CPR is started immediately. When clients have had prolonged periods of cardiac arrest before initiation of CPR, it is unlikely that resuscitation will be successful. In addition, irreversible hypoxic brain injury occurs when there is no brain perfusion for 4 minutes. The client gender and age will not affect the decision making by the resuscitation team. The use of nitroglycerin indicates that the client likely had angina before the cardiac arrest, but it will not affect the immediate resuscitation efforts. A history of coronary artery disease and cardiac surgery will be reported to the health care provider, but it will not affect resuscitation decision-making.
Which information can be obtained from monitoring the pulmonary artery pressure? a. stroke volume b. lung function c. coronary artery patency d. left ventricular functioning
d. left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Pulmonary artery pressure is not a measure of lung function, which is usually tested through spirometry. The patency of the coronary arteries usually is evaluated by cardiac catheterization.
Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? a. chest tube insertion b. aggressive diuretic therapy c. administration of beta-blockers d. positive end-expiratory pressure (PEEP)
d. positive end-expiratory pressure (PEEP) Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.
Which prescribed action would the nurse question when caring for a client who has heart failure, with blood pressure 102/70mmHg, pulse 106 beats/min, and bilateral lung crackles? a. infuse normal saline at 100ml/hr b. give furosemide 40mg intravenous now c. administer potassium chloride 10mEq orally now d. titrate oxygen by mask to keep oxygen saturation 93% or higher
a. infuse normal saline at 100ml/hr Because the likely cause of hypotension, tachycardia, and lung crackles in this client is decreased cardiac output and increased pulmonary congestion caused by heart failure, infusing normal saline would worse the symptoms of fluid overload and should be questioned by the nurse. Administration of diuretics such as furosemide will decrease fluid overload in the left ventricle and improve cardiac output. Because furosemide does lead to lower potassium, the administration of potassium is appropriate. Titration of oxygen to assure adequate oxygen saturation is appropriate for a client with pulmonary congestion.
When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first? a. attach the cardiac monitor b. auscultate the heart sounds c. check the intravenous fluid rate d. assess alertness and orientation
a. attach the cardiac monitor Because fatal dysrhythmias may occur in the first hours after myocardial infarction, cardiac monitoring is a priority. The nurse will also do auscultation of the heart, but changes in heart sounds as not expected with ACS and PCI. Checking the intravenous line for patency and correct infusion rate is also important, but would be done after establishing cardiac monitoring. Neurological status would be assessed, but changes in neurological status are not expected after PCI, which does not require general anesthesia.
Which prescribed action would the nurse perform first when caring for a client with hemodynamically stable sepsis who complains of abdominal pain? a. draw peripheral blood cultures from two different sites b. administer levofloxacin 500mg intravenously over 30min c. administration 1L intravenous bolus of Ringer's lactate over 30min d. take the client to x-ray for an abdominal CT scan
a. draw peripheral blood cultures from two different sites This question requires the learner to recall the priority treatments for clients with sepsis. Mortality in septic clients increases by 7.6% for every hour an antibiotic is delayed. Because this client is hemodynamically stable, the priority is to draw the blood cultures so that the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation.
When assessing a client's blood pressure, the nurse notes that the diastolic blood pressure reading in the right arm is 10mmHg higher than the blood pressure reading in the left arm. Which statement reflects the nurse's understanding of this occurrence? a. it is a normal occurrence b. it may indicate atherosclerosis c. it can be attributed to aortic disease d. it indicates lymphedema
a. it is a normal occurrence When auscultating blood pressures, readings between the arms can vary as much as 10mmHg and are often higher in the right arm. Readings that differ by 15mmHg or more suggest atherosclerosis or disease of the aorta. Lymphedema is swelling in one or more extremities that is the result of impaired flow of the lymphatic system.
Which explanation will the nurse give when a client who is admitted for coronary artery bypass graft (CABG) surgery asks about the purpose of pacemaker wires inserted during surgery? a. defibrillation of the heart after surgery b. prevention of slow heart rate after surgery c. maintenance of rate of at least 100 beats/min during surgery d. inhibition of too-rapid heart rate during the postoperative period
b. prevention of slow heart rate after surgery Pacing wires are sometimes placed during CABG so that pacing is rapidly available in case of bradycardia during the postoperative period. Pacing wires are not used for defibrillation. The heart is usually placed into cardiac arrest during CABG to facilitate the suturing of grafts into place. Medications to slow heart rate would be used rather than overdrive pacing during the postoperative period after CABG.
Which type of medication is indicated for management of cardiogenic shock? a. loop diuretic b. cardiac glycoside c. sympathomimetic d. alpha-adrenergic blocker
c. sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output. Diuretics promote excretion of fluid, which is not indicated. Cardiac glycosides slow and strengthen the heartbeat; they do not increase the blood pressure and may decrease it. Alpha-adrenergic blockers decrease peripheral resistance, resulting in a decreased blood pressure.
Which finding requires rapid action by the nurse after a client has had a cardiac catheterization? a. heart rate 114 beats/minute b. respiratory rate of 24 breaths/minute c. urine output of 1200 ml in the first hour postprocedure d. premature atrial contractions noted on the cardiac monitor
a. heart rate 114 beats/minute Increased heart rate is the initial compensatory mechanism for bleeding at the arterial catheter insertion site, which is the most common complication after cardiac catheterization. The nurse would quickly assess for other signs of bleeding, such as decreased blood pressure and blood or swelling at the catheter insertion site. A respiratory rate of 24 breaths/minute is slightly above normal and the nurse will continue to monitor the rate, but no other immediate action is needed. Urine output usually is increased post cardiac catheterization because of the osmotic effect of the contrast dye. Premature atrial contractions are common in clients with coronary artery disease and usually do not require any treatment.
Which manifestation in a client with heart failure indicates digoxin toxicity? Select all that apply. a. nausea b. yellow vision c. irregular pulse d. increased urine output e. heart rate of 64 beats/min
a, b, c Signs and symptoms of digoxin toxicity include nausea, visual disturbances (blurred vision of yellow vision), bradycardia, headache, dizziness, and confusion. In addition, electrocardiogram (ECG) findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of improved cardiac output; a pulse rate of 64 beats/min is an acceptable rate when a client is receiving digoxin.
Which clinical indicator would the nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. a. crackles b. atelectasis c. hypoxemia d. severe dyspnea e. increased pulmonary wedge pressure
a, b, c, d Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12-48hrs after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin.
Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. a. providing oxygen b. assessing vital signs c. obtaining a 12-lead EKG d. drawing blood for cardiac enzymes e. auscultating heart sounds f. administering nitroglycerin
a, b, c, d, e, f The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital signs, obtain a 12-lead EKG, and auscultate heart sounds to determine rhythm changes related to cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enyzmes. Changes in the levels of these enzymes (including troponin, creatine kinase, and myoglobin) can indicate damage to heart tissue. Nitroglycerin is administered to promote coronary vasodilation.
Which alteration is a client's condition post-operatively would indicate to the nurse that the client is experiencing a pulmonary embolus? a. bradycardia b. flushed face c. unilateral chest pain d. decreased blood pressure
c. unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or by pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence blood pressure.
Which finding would the nurse expect when assessing a client admitted for elective endovascular repair of a large abdominal aortic aneurysm? a. severe radiating abdominal pain b. pattern of visible peristaltic waves c. visible pulsating abdominal mass d. bilateral ankle swelling and redness
c. visible pulsating abdominal mass With a large abdominal aortic aneurysm, the pulsation of the aorta may be visible in the abdomen. Severe radiating abdominal pain might occur with a dissecting abdominal aortic aneurysm, which would be treated with emergency surgery. Visible peristaltic waves might be seen with a diagnosis such as intestinal obstruction, but peristalsis is not affected by an aortic aneurysm. Bilateral ankle swelling and redness is consistent with venous insufficiency, but not with aortic disease.
Where would the nurse place the stethoscope to listen for mitral valve insufficiency (regurgitation)? a. at the second intercostal space to the right of the sternum b. at the second intercostal space to the left of the sternum c. area over the right main bronchus d. at the fifth intercostal space at the left midclavicular line
d. at the fifth intercostal space at the left midclavicular line Point d is the mitral area at the 5th intercostal space at the left midclavicular line (also called the apex of the heart), where mitral valve murmurs can best be heard. Point a is the aortic area at the second intercostal space to the right of the sternum, where aortic valve murmurs are best heart. Point b is the pulmonic area at the second intercostal space to the left of the sternum; this area best reflects problems of the pulmonic valve. Point C is not part of the assessment of the heart; this is the area over the right main bronchus, which is used to assess bronchovesicular breath sounds.
Which adverse hemodynamic effect typically occurs when a client develops tachycardia? a. decreased ventricular filling time b. increased coronary artery filling c. lower cardiac output d. enhanced atrial kick e. weaker pulse quality
a, c, e Tachycardia may cause a decrease in cardiac output because of the decreased filling time for the ventricles and lower stroke volume. Pulse quality is weaker because of the lower stroke volume secondary to decreased ventricular filling time. There is a decreased time for coronary artery filling during diastole. During atrial systole, a bolus of atrial blood is ejected into the ventricles; this step is called the atrial kick, and it contributes more blood to the cardiac output of the ventricles. With fast heart rates, there is less time for the atria to fill, and less blood (atrial kick) to pump.
Which response would a nurse give when a client with a prosthetic heart valve asks why it is important to take antibiotics before a dental procedure? a. "the antibiotic is taken to prevent infection around your artificial heart valve" b. "valvular heart disease increases the risk for dental caries and gum disease" c. all clients with murmurs need prophylactic antibiotics before dental procedures" d. "you only need to take the antibiotic if you have a fever before your dental procedure"
a. "the antibiotic is taken to prevent infection around your artificial heart valve" An antibiotic is taken prophylactically to prevent infection of the heart if bacteria from the mouth enter the bloodstream. The risk for valvular heart disease (e.g., endocarditis) after invasive dental procedures is increased in clients with artificial heart valves, but the risk for dental infections such as caries or inflammatory gum disease is not increased by artificial heart valves. Current recommendations are that clients with artificial heart valves, a history of endocarditis, or uncorrected congenital heart disease should receive prophylactic antibiotics, but must clients with murmurs do not need antibiotic prophylaxis before invasive procedures. The prophylactic antibiotics should be taken as prescribed before the dental procedure to prevent endocarditis. If the client experiences fever, it should be reported to the dentist and health care provider and may require further evaluation and treatment.
Which action would the nurse take first when a 20-year-old client seen in the emergency department reports frequent "skipped heart beats," and the nurse notes frequent premature ventricular complexes (PVCs) on the cardiac monitor? a. ask the client about use of caffeine or stimulant drugs b. teach the client that PVCs may lead to cardiac arrest unless treated c. question the client about any family history of sudden cardiac death d. prepare to insert an intravenous catheter, anticipating medication administration
a. ask the client about use of caffeine or stimulant drugs In a 20-year-old, a common cause of PVCs is the use of stimulants such as caffeine-containing drinks or stimulant drugs such as methamphetamine. PVCs may cause ventricular tachycardia or ventricular fibrillation in clients with coronary artery disease, but educating a young person about these complications would not be the priority action. Questioning the client about any family history of sudden cardiac death is appropriate, especially if the client does not ingest any cardiac stimulants. When there is no underlying heart disease, PVCs are not usually treated except by eliminating any possible causes, such as stress or overuse of caffeine.
Which action would the nurse take for the first hour after a client has a cardiac catheterization using the brachial artery? a. monitor the vital signs every 15 minutes b. maintain the client in the supine position c. keep the client's lower extremities in extension d. ensure that the client is able to swallow clear liquids
a. monitor the vital signs every 15 minutes A cardiac catheterization may cause complications such as bleeding or dysrhythmias; therefore, the client's vital signs should be monitored every 15 minutes for 1hr and then every 30min for the next 2hrs until stable. When a brachial artery is used for catheter insertion, a low-Fowler, not supine, position usually is recommended because it promotes respirations. Keeping the client's lower extremities in extension is not necessary when the brachial artery was used for the catheter insertion. Because general anesthesia is not used for cardiac catheterization, swallowing does not need to be assessed postprocedure.
Which finding in a client who had coronary artery bypass graft (CABG) surgery 1 day previously is most important for the nurse to communicate to the health care provider? a. temperature of 102 F (38.9 C) b. 7/10 incisional pain (0-10 scale) c. sinus rhythm with PR interval of 0.22 seconds d. 120ml of blood in the chest tube collection chamber
a. temperature of 102 F (38.9 C) Although mild temperature elevations are common after surgery due to the inflammatory response, a high temperature may indicate wound infection and a need for actions such as blood cultures and antibiotic administration. Incisional pain is common after cardiac surgery and would be addressed by the nurse with prescribed postoperative analgesics and actions such as repositioning the client. The client's PR interval is mildly prolonged, but first-degree AV block does not affect cardiac output. A small amount of blood in the drainage device is common after cardiac or vascular surgery.
A client is intubated and receiving mechanical ventilation. The nurse reports to the client's room when the ventilator alarms. Which nursing action indicates that the ventilator was signaling a high-pressure alarm? a. the nurse removes secretions by suctioning b. the nurse lowers the setting of the tidal volume c. the nurse checks that tubing connections are secure d. the nurse obtains a specimen for arterial blood gases (ABGs)
a. the nurse removes secretions by suctioning Secretions in the airway will increase pressure by blocking air flow and must be removed. The nurse must identify/correct the problem so that the set tidal volume can be delivered. Connections that are not intact would cause a low-pressure alarm. ABGs are used to assess client status, but they are not taken each time a pressure alarm in heard.
Which finding in a client who has just arrived in the cardiac intensive care unit after having coronary artery bypass grafting (CABG) requires the most rapid action by the nurse? a. the serum potassium level is 3.1mEq/L (3.1mmol/L) b. the client is confused about the date and time of day c. the client reports incisional pain at level 8 (0 to 10 scale) d. chest tube collection chamber has 150ml of bloody fluid
a. the serum potassium level is 3.1mEq/L (3.1mmol/L) Hypokalemia is a common complication after CABG and immediate infusion of potassium to correct hypokalemia is needed to prevent postoperative dysrhythmias. Confusion in the immediate postoperative period is common after cardiopulmonary bypass and will be monitored by the nurse, but does not require any other action at this time. Incisional pain is common after CABG and the nurse will administer prescribed pain medications, but pain is not a life-threatening complication. Chest tube drainage of 100-200ml is not unusual in the first hours after CABG; the nurse will monitor the chest tube drainage hourly, but no other action is needed.
Which clinical manifestation would the nurse include when teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider? Select all that apply a. weight loss b. extreme fatigue c. coughing at night d. excessive urination e. difficulty breathing
b, c, e Fatigue is caused by a lack of adequate oxygenation of body cells caused by a decreased cardiac output. As the cardiac output decreases, pulmonary congestion increases, resulting in pulmonary edema; coughing, especially when lying down, and blood-tinged sputum occur. Dyspnea (difficulty breathing) is associated with pulmonary congestion that occurs as cardiac output decreases. Weight gain, not loss, occurs are fluid is retained by the kidneys. Fluid retention, not diuresis (excessive urination), occurs because of decreased circulation to the kidneys, resulting from decreased cardiac output.
Which type of medication will the nurse be prepared to administer when a client exhibits severe bradycardia? a. nitrate b. anticholinergic c. antihypertensive d. cardiac glycoside
b. anticholinergic An anticholinergic medication will block parasympathetic effects, causing an increased heart rate. Nitrates will decrease preload, not increase the heart rate. Antihypertensive medications will lower the blood pressure and may decrease the heart rate. Cardiac glycoside will improve cardiac contractility but will decrease the heart rate.
Which finding by the nurse is most important to communicate to the health care provider when assessing a client who has aortic stenosis and is scheduled for aortic valve replacement? a. loud systolic murmur b. multiple dental caries c. heartburn when lying down d. paroxysmal noctural dyspnea
b. multiple dental caries Multiple dental caries increase the risk for endocarditis in clients with valvular disease, and caries should be treated before surgery. A loud systolic murmur is typical for aortic stenosis. Heartburn will be treated with medications such as histamine blockers or protein pump inhibitors but is not a reason to postpone surgery. Paroxysmal nocturnal dyspnea is a common symptom of severe aortic stenosis.
Which action would the nurse take first when a client suddenly reports lightheadedness and blood pressure drops while waiting in the preoperative holding area for endovascular repair of an abdominal aortic aneurysm? a. prepare for blood transfusions b. notify the surgeon immediately c. ensure that the surgical consent form is signed d. administer the prescribed preoperative sedative
b. notify the surgeon immediately Because the client's symptoms indicate a likely rupture of the aneurysm, immediate surgical intervention is needed. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. Surgical consent will be obtained, but the surgeon needs to be rapidly available to intervene. Preoperative medications will eventually be administered, but they mask clinical manifestations of shock and would not be given until the health care provider evaluates the client.
Which client information is important to communicate to the health care provider when the nurse is obtaining a health history for a client scheduled for cardiac catheterization? a. drink 2 cups of coffee daily b. reports allergy to most shellfish c. recently had dobutamine stress test d. takes daily low-dose aspirin tablet
b. reports allergy to most shellfish Because cardiac catheterization uses iodine-based contrast for imaging, shellfish and iodine allergies must be identified so that pretreatment with antihistamines and steroids can be used if indicated. Moderate coffee consumption does not require any change in the cardiac catheterization protocol. Many clients scheduled for cardiac catheterization have had noninvasive cardiac stress testing, and a dobutamine stress test is not a contraindication to the planned procedure. Aspirin therapy is recommended for clients with possible coronary artery disease and is not a contraindication to the procedure.
Which answer would the nurse provide when a client who has had a myocardial infarction asks why a thallium scan has been prescribed? a. to check heart valve function b. to establish viability of heart muscle c. to visualize ventricular systole and diastole d. to monitor the heart's electrical conduction
b. to establish viability of heart muscle A thallium scan is a radionuclear study that establishes the viability of myocardial tissue; necrotic or scar tissue does not extract the thallium isotope. Heart valve function would be checked with echocardiography. Ventricular systole and diastole would also be assessed with an echocardiogram. The cardiac conduction system is monitored with an electrocardiogram.
Which explanation would the nurse give to the spouse of a client who had coronary artery bypass graft (CABG) surgery when asked why there is a dressing on the client's left leg? a. "this is the access site for the heart-lung machine" b. "a filter is inserted in the leg to prevent embolization" c. "a vein in the leg was used to bypass the coronary artery" d. "the arteries in the extremities are examined during surgery"
c. "a vein in the leg was used to bypass the coronary artery" The response that a vein in the leg was used to bypass the coronary artery provides information and reduces anxiety. The nurse understands that the greater saphenous vein of the leg is used to bypass the diseased coronary artery. Cardiopulmonary bypass (extracorporeal circulation) is accomplished by placement of a cannula in the right atrium, vena cava, or femoral vein to withdraw blood from the body; blood is returned to the body via a cannula in the aorta or the femoral artery. A filter is not inserted in the leg to prevent embolization during a coronary artery bypass graft (CABG). The arteries in the extremities are not examined during a CABG.
Which statement by a client indicates that the nurse's preprocedure teaching about cardiac catheterization has been effective. a. "i will be asleep during most of the procedure" b. "i will be in the catheterization laboratory for about 15 minutes" c. "i will need to be in bed for several hours after the procedure" d. "i will need to deep breathe and cough frequently after the procedure"
c. "i will need to be in bed for several hours after the procedure" Clients need to be on best rest for several hours after cardiac catheterization to decrease the risk of bleeding from the catheter insertion site and because they require frequent monitoring of blood pressure and heart rate. Clients are given a mild sedative, but they are awake during the procedure. Cardiac catheterization requires about an hour because of the time needed to prepare the client and insert arterial catheters before injection of contrast dye. Because the client is awake during the procedure and general anesthesia is not used, deep breathing and coughing is not needed after the procedure.
Which finding would be of most concern when the nurse is caring for a client who has just arrived in the intensive care unit after coronary artery bypass graft surgery? a. blood pressure 152/92mmHg b. blood glucose 120mg/dL (6.68mmol/L) c. atrial fibrillation, rate of 112 beats/min d. 100ml of blood in the chest drainage system
c. atrial fibrillation, rate of 112 beats/min Atrial fibrillation is common after cardiac surgery and can adversely affect cardiac output and blood pressure. The nurse would discuss the dysrhythmia with the health care provider and anticipate a prescription for an antidysrhythmic medication. An elevated blood pressure immediately after surgery is common because of the stress response; the nurse would continue to monitor the blood pressure but no other immediate action is needed. Mild elevations in blood glucose are expected with stress and would not adversely affect wound healing or other client outcomes. The nurse would continue to monitor the glucose, but no other immediate action is needed. Moderate bleeding in the immediate postoperative period after cardiac surgery is common. The nurse would continue to monitor the chest drainage system and expect that bleeding would decrease, but no other immediate action is needed.
Which information will the nurse include when planning dischrge teaching or a client who had coronary artery bypass graft (CABG) surgery using a vein graft? a. call immediately if you experience any incisional pain b. mild fever is expected for several weeks after a CABG c. elevate the leg that provided the vein graft whenever you are sitting d. avoid walking or light housework until after the follow-up appointment
c. elevate the leg that provided the vein graft whenever you are sitting Because the leg that provided the vein graft is likely to be edematous after surgery, the client should keep the leg elevated when possible. Incisional pain is expected for several weeks, and the client will be prescribed medication for pain control and should not need to call because of pain. Elevated temperature for a few days after surgery is normal, but fever occurring after discharge should be reported to the health care provider. Walking a few hundred feet and doing light housework are appropriate activities after discharge. More vigorous exercise of lifting heavier objects should be avoided until after seeing the health care provider or being evaluated in a cardiac rehab program.
The nurse caring for a client with the following arterial blood gas (ABG) values: PO2 89mmHg, PCO2 35mmHg, and pH of 7.37. These findings indicate that the client is experiencing which condition? a. respiratory alakalosis b. poor oxygen perfusion c. normal acid-base balance d. compensated metabolic acidosis
c. normal acid-base balance All data are within expected limits; PO2 is 80-100mmHg, PCO2 is 35-45mmHg, and the pH is 7.35-7.45. None of the data are indicators of fluid balance., but of acid-base balance. Oxygen (PO2) is within the expected limits of 80-100mmHg. With respiratory alkalosis, the blood pH is greater than 7.45 and the PCO2 is greatly decreased. With metabolic acidosis, the pH is less than 7.35.
When a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the client's left ventricular pressure? a. right atrial pressure b. central venous pressure c. pulmonary artery diastolic pressure d. pulmonary artery wedge pressure
d. pulmonary artery wedge pressure Pulmonary artery wedge pressure (PAWP) is an indirect measure of left ventricular end-diastolic pressure. Right atrial pressure measures only the function of the right side of the heart, which frequently does not reflect left ventricular function. Central venous pressure (CVP) is the same as right atrial pressure, because the large central veins are contiguous with the right atrium. CVP also reflects right-sided cardiac pressures and is not usually a good indicator of left ventricular function. Pulmonary artery diastolic pressure is frequently a good indicator of left ventricular end-diastolic pressure, but may be inaccurate in clients with chronic obstructive pulmonary disease or pulmonary hypertension.
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? a. administer sedatives are frequently as possible b. turn the client every 4 hours c. increase ventilator settings every 2 hours d. suction as needed
d. suction as needed The nurse should observe the client's need for tracheal/oral/nasal suctioning every 2hrs and provide adequate suctioning as needed. The nurse should not routinely administer sedatives as frequently as possible; they should be administered as needed, based on the needs of the client. The nurse should turn the client every 2hrs, not 4hrs. The nurse should not adjust vent settings every 2hrs; however, the nurse should check ventilation settings at least once a shift.
