Lippincott cardio 134Qw/EXP *YASSS*

1. A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time? 1. Monitor daily weights and urine output. 2. Permit unrestricted visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand.

1. 4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored . Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

10. A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/ min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: 1. Administer the morphine. 2. Obtain a 12-lead ECG. 3. Obtain the blood work. 4. Prescribe the chest radiograph.

10. 1. Although obtaining the ECG, chestradiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

12. When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to: 1. Promote hydration. 2. Dissolve clots. 3. Prevent kidney failure. 4. Treat dysrhythmias.

12. 2. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.

18. The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as: 1. Atrial fibrillation. 2. Ventricular tachycardia. 3. Premature ventricular contractions. 4. Sinus tachycardia.

18. 4. Sinus tachycardia is characterized by normal conduction and a regular rhythm, but with a rate exceeding 100 bpm. A P wave precedes each QRS, and the QRS is usually normal.

20. Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI )? The client: 1. Continues to have severe chest pain. 2. Can identify risk factors for MI. 3. Participates in a cardiac rehabilitation walking program. 4. Can perform personal self-care activities without pain.

20. 4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.

21. Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? 1. Increased blood pressure. 2. Increased urine output. 3. Decreased pain. 4. Decreased premature ventricular contractions.

21. 2. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias.

22. The nurse is preparing to measure central venous pressure (CVP). Mark the spot on the torsoindicating the location for leveling the transducer.

22. 22. Correct location: The zero point on the CVP transducer needs to be at the level of the right atrium. The right atrium is located at the midaxillary line at the fourth intercostal space. The phlebostatic axis is determined by drawing an imaginary vertical line from the fourth intercostal space at the sternal border to the right side of the chest (A). A secondary imaginary line is drawn horizontally at the level of the midpoint between the anterior and posterior surfaces of the chest (B). The phlebostatic axis is located at the intersection of points A and B.

25. Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction? 1. Liquids as desired. 2. Small, easily digested meals. 3. Three regular meals per day. 4. Nothing by mouth.

25. 2. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.

30. If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentarylifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: 1. Explaining how the risk factor behavior leads to poor health. 2. Withholding praise until the new behavior is well established. 3. Rewarding the client whenever the acceptable behavior is performed. 4. Instilling mild fear into the client to extinguish the behavior.

30. 3. A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

34. Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contradictions to administering the drug? 1. Age greater than 60 years. 2. History of cerebral hemorrhage. 3. History of heart failure.4. Cigarette smoking.

34. 2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.

38. The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following? 1. Left ventricular atrophy. 2. Irregular heartbeats. 3. Peripheral vascular occlusion. 4. Pacemaker placement.

38. 1. In older adults who are less active and do not exercise the heart muscle, atrophy can result . Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output , cardiac hypertrophy, and heart failure are examples of the chronic conditions that maydevelop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle . Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

39. Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem?1. Climb the steps early in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down after climbing the stairs.

39. 3. Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact on decreasing pain episodes . Resting before or after an activity is not as likely to help prevent an activity -related pain episode.

4. A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine? Select all that apply. 1. Reduces myocardial oxygen consumption. 2. Promotes reduction in respiratory rate. 3. Prevents ventricular remodeling. 4. Reduces blood pressure and heart rate. 5. Reduces anxiety and fear.

4. 1, 4, 5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate . Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme- inhibitor drugs, not morphine, may help to prevent ventricular remodeling.

95. A client who has diabetes is taking metoprolol (Lopressor) for hypertension. Which of the following information should the nurse include in the teaching plan? Select all that apply 1. These tablets should be taken with food at same time each day. 2. Do not crush or chew the tablets. 3. Notify the health care provider if pulse is 82 per minute. 4. Have a blood glucose level drawn every 6 to 12 months during therapy. 5. Use an appropriate decongestant if needed. 6. Report any fainting spells to the health care provider.

95. 1, 2, 4, 6. Metoprolol (Lopressor) is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The health care provider should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, andtremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need to be reduced or discontinued.

54. Which of the following sets of conditions is an indication that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply. 1. Distended jugular veins. 2. Dependent edema. 3. Anorexia. 4. Coarse crackles. 5. Tachycardia.

those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.

11. An older adult had a myocardial infarction (MI) 4 days ago. At 9: 30 am, the client's blood pressure is 102/ 64. After reviewing the client's progress notes (see chart), the nurse should first:1. Give a fluid challenge/ bolus. 2. Notify the health care provider. 3. Assist the client to walk. 4. Administer Lasix as prescribed.

11. 2. All of the 12 pm assessments are signs of decreased cardiac output and can be an ominous sign in a client who has recently experienced an MI; the nurse should notify the health care provider of these changes. Cardiac output and blood pressure may continue to fall to dangerous levels, which can induce further coronary ischemia and extension of the infarct. While the client is currently hypotensive, giving a fluid challenge/ bolus can precipitate increased workload on a damaged heart and extend the myocardial infarction. Exercise or walking for this client will increase both the heart rate and stroke volume, both of which will increase cardiac output , but the increased cardiac output will increase oxygen needs especially in the heart muscle and can induce further coronary ischemia and extension of the infarct. The client is hypotensive. Although the client has decreased urinary output, this is the body's response to a decreasing cardiac output, and it is not appropriate to administer Lasix.

13. The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram strip below). The nurse should: 1. Notify the physician. 2. Call the rapid response team. 3. Assess the client for changes in the rhythm. 4. Administer lidocaine as prescribed.

13. 3. The client is experiencing a single PVC . PVCs are characterized by a QRS of longer than 0.12 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted. PVCs are potentially serious and can lead to ventricular fibrillation or cardiac arrest when they occur more than 6 to 10 in an hour in clients with myocardial infarction. The nurse should continue to monitor the client and note if the PVCs are increasing. It is notnecessary to notify the physician or call the rapid response team at this point. Lidocaine is not indicated from the data on this ECG.

15. The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which of the following changes on the client's chart to the physician? 1. Urine output. 2. Heart rate. 3. Blood pressure. 4. Respiratory rate.

15. 1. Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client's chart are not as significant as the decreased urinary output.

24. After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to: 1. Prepare the client for ambulation. 2. Promote urinary and intestinal elimination. 3. Prevent thrombophlebitis and blood clot formation. 4. Decrease the likelihood of pressure ulcer formation.

24. 3. Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.

26. The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take Plavix with food. 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot.5. The client should drink a glass of water after taking Plavix.

26. 1, 3, 4. Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood inurine or stool . Increased bruising and bleeding gums are possible side effects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction , ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.

31. Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: 1. Control chest pain. 2. Reduce coronary artery vasospasm. 3. Control the arrhythmias associated with MI. 4. Revascularize the blocked coronary artery.

31. 4. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.

32. After the administration of t-PA, the nurse should: 1. Observe the client for chest pain. 2. Monitor for fever. 3. Review the 12-lead electrocardiogram (ECG). 4. Auscultate breath sounds.

32. 1. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t- PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.

33. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? 1. Cardiac arrhythmias. 2. Hypertension. 3. Seizure. 4. Hypothermia.

33. 1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue . Hypotension is commonly observed with administration of t-PA. Seizures andhypothermia are not generally associated with reperfusion of the cardiac tissue.

36. Crackles heard on lung auscultation indicate which of the following? 1. Cyanosis. 2. Bronchospasm. 3. Airway narrowing. 4. Fluid-filled alveoli.

36. 4. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

41. Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to the physician? 1. A change in the pattern of the chest pain. 2. Pain during sexual activity. 3. Pain during an argument. 4. Pain during or after a physical activity.

41. 1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.

14. A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following prescriptions from the health care provider should the nurse verify before implementing? 1. Call for urine output less than 30 mL/ h for 2 consecutive hours. 2. Metoprolol (Lopressor) 5 mg IV push. 3. Prepare for a pulmonary artery catheter insertion. 4. Titrate dobutamine (Dobutrex) to keep systolic

14. 2. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.

16. The physician prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. The nurse should: 1. Obtain an infusion pump for the medication. 2. Take the blood pressure every 4 hours. 3. Monitor urine output hourly. 4. Obtain serum potassium levels daily.

16. 1. IV nitroglycerin infusion requires an infusion pump for precise control of the medication . Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

2. A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? 1. Serum potassium is 3.5 mEq/ L (3.5 mmol/ L).2. Blood pressure is 88/ 46. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61.

2. 2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin . The potassiumand heart rate are within normal range.

27. Which client is at greatest risk for coronary artery disease? 1. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. 2. A 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/ L). 3. A 56-year-old male with an HDL of 60 (3.3 mmol/ L) who takes atorvastatin. 4. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/ L).

27. 4. The woman who is 65 years old, overweight, and has an elevated LDL is at greatest risk. Total cholesterol greater than 200 (11.1 mmol/ L), LDL greater than 100 (5.5 mmol/ L), HDL less than 40 ( 2.2 mmol/ L) in men, HDL less than 50 (2.8 mmol/ L) in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.

28. A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/ L); LDL cholesterol 120 (6.7 mmol/ L); HDL cholesterol 58 (3.2 mmol/ L); triglycerides 148 (8.2 mmol/ L); blood sugar 102 (5.7 mmol/ L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed . Which is the best response by the nurse? 1. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." 2. "The triglycerides are elevated and will not return to normal without these medications." 3. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed." 4. "These medications will reduce the risk of type 2 diabetes."

28. 3. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease . The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels, and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke. The blood sugar is within normal limits.

35. A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/ min per nasal cannula. The nurse's next action should be to: 1. Call for the physician. 2. Start an IV infusion. 3. Obtain a portable chest radiograph. 4. Draw blood for laboratory studies.

35. 2. Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the physician , obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.

37. A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. Administer oxygen via nasal cannula. 3. Offer pain medication for the chest heaviness. 4. Inform the physician of the chest heaviness.

37. 1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.

42. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific situation to: 1. Open and dilate blocked coronary arteries. 2. Assess the extent of arterial blockage. 3. Bypass obstructed vessels. 4. Assess the functional adequacy of the valves and heart muscle.

42. 2. Cardiac catheterization is done in clients with angina primarily to assess the extent and the severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, inthis case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage.

65. Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? 1. Apples. 2. Tomato juice. 3. Whole wheat bread. 4. Beef tenderloin.

65. 2. Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.

66. A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply. 1. Angel food cake. 2. Banana. 3. Dried fruit. 4. Orange juice. 5. Peppers.

66. 2, 3, 4. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake, yellow cake, and peppers are low in potassium.

100. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol: 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. 2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. 3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.

100. 1. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to angiotensin II.

17. The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. The nurse should do the following in which order from first to last? 1. Obtain a history of which drugs the client has used recently. 2. Administer the prescribed dose of morphine. 3. Position electrodes on the chest. 4. Take vital signs.

17. 17. 3. Position electrodes on the chest.4. Take vital signs. 2. Administer the prescribed dose of morphine. 1. Obtain a history of which drugs the client has used recently. The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain ; it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a history of the client's drug use.

19. While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D 5W) and oxygen at 2 L /min. The nurse's first course of action should be to: 1. Increase the IV infusion rate. 2. Notify the physician promptly. 3. Increase the oxygen concentration. 4. Administer a prescribed analgesic.

19. 2. PVCs are often a precursor of life -threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

23. A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following? 1. Cardiac output. 2. Right atrial blood flow. 3. Left end-diastolic pressure. 4. Cardiac index.

23. 3. When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitralvalve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure . Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area, and is considered a more accurate reflection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.

29. The client has been managing angina episodes with nitroglycerin. Which of the following indicate the drug is effective? 1. Decreased chest pain. 2. Increased blood pressure. 3. Decreased blood pressure. 4. Decreased heart rate.

29. 1. Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerine, it is only secondary and not related tothe angina the patient is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerine.

3. The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first: 1. Assess for changes in vital signs. 2. Draw an arterial blood gas. 3. Evaluate heart sounds with the client leaning forward. 4. Obtain a 12-lead electrocardiogram.

3. 1. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure , increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.

40. The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals would be best? 1. Hamburger, salad, and milkshake. 2. Baked liver, green beans, and coffee. 3. Spaghetti with tomato sauce, salad, and coffee. 4. Fried chicken, green beans, and skim milk.

40. 3. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

43. The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include: 1. Minimizing dyspnea. 2. Maintaining adequate blood pressure control. 3. Decreasing myocardial contractility. 4. Preventing fluid volume deficit.

43. 4. Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally , potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure . Increased myocardial contractility would be a goal, not decreased contractility.

44. Which of the following is not a risk factor for the development of atherosclerosis? 1. Family history of early heart attack. 2. Late onset of puberty.3. Total blood cholesterol level greater than 220 mg/ dL (12.2 mmol/ L). 4. Elevated fasting blood glucose concentration.

44. 2. Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level , male gender, diabetes mellitus, obesity, and physical inactivity.

45. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: 1. Antispasmodic effects on the pericardium. 2. Causing an increased myocardial oxygen demand. 3. Vasodilation of peripheral vasculature. 4. Improved conductivity in the myocardium.

45. 3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

46. A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: 1. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect. 2. Nitroglycerin should be avoided if the client is experiencing this serious side effect. 3. Taking the nitroglycerin with a few glasses of water will reduce the problem. 4. The client should lie in a supine position to alleviate the headache.

46. 1. Headache is a common side effect of nitroglycerin that can be alleviated with aspirin , acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase painand exacerbate other symptoms, such as shortness of breath.

55. An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission which of the following should the nurse assess first? 1. Blood pressure. 2. Skin breakdown. 3. Serum potassium level. 4. Urine output.

55. 1. It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.

47. How should the nurse instruct the client with unstable angina to use sublingual nitroglycerin tablets when chest pain occurs? "Sit down and then 1. take one tablet every 2 to 5 minutes until the pain stops." 2. take one tablet and rest for 15 minutes. Call the physician if pain persists after 15 minutes." 3. take one tablet, then if the pain persists take additional two tablets in 5 minutes. Call the physician if pain persists after 15 minutes." 4. take one tablet. If pain persists after 5 minutes call 911."

47. 4. The nurse should instruct the client that correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, the client should call 911. Although some physicians may recommend taking a second or third tablet spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take two tablets at once. Nitroglycerin acts within 2 to 3 minutes and the client should not wait 15 minutes to take further action. The client should call 911 to obtain emergency help rather than calling the physician.

48. A client with angina is taking nifedipine. The nurse should teach the client to: 1. Monitor blood pressure monthly. 2. Perform daily weights. 3. Inspect gums daily. 4. Limit intake of green leafy vegetables.

48. 3. The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia . This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables.

49. The nurse is developing a teaching plan for a client who will be starting a prescription for Zocor (simvastatin) 40 mg/ day. The nurse should instruct the client about which of the following? Select all that apply. 1. "Take once a day in the morning." 2. "If you miss a dose, take it when you remember it, but do not double the dose if you do not remember to take it until it is time for your next dose." 3. "Limit greens such as lettuce in the diet to prevent bleeding." 4. "Be sure to take the pill with food." 5. "Report muscle pain or tenderness to your health care provider." 6. "Continue to follow a diet that is low in saturated fats."

49. 2, 5, 6. Zocor (simvastatin) is used in combination with diet and exercise to decrease elevated total cholesterol . The client should take Zocor in the evening, and the nurse should instruct the client that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next scheduled dose. It is not necessary to take the pill with food. The client does not need to limit greens (limiting greens is appropriate for clients taking Coumadin), but the nurse should instruct the client toavoid grapefruit and grapefruit juice, which can increase the amount of the drug in the bloodstream. A serious side effect is myopathy, and the client should report muscle pain or tenderness to the health care provider.

A client is receiving an IV infusion of heparin sodium at 1,200 units/ h. The dilution is 25,000 units/ 500 mL. How many milliliters per hour will this client receive? _________________ mL/ h.

5. 24 mL/ h First, calculate how many units are in each milliliter of the medication: Next, calculate how many milliliters the client receives per hour: CN: Pharmacological and parenteral therapies; CL: Apply

50. Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/ 82 and the heart rate is 65. Prior to medication administration at 9 am, the nurse reviews the following lab tests (see chart ). Which of the following should the nurse do first? 1. Administer the medications. 2. Call the physician. 3. Withhold the captopril. 4. Question the metoprolol dose.

50. 3. The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine , which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic . The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.

51. A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: 1. Decrease circulatory overload. 2. Improve the myocardial workload.3. Prevent thrombus formation. 4. Regulate cardiac rhythm.

51. 3. Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm.

52. A client has a history of heart failure and has been furosemide (Lasix), digoxin (Lanoxin), and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which of the following? 1. Hyperkalemia. 2. Digoxin toxicity. 3. Fluid deficit. 4. Pulmonary edema.

52. 2. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonaryedema is manifested by dyspnea and coughing.

53. The nurse should assess the client with left-sided heart failure for which of the following? Select all that apply. 1. Dyspnea. 2. Jugular vein distention (JVD). 3. Crackles. 4. Right upper quadrant pain. 5. Oliguria. 6. Decreased oxygen saturation levels.

53. 1, 3 , 5, 6. Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure.

56. The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonalcompensatory mechanisms. Which of the following are expected findings on assessment? Select all that apply. 1. Decreased cardiac output. 2. Increased heart rate. 3. Vasoconstriction in skin, GI tract, and kidneys. 4. Decreased pulmonary perfusion. 5. Fluid overload.

56. 1, 2, 3, 5. Heart failure can be a result of several cardiovascular conditions, which will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiacoutput stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure , therefore cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease.

Lasix (furosemide) 40 mg intravenous push (IVP ) is prescribed. Lasix 10 mg/ mL is available. The nurse should administer _________________________ mL.

57. 4 mL. Desired amount (D) divided by what is available (H), times quantity (Q) = amount to administer. D = 40 mg divided by H = 10 mg/ mL; equals 40 divided by 10 = 4 mL.

58. In which of the following positions should the nurse place a client with heart failure who has orthopnea? 1. Semisitting (low Fowler's position) with legs elevated on pillows. 2. Lying on the right side (Sims' position) with a pillow between the legs. 3. Sitting upright (high Fowler's position) with legs resting on the mattress. 4. Lying on the back with the head lowered (Trendelenburg's position) and legs elevated.

58. 3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also , the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg's position.

59. The major goal of nursing care for a client with heart failure and pulmonary edema is to: 1. Increase cardiac output. 2. Improve respiratory status. 3. Decrease peripheral edema. 4. Enhance comfort.

59. 1. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention . Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated withpulmonary edema.

6. An older adult has chest pain and shortness of breath. The health care provider prescribes nitroglycerin tablets. What should the nurse instruct the client to do? 1. Put the tablet under the tongue until it is absorbed. 2. Swallow the tablet with 120 mL of water. 3. Chew the tablet until it is dissolved. 4. Place the tablet between the cheek and gums until it disappears.

6. 1. The client is having symptoms of amyocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The client should place the tablet under the tongue and wait until it is absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or placed between the cheek and gums.

60. A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? 1. Dilated coronary arteries. 2. Increased myocardial contractility. 3. Decreased cardiac arrhythmias. 4. Decreased electrical conductivity in the heart.

60. 2. Digoxin is a cardiac glycoside with positive inotropic activity . This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries . Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema.

61. Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect?1. 5 to 10 minutes. 2. 30 to 60 minutes. 3. 2 to 4 hours. 4. 6 to 8 hours.

61. 1. After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.

62. The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help: 1. Prevent electrolyte imbalances. 2. Retard rapid drug absorption. 3. Excrete excessive fluids accumulated during the night. 4. Prevent sleep disturbances during the night.

62. 4. When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.

63. The nurse should teach the client that signs of digoxin toxicity include which of the following? 1. Rash over the chest and back. 2. Increased appetite. 3. Visual disturbances such as seeing yellow spots. 4. Elevated blood pressure.

63. 3. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain , anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias , such as atrial fibrillation or bradycardia . Rash, increased appetite, and elevated blood pressure are not associated with digoxin

64. The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a: 1. Low sodium level. 2. High glucose level. 3. High calcium level. 4. Low potassium level.

64. 4. A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.

67. When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal spaceThe nurse should further assess the client for: 1. Left atrial enlargement. 2. Left ventricular enlargement. 3. Right atrial enlargement. 4. Right ventricular enlargement.

67. 2. A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

68. The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2 + pitting edema in the ankles when getting the client into bed . Based on this finding, what should the nurse do first? 1. Assess respiratory status. 2. Draw blood for laboratory studies. 3. Insert a Foley catheter. 4. Weigh the client.

68. 1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate , lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention . The nurse can then draw bloodfor laboratory studies, insert the Foley catheter, and weigh the client.

69. The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of doing which of the following? 1. Maintaining a high-fiber diet. 2. Walking 2 miles (3.2 km) every day. 3. Obtaining daily weights at the same time each day. 4. Remaining sedentary for most of the day.

69. 3. Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important . The client should be told to call the physician if there has been a weight gain of 2 lb (0.91 kg) or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure . Prescribing an exercise program for the client, such as walking 2 miles (3.2 km) every day, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the physician and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.

7. The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? 1. BP 110/ 62, atrial fibrillation with HR 82, bibasilar crackles.2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. 3. SpO2 92 on 2 L nasal cannula, respirations 20, 1 + edema of lower extremities. 4. Weight gain of 1 kg in 3 days, BP 130/ 80, mild dyspnea with exercise.

7. 2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure . Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.

70. When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. 1. Becoming increasingly short of breath at rest. 2. Weight gain of 2 lb (0.9 kg) or more in 1 day. 3. High intake of sodium for breakfast. 4. Having to sleep sitting up in a reclining chair. 5. Weight loss of 2 lb (0.9 kg) in 1 day.

70. 1, 2, 4. If the client will call the physician when there is increasing shortness of breath, weight gain over 2 lb (0.9 kg) in 1 day, and need to sleep sitting up, this indicates an understanding of the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.

71. A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?1. A low, grade 1 intensity mitral regurgitation murmur. 2. SpO2 is 94% on 2 L of oxygen via nasal cannula. 3. The client has become more somnolent. 4. Urine output has decreased from 60 mL/ h to 40 mL over the last hour.

71. 3. A complication of balloon valvuloplasty is emboli resulting in a stroke. The client's increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely, but do not warrant concern.

72. An elderly client with diabetes who has been maintained on metformin (Glucophage) has been scheduled for a cardiac catheterization. The nurse should verify that the physician has written a prescription to: 1. Limit the amount of protein in the diet prior to the cardiac cath. 2. Withhold the Glucophage prior to the cardiac catheterization. 3. Administer the Glucophage with only a sip of water prior to the cardiac catheterization. 4. Give the Glucophage before breakfast.

72. 2. The nurse should verify that the physician has requested to withhold the Glucophage prior to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system. The physician may prescribe sliding scale insulin during this time if needed . Regardless of how or when the medication is administered, the medication should be withheld. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.

73. A client with aortic stenosis has increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis?

73. 73. The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area, (2) is the pulmonic valve area, (3) is Erb's point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.

74. A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply. 1. Administer all prescribed oral medications. 2. Check for iodine sensitivity. 3. Verify that written consent has been obtained. 4. Withhold food and oral fluids before the procedure. 5. Insert a urinary drainage catheter.

74. 2, 3, 4. For clients scheduled for a cardiac catheterization it is important to assess for iodinesensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.

75. Which is the most important initial postprocedure nursing assessment for a client whohas had a cardiac catheterization? 1. Monitor the laboratory values. 2. Observe neurologic function every 15 minutes. 3. Observe the puncture site for swelling and bleeding. 4. Monitor skin warmth and turgor. 76. A client experiences initial indications

75. 3. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

76. A client experiences initial indications of excitation after having an IV infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having: 1. Palpitations. 2. Tinnitus. 3. Urinary frequency. 4. Lethargy.

76. 2. Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and finally coma . Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.

77. A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation . The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip per physician prescriptions. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. The nurse should first assess: 1. 12-lead EKG. 2. Blood pressure. 3. Lung sounds. 4. Urine output.

77. 2. The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.

78. A client has mitral stenosis and will have a valve replacement . The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time? 1. Medication therapy. 2. Diet modification. 3. Activity restrictions. 4. Dental care.

78. 1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprosthesis are maintained indefinitely onanticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.

79. In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that: 1. The client will remain in the ICU for 5 days. 2. The client will sleep most of the time while inthe ICU. 3. Noise and activity within the ICU are minimal. 4. The client will receive medication to relieve pain.

79. 4. Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.

8. The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first: 1. Administer atropine 0.5 mg IV push. 2. Auscultate for abnormal heart sounds. 3. Prepare for transcutaneous pacing. 4. Take the client's blood pressure.

8. 4. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply. 1. Administer warfarin. 2. Check the postoperative CBC, INR, PTT, and platelet levels. 3. Confirm availability of blood products. 4. Monitor the mediastinal chest tube drainage. 5. Start a dopamine drip for a systolic BP less than 100.

80. 2, 3, 4. The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding; therefore, availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in ahypovolemic client prior to starting an inotrope such as dopamine.

81. The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: 1. Observe careful handwashing procedures. 2. Clean the incisional area with an antiseptic. 3. Use prepackaged sterile dressings to cover the incision. 4. Place soiled dressings in a waterproof bag before disposing of them.

81. 1. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.

82. For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? 1. Ensure a liberal fluid intake. 2. Provide an alkaline-ash diet. 3. Prevent constipation. 4. Enrich the client's diet with dairy products.

82. 1. In an immobilized client , calcium leaves the bone and concentrates in the extracellular fluid . When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi . Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.

83. The nurse should teach the client who is receiving warfarin sodium that: 1. Partial thromboplastin time values determine the dosage of warfarin sodium. 2. Protamine sulfate is used to reverse the effects of warfarin sodium.3. International Normalized Ratio (INR) is used to assess effectiveness. 4. Warfarin sodium will facilitate clotting of the blood.

83. 3. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasmaor vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.

84. Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include instructing the client to do which of the following? Select all that apply. 1. Brush the teeth at least twice a day. 2. Avoid use of an electric toothbrush. 3. Take an antibiotic prior to oral surgery. 4. Floss the teeth at least once a day. 5. Have regular dental checkups. 6. Rinse the mouth with an antibiotic mouthwash once a day.

84. 1, 4, 5. Daily dental care including brushing the teeth twice a day and flossing once a day and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. The client can use a regular tooth brush; it is not necessary to avoid use of an electric toothbrush. Taking antibiotics prior to certain dental procedures is recommended only if the client has a prosthetic valve or a heart transplant. It is not necessary to use an antibiotic mouthwash.

85. Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon? 1. Showering. 2. Lifting anything heavier than 10 lb (4.5 kg). 3. A program of gradually progressive walking. 4. Light housework.

85. 2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.

86. Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision and the incision seems to becoming larger. The nurse's response should reflect the understanding that the client may be experiencing which of the following? 1. Anxiety related to altered body image. 2. Anxiety related to altered health status. 3. Altered tissue perfusion. 4. Lack of knowledge regarding the postoperative course.

86. 1. Verbalized concerns from this client may stem from anxiety over the changes in the body after open heart surgery. Although the client may experience anxiety related to altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in the body image. The client is not concerned about altered tissue perfusion.

87. Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female diagnosedwith stage 2 hypertension initially treated with Furosemide (Lasix) and Ramipril (Altace). An expected therapeutic effect is: 1. Decrease in heart rate. 2. Lessening of fatigue. 3. Improvement in blood sugar levels. 4. Increase in urine output.

87. 1. The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the betablocker. The mechanism of action does not improve blood sugar or urine output.

88. Which set of postural vital signs (BP and heart rate) indicate inadequate blood volume? Supine 124/ 76, 88. Sitting 124/ 74, 92. Standing 122/ 74, 92. Supine 120/ 70, 70. Sitting 102/ 64, 86. Standing 100/ 60, 92. Supine 138/ 86, 74. Sitting 136/ 84, 80. Standing 134/ 82, 82. Supine 100/ 70, 72. Sitting 100/ 68, 74. Standing 98/ 68, 80.

88. 2. There was a significant change in both blood pressure and heart rate with position change . This indicates inadequate blood volume to sustain normal values. Normal postural changes allow for an increase in heart rate of 5 to 20 bpm, a possible slight decrease of less than 5 mm Hg in the systolic blood pressure, and a possible slight increase of less than 5 mm Hg in the diastolic blood pressure.

89. A client is taking clonidine (Catapres) for treatment of hypertension . The nurse should teach the client about which of the following common adverse effects of this drug? Select all that apply. 1. Dry mouth. 2. Hyperkalemia. 3. Impotence. 4. Pancreatitis. 5. Sleep disturbance.

89. 1, 3, 5. Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth , impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.

9. A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: 1. Heart rate irregular with S3. 2. Heart rate irregular with S4. 3. Heart rate irregular with aortic regurgitation. 4. Heart rate irregular with mitral stenosis.

9. 1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve. CN: Physiological adaptation;

A client with hypertensive emergency is being treated with sodium nitroprusside (Nipride). In a dilution of 50 mg/ 250 mL, how many micrograms of Nipride are in each milliliter? __________________ mcg.

90. 200 mcg First, calculate the number of milligrams per milliliter: Next, calculate the number of micrograms in each milligram:

91. The nurse is discussing medications with a client with hypertension who has a prescription forfurosemide (Lasix) daily. The client needs further education when the client states which of the following? 1. "I know I should not drive after taking my Lasix." 2. "I should be careful not to stand up too quickly when taking Lasix." 3. "I should take the Lasix in the morning instead of before bed." 4. "I need to be sure to also take the potassium supplement that the doctor prescribed along with my Lasix."

91. 1 Furosemide (Lasix) is a diuretic often prescribed for clients with hypertension or heart failure; the drug should not affect a client's ability to drive safely. Lasix may cause orthostatic hypotension and clients should be instructed to be careful when changing from supine to sitting to standing position. Diuretics should be taken in the morning if possible to prevent sleep disturbance due to the need to get up to void. Lasix is a loop diuretic that is not potassium sparing; clients should take potassium supplements as prescribed and have their serum potassium levels checked at prescribed intervals.

92. In teaching the client with hypertension to avoid orthostatic hypotension, the nurse should emphasize which of the following instructions? Select all that apply. 1. Plan regular times for taking medications. 2. Arise slowly from bed. 3. Avoid standing still for long periods. 4. Avoid excessive alcohol intake. 5. Avoid hot baths.

92. 2, 3. Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension . Scheduling regular medication times is important for blood pressure management, but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.

93. The nurse is teaching a client with hypertension about taking atenolol (Tenormin). The nurse should instruct the client to: 1. Avoid sudden discontinuation of the drug. 2. Monitor the blood pressure annually. 3. Follow a 2-g sodium diet. 4. Discontinue the medication if severe headaches develop.

93. 1. Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a physician's prescription. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.

94. The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs? 1. Mixed green salad with blue cheese dressing, crackers, and cold cuts. 2. Ham sandwich on rye bread and an orange. 3. Baked chicken, an apple, and a slice of white bread. 4. Hot dogs, baked beans, and celery and carrot sticks.

94. 3. Processed and cured meat products, such as cold cuts, ham, and hot dogs , are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic.

96. An older adult with a history of hypertension is admitted with diagnosis of dehydration. The client is becoming increasingly confused and weak. The client reports taking one tablet of hydrochlorothiazide (HydroDIURIL) daily, and the prescription is written for 1/ 2 tablet. The nurse should obtain additional information about: 1. Decreased drug half-life of the HydroDIURIL. 2. Decreased hepatic blood flow. 3. Increased GI activity. 4. Increased urinary elimination.

96. 2. Aging causes decreased hepatic blood flow. Decreased drug metabolism, which occurs with aging, along with more drug in circulation means the drug will remain in the body longer and produce greater drug effects. The client has also taken more drug than prescribed increasing the opportunity for more drug action to occur. When there is decreased metabolism of drugs , an increase in the half-life will occur most especially in the older adult. In older adults transit time (GI motility) is slower, allowing more drug to be absorbed. Increased urinary elimination would mean that drug elimination could be higher not lower and accumulating in the body.

97. A client diagnosed with primary (essential) hypertension is taking chlorothiazide (Diuril). The nurse determines teaching about this medication is effective when the client makes the following statement. "I will (Select all that apply.) 1. take my weight daily at the same time each day." 2. not drink alcoholic beverages while on this medication." 3. reduce salt intake in my diet." 4. reduce my dosage if I have severe dizziness." 5. use sunscreen if I have prolonged exposure to sunlight." 6. take the drug late in the evening."

97. 1, 2, 3, 5. Chlorothiazide (Diuril) causes increased urination and decreased swelling (if there is edema) and weight loss. It is important to check and record weight two to three times per week at same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or take other medications without the approval of the health care provider. Reducing sodium intake in the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses are less likely to cause adverse effects and hence excessive table salt as well as salty foods should be avoided. Chlorothiazide (Diuril) is a diuretic that is prescribed for lower blood pressure and may cause dizziness and faintness when the patient stands up suddenly. This can be prevented or decreased by changing positions slowly. If dizziness is severe, the health care provider must be notified. Diuretics may cause sensitivity to sunlight , hence the need to avoid prolonged exposure to sunlight, use sunscreens, and wear protectiveclothing. Chlorothiazide (Diuril) causes increased urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer bathroom trips mean less interference with sleep and less risk of falls.

98. Which intervention would be most likely to assist the client with hypertension in maintaining an exercise program? 1. Giving the client a written exercise program.2. Explaining the exercise program to the client's spouse. 3. Reassuring the client that he or she can do the exercise program. 4. Tailoring a program to the client's needs and abilities.

98. 4. Tailoring or individualizing a program to the client's lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client's spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.

99. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan? 1. Review the negative effects of smoking on the body. 2. Discuss the effects of passive smoking on environmental pollution. 3. Establish the client's daily smoking pattern. 4. Explain how smoking worsens high blood pressure.

99. 3. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.