Managements of Patients With Structural, Infectious and Inflammatory Cardiac Disorders
10. A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The physician's choice of antibiotics would be primarily based on what diagnostic test? A) Echocardiography B) Blood cultures C) Cardiac aspiration D) Complete blood count
B Feedback: To help determine the causative organisms and the most effective antibiotic treatment for the patient, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. "Cardiac aspiration" is not a diagnostic test.
Physiological Integrity 3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae on the inside of the mouth and conjunctiva d. Increase in heart rate of 15 beats/minute with walking
B Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise. DIF: Cognitive Level: Apply (application) REF: 812 TOP: Nursing Process: Diagnosis MSC:
37. The nurse is caring for a recent immigrant who has been diagnosed with mitral valve regurgitation. The nurse should know that in developing countries the most common cause of mitral valve regurgitation is what? A) A decrease in gamma globulins B) An insect bite C) Rheumatic heart disease and its sequelae D) Sepsis and its sequelae
C Feedback: The most common cause of mitral valve regurgitation in developing countries is rheumatic heart disease and its sequelae.
Physiological Integrity 22. The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? a. Patient admitted with a large acute myocardial infarction. b. Patient being discharged after an exacerbation of heart failure. c. Patient who had a mitral valve replacement with a mechanical valve. d. Patient being treated for rheumatic fever after a streptococcal infection.
C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE. DIF: Cognitive Level: Apply (application) REF: 813 TOP: Nursing Process: Planning MSC:
12. A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this? A) To prevent bacterial endocarditis B) To prevent hospital-acquired pneumonia C) To minimize the need for antibiotic use during the procedure D) To decrease the need for surgical asepsis
A Feedback: Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after the following invasive procedures, such as bronchoscopy. Gentamicin would not be given to prevent pneumonia, to avoid antibiotic use during the procedure, or to decrease the need for surgical asepsis.
25. A patient is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this procedure will affect her busy work schedule. What guidance should the nurse provide to the patient? A) "Patients generally stay in the hospital for 6 to 8 days." B) "Patients are kept in the hospital until they are independent with all aspects of their care." C) "Patients need to stay in the hospital until they regain normal heart function for their age." D) "Patients usually remain at the hospital for 24 to 48 hours."
D Feedback: After undergoing percutaneous balloon valvuloplasty, the patient usually remains in the hospital for 24 to 48 hours. Prediagnosis levels of heart function are not always attainable and the patient does not need to be wholly independent prior to discharge.
Safe and Effective Care Environment 35. The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear any murmur that the patient has? a. 1 b. 2 c. 3 d. 4
D Sounds from the mitral valve are best heard at the apex of the heart, fifth intercostal space, midclavicular line. DIF: Cognitive Level: Understand (comprehension) REF: 821 TOP: Nursing Process: Assessment MSC:
A patient is admitted with aortic regurgitation. Which of the following medication classifications are contraindicated since they can cause bradycardia and decrease ventricular contractility? a) Calcium channel blockers b) Beta blockers c) Ace inhibitors d) Nitrates
a) Calcium channel blockers The calcium channel blockers diltiazem (Cardizem) and verapamil (Calan, Isoptin) are contraindicated for patients with aortic regurgitation as they decrease ventricular contractility and may cause bradycardia.
A 62-year-old female who is 2 weeks CABG returns to her cardiologist due to new symptoms, including heaviness in her chest and pain between her breasts. She reports that leaning forward decreases the pain. The cardiologist admits her to the hospital to rule out pericarditis. Which of the following is a contributing cause to pericarditis? Select all that apply. a) Chest trauma b) Cardiac surgery c) Tuberculosis d) Myocarditis e) Pneumonia
a) Chest trauma b) Cardiac surgery c) Tuberculosis d) Myocarditis Pericarditis usually is secondary to endocarditis, myocarditis, chest trauma, or MI (heart attack) or develops after cardiac surgery.
On auscultation, the nurse suspects a diagnosis of mitral valve stenosis when which of the following is heard? a) Low-pitched, rumbling diastolic murmur at the apex of the heart b) High-pitched blowing sound at the apex c) Mitral valve click d) Diastolic murmur at the left sternal border of the heart
a) Low-pitched, rumbling diastolic murmur at the apex of the heart The murmur is caused by turbulent blood flow through the abnormally tight valve opening. A low-pitched, rumbling, diastolic murmur (heard on S2) is heard best at the apex. A loud S1, due to abrupt closure of the mitral valve, and an early diastolic opening snap can be heard. The snap is the premature opening of the stenotic mitral valve.
For patients diagnosed with aortic stenosis, digoxin would be ordered for which of the following clinical manifestations? a) Edema b) Left ventricular dysfunction c) Angina d) Dyspnea
b) Left ventricular dysfunction Digoxin may be used to treat left ventricular dysfunction, and diuretics may be used for dyspnea. Nitrates may be prescribed for the treatment of angina, but must be used with caution due to the risk of orthostatic hypotension and syncope.
A patient is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the patient for which diagnostic test used to confirm the patient's diagnosis? a) Chest x-ray b) Cardiac cauterization c) CT scan d) Echocardiogram
d) Echocardiogram Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.
19. An older adult patient has been diagnosed with aortic regurgitation. What change in blood flow should the nurse expect to see on this patient's echocardiogram? A) Blood to flow back from the aorta to the left ventricle B) Obstruction of blood flow from the left ventricle C) Blood to flow back from the left atrium to the left ventricle D) Obstruction of blood from the left atrium to left ventricle
A Feedback: Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of blood from the left atrium to left ventricle.
39. A cardiac surgery patient's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action? A) Prepare to assist with pericardiocentesis. B) Reposition the patient into a prone position. C) Administer a dose of metoprolol. D) Administer a bolus of normal saline.
A Feedback: Cardiac tamponade requires immediate pericardiocentesis. Beta-blockers and fluid boluses will not relieve the pressure on the heart and prone positioning would likely exacerbate symptoms.
29. The cardiac nurse is caring for a patient who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding? A) Decreased ejection fraction B) Decreased heart rate C) Ventricular hypertrophy D) Mitral valve regurgitation
A Feedback: DCM is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. The ventricles have elevated systolic and diastolic volumes, but a decreased ejection fraction. Bradycardia and mitral valve regurgitation do not typically occur in patients with DCM.
11. A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease? A) Recognizing and promptly treating streptococcal infections B) Prophylactic use of calcium channel blockers in high-risk populations C) Adhering closely to the recommended child immunization schedule D) Smoking cessation
A Feedback: Group A streptococcus can cause rheumatic heart fever, resulting in rheumatic endocarditis. Being aware of signs and symptoms of streptococcal infections, identifying them quickly, and treating them promptly, are the best preventative techniques for rheumatic endocarditis. Smoking cessation, immunizations, and calcium channel blockers will not prevent rheumatic heart disease.
36. The nurse on the hospital's infection control committee is looking into two cases of hospital-acquired infective endocarditis among a specific classification of patients. What classification of patients would be at greatest risk for hospital-acquired endocarditis? A) Hemodialysis patients B) Patients on immunoglobulins C) Patients who undergo intermittent urinary catheterization D) Children under the age of 12
A Feedback: Hospital-acquired infective endocarditis occurs most often in patients with debilitating disease or indwelling catheters and in patients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy. Patients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis. Patients on immunoglobulins, those who need in and out catheterization, and children are not at increased risk for nosocomial infective endocarditis.
20. A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following? A) The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) B) The need to learn to sleep in a semi-Fowler's position for the first 6 to 8 weeks to prevent emboli C) The need to avoid foods that contain vitamin K D) The need to take enteric-coated ASA on a daily basis
A Feedback: Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.
23. A patient is admitted to the critical care unit (CCU) with a diagnosis of cardiomyopathy. When reviewing the patient's most recent laboratory results, the nurse should prioritize assessment of which of the following? A) Sodium B) AST, ALT, and bilirubin C) White blood cell differential D) BUN
A Feedback: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels. Consequently, sodium levels are followed more closely than other important laboratory values, including BUN, leukocytes, and liver function tests.
26. A patient has been diagnosed with a valvular disorder. The patient tells the nurse that he has read about numerous treatment options, including valvuloplasty. What should the nurse teach the patient about valvuloplasty? A) "For some patients, valvuloplasty can be done in a cardiac catheterization laboratory." B) "Valvuloplasty is a dangerous procedure, but it has excellent potential if it goes well." C) "Valvuloplasty is open heart surgery, but this is very safe these days and normally requires only an overnight hospital stay." D) "It's prudent to get a second opinion before deciding to have valvuloplasty."
A Feedback: Some valvuloplasty procedures do not require general anesthesia or cardiopulmonary bypass and can be performed in a cardiac catheterization laboratory or hybrid room. Open heart surgery is not required and the procedure does not carry exceptional risks that would designate it as being dangerous. Normally there is no need for the nurse to advocate for a second opinion.
32. A patient has been living with dilated cardiomyopathy for several years but has experienced worsening symptoms despite aggressive medical management. The nurse should anticipate what potential treatment? A) Heart transplantation B) Balloon valvuloplasty C) Cardiac catheterization D) Stent placement
A Feedback: When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Valvuloplasty, stent placement, and cardiac catheterization will not address the pathophysiology of cardiomyopathy.
Physiological Integrity 26. The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? a. The patient complains of chest pressure when ambulating. b. A loud systolic murmur is heard along the right sternal border. c. A thrill is palpated at the second intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.
A Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal. DIF: Cognitive Level: Apply (application) REF: 823 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
Physiological Integrity 28. The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? a. The patient has bilateral crackles. b. The patient has bilateral, 4+ peripheral edema. c. The patient has a loud systolic murmur across the precordium. d. The patient has a palpable thrill felt over the left anterior chest.
A Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently. DIF: Cognitive Level: Apply (application) REF: 821-822 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
Physiological Integrity 5. A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of a. echocardiography. b. daily blood cultures. c. cardiac catheterization. d. 24-hour Holter monitor.
A Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor is not a diagnostic procedure for pericarditis. DIF: Cognitive Level: Apply (application) REF: 816 TOP: Nursing Process: Planning MSC:
Physiological Integrity 16. While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to a. promote rest to decrease myocardial oxygen demand. b. teach the patient about the need for anticoagulant therapy. c. teach the patient to use sublingual nitroglycerin for chest pain. d. raise the head of the bed 60 degrees to decrease venous return.
A Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation. DIF: Cognitive Level: Apply (application) REF: 823 | 826 TOP: Nursing Process: Implementation MSC:
Physiological Integrity 27. Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's temperature. c. Notify the patient's health care provider. d. Give the PRN acetaminophen (Tylenol).
A The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. It is not stated for what symptom (e.g., headache) or finding (e.g., increased temperature) the PRN acetaminophen (Tylenol) is ordered. DIF: Cognitive Level: Apply (application) REF: 815 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
5. A patient with a history rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the patient knows the importance of taking which of the following drugs? A) Enoxaparin (Lovenox) B) Metoprolol (Lopressor) C) Azathioprine (Imuran) D) Amoxicillin (Amoxil)
D Feedback: Although rare, bacterial endocarditis may be life-threatening. A key strategy is primary prevention in high-risk patients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic.
28. The nurse is caring for a patient with right ventricular hypertrophy and consequently decreased right ventricular function. What valvular disorder may have contributed to this patient's diagnosis? A) Mitral valve regurgitation B) Aortic stenosis C) Aortic regurgitation D) Mitral valve stenosis
D Feedback: Because no valve protects the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. As a result, the right ventricle must contract against an abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right ventricle fails. None of the other listed valvular disorders has this pathophysiological effect.
21. A nurse is planning discharge health education for a patient who will soon undergo placement of a mechanical valve prosthesis. What aspect of health education should the nurse prioritize in anticipation of discharge? A) The need for long-term antibiotics B) The need for 7 to 10 days of bed rest C) Strategies for preventing atherosclerosis D) Strategies for infection prevention
D Feedback: Patients with a mechanical valve prosthesis (including annuloplasty rings and other prosthetic materials used in valvuloplasty) require education to prevent infective endocarditis. Despite these infections risks, antibiotics are not used long term. Activity management is important, but extended bed rest is unnecessary. Valve replacement does not create a heightened risk for atherosclerosis.
35. A patient who has recently recovered from a systemic viral infection is undergoing diagnostic testing for myocarditis. Which of the nurse's assessment findings is most consistent with myocarditis? A) Sudden changes in level of consciousness (LOC) B) Peripheral edema and pulmonary edema C) Pleuritic chest pain D) Flulike symptoms
D Feedback: The most common symptoms of myocarditis are flulike. Chest pain, edema, and changes in LOC are not characteristic of myocarditis.
31. The nurse is teaching a patient diagnosed with aortic stenosis appropriate strategies for attempting to relieve the symptom of angina without drugs. What should the nurse teach the patient? A) To eat a small meal before taking nitroglycerin B) To drink a glass of milk before taking nitroglycerin C) To engage in 15 minutes of light exercise before taking nitroglycerin D) To rest and relax before taking nitroglycerin
D Feedback: The venous dilation that results from nitroglycerin decreases blood return to the heart, thus decreasing cardiac output and increasing the risk of syncope and decreased coronary artery blood flow. The nurse teaches the patient about the importance of attempting to relieve the symptoms of angina with rest and relaxation before taking nitroglycerin and to anticipate the potential adverse effects. Exercising, eating, and drinking are not recommended prior to using nitroglycerin.
Physiological Integrity 21. The nurse is obtaining a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most important? a. The patient has a history of a recent upper respiratory infection. b. The patient has a family history of coronary artery disease (CAD). c. The patient reports using cocaine a "couple of times" as a teenager. d. The patient's 29-year-old brother died from a sudden cardiac arrest.
D About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC. DIF: Cognitive Level: Apply (application) REF: 828 TOP: Nursing Process: Assessment MSC:
1. The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? a. "Do you have a history of a heart attack?" b. "Is there a family history of endocarditis?" c. "Have you had any recent immunizations?" d. "Have you had dental work done recently?"
D Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE. DIF: Cognitive Level: Apply (application) REF: 812 TOP: Nursing Process: Assessment MSC:
27. The patient has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should know that complications following this procedure include what? Select all that apply. A) Emboli B) Mitral valve damage C) Ventricular dysrhythmia D) Atrial-septal defect E) Plaque formation
A, B, C Feedback: Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty.
38. Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient have with mitral valve prolapse? Select all that apply. A) Anxiety B) Fatigue C) Shoulder pain D) Tachypnea E) Palpitations
A, B, E Feedback: Most people who have mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not characteristic symptoms of mitral valve prolapse.
Physiological Integrity 8. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to a. teach the patient to take deep, slow breaths to control the pain. b. force fluids to 3000 mL/day to decrease fever and inflammation. c. remind the patient to request opioid pain medication every 4 hours. d. place the patient in Fowler's position, leaning forward on the overbed table.
D Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal antiinflammatory drug (NSAID). DIF: Cognitive Level: Apply (application) REF: 817 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
A patient with pericarditis has just been admitted to the CCU. The nurse planning the patients care should prioritize what nursing diagnosis? A) Anxiety related to pericarditis B) Acute pain related to pericarditis C) Ineffective tissue perfusion related to pericarditis D) Ineffective breathing pattern related to pericarditis
Ans: B Feedback: The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment.
Physiological Integrity 20. A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder? a. A heart transplant should be scheduled as soon as possible. b. Elevating the legs above the heart will help relieve dyspnea. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the doctor about any symptoms of heart failure such as shortness of breath.
D The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation. DIF: Cognitive Level: Apply (application) REF: 828 TOP: Nursing Process: Planning MSC:
Safe and Effective Care Environment 34. Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.
D Under the supervision of registered nurses (RNs), UAP check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:
The critical care nurse is caring for a patient who is receiving cyclosporine postoperative heart transplant. The patient asks the nurse to remind him what this medication is for. How should the nurse best respond? A) Azathioprine decreases the risk of thrombus formation. B) Azathioprine ensures adequate cardiac output. C) Azathioprine increases the number of white blood cells. D) Azathioprine minimizes rejection of the transplant.
Ans: D Feedback: After heart transplant, patients are constantly balancing the risk of rejection with the risk of infection. Most commonly, patients receive cyclosporine or tacrolimus (FK506, Prograf), azathioprine (Imuran), or mycophenolate mofetil (CellCept), and corticosteroids (prednisone) to minimize rejection. Cyclosporine does not prevent thrombus formation, enhance cardiac output, or increase white cell counts.
Physiological Integrity 15. While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to a. take antibiotics before any dental appointments. b. limit physical activity to avoid stressing the heart. c. take an aspirin a day to prevent clots from forming on the valve. d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs.
D Use of stimulant medications should be avoided by patients with MVP because these may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient. DIF: Cognitive Level: Apply (application) REF: 822 TOP: Nursing Process: Evaluation MSC:
40. The nurse is auscultating the breath sounds of a patient with pericarditis. What finding is most consistent with this diagnosis? A) Wheezes B) Friction rub C) Fine crackles D) Coarse crackles
B Feedback: A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with pericarditis.
17. The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic regurgitation causes what? A) Cardiac tamponade B) Left ventricular hypertrophy C) Right-sided heart failure D) Ventricular insufficiency
B Feedback: Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood from the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. Aortic regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular insufficiency.
9. The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM? A) Dilated ventricles with atrophy of the ventricles B) Dilated ventricles without hypertrophy of the ventricles C) Dilation and hypertrophy of all four heart chambers D) Dilation of the atria and hypertrophy of the ventricles
B Feedback: DCM is characterized by significant dilation of the ventricles without significant concomitant hypertrophy and systolic dysfunction. The ventricles do not atrophy in patients with DCM.
33. A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patient's medication regimen, what nursing diagnosis should be prioritized? A) Risk for injury B) Risk for infection C) Risk for peripheral neurovascular dysfunction D) Risk for unstable blood glucose
B Feedback: Immunosuppressants decrease the body's ability to resist infections, and a satisfactory balance must be achieved between suppressing rejection and avoiding infection. These drugs do not create a heightened risk of injury, neurovascular dysfunction, or unstable blood glucose levels.
8. The nurse is caring for a patient with mitral stenosis who is scheduled for a balloon valvuloplasty. The patient tells the nurse that he is unsure why the surgeon did not opt to replace his damaged valve rather than repairing it. What is an advantage of valvuloplasty that the nurse should cite? A) The procedure can be performed on an outpatient basis in a physician's office. B) Repaired valves tend to function longer than replaced valves. C) The procedure is not associated with a risk for infection. D) Lower doses of antirejection drugs are required than with valve replacement.
B Feedback: In general, valves that undergo valvuloplasty function longer than prosthetic valve replacements and patients do not require continuous anticoagulation. Valvuloplasty carries a risk of infection, like all surgical procedures, and it is not performed in a physician's office. Antirejection drugs are unnecessary because foreign tissue is not introduced.
16. The nurse is caring for a patient who is scheduled to undergo mechanical valve replacement. Patient education should include which of the following? A) Use of patient-controlled analgesia B) Long-term anticoagulant therapy C) Steroid therapy D) Use of IV diuretics
B Feedback: Mechanical valves necessitate long-term use of required anticoagulants. Diuretics and steroids are not indicated and patient-controlled analgesia may or may be not be used in the immediate postoperative period.
22. A patient with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the patient's symptoms, the nurse should teach the patient to do which of the following? A) Eat a high-protein, low-carbohydrate diet. B) Avoid activities that cause an increased heart rate. C) Avoid large crowds and public events. D) Perform deep breathing and coughing exercises.
B Feedback: Patients with mitral stenosis are advised to avoid strenuous activities, competitive sports, and pregnancy, all of which increase heart rate. Infection prevention is important, but avoiding crowds is not usually necessary. Deep breathing and coughing are not likely to prevent exacerbations of symptoms and increased protein intake is not necessary.
7. A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension. What valvular disorder should the nurse anticipate being diagnosed in this patient? A) Aortic regurgitation B) Mitral stenosis C) Mitral valve prolapse D) Aortic stenosis
B Feedback: The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its usual size. Patients are likely to show progressive fatigue as a result of low cardiac output. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Patients may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections. Pulmonary venous hypertension is not typically caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis.
Physiological Integrity 32. After receiving report on the following patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg c. Patient with infective endocarditis who has a murmur and splinter hemorrhages d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases
B Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention. DIF: Cognitive Level: Analyze (analysis) REF: 823 OBJ: Special Questions: Multiple Patients; Prioritization TOP: Nursing Process: Assessment MSC:
Physiological Integrity 31. The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? a. Leukocytosis b. Irregular pulse c. Generalized myalgia d. Complaint of fatigue
B Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these. DIF: Cognitive Level: Apply (application) REF: 818 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
Physiological Integrity 9. The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask? a. "Do you use any illegal IV drugs?" b. "Have you had a recent sore throat?" c. "Have you injured your chest in the last few weeks?" d. "Do you have a family history of congenital heart disease?"
B Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever. DIF: Cognitive Level: Apply (application) REF: 819 TOP: Nursing Process: Assessment MSC:
Physiological Integrity 24. Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? a. Generalized muscle aching b. Sudden onset right flank pain c. Janeway's lesions on the palms d. Temperature 100.7° F (38.1° C)
B Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions. DIF: Cognitive Level: Apply (application) REF: 812 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
Physiological Integrity 12. When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include? a. Vaccinate high-risk groups in the community with streptococcal vaccine. b. Teach community members to seek treatment for streptococcal pharyngitis. c. Teach about the importance of monitoring temperature when sore throats occur. d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.
B The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever. DIF: Cognitive Level: Apply (application) REF: 820 TOP: Nursing Process: Planning MSC:
Safe and Effective Care Environment 33. After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first? a. Patient with acute pericarditis who has a pericardial friction rub b. Patient who has just returned to the unit after balloon valvuloplasty c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116 d. Patient with a mitral valve replacement who has an anticoagulant scheduled
B The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention. DIF: Cognitive Level: Analyze (analysis) REF: 824 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC:
Physiological Integrity 23. Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? a. Administer ceftriaxone (Rocephin) 1 g IV. b. Order blood cultures drawn from two sites. c. Give acetaminophen (Tylenol) PRN for fever. d. Arrange for a transesophageal echocardiogram.
B Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority. DIF: Cognitive Level: Apply (application) REF: 812-813 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
2. A patient who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following? A) Exposure to immunocompromised individuals B) Future hospital admissions C) Dental procedures D) Live vaccinations
C Feedback: Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to vaccination, future hospital admissions, or exposure to people who are immunosuppressed.
1. A patient with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the patient to exhibit what heart rhythm? A) Ventricular fibrillation (VF) B) Ventricular tachycardia (VT) C) Atrial fibrillation D) Sinus bradycardia
C Feedback: In patients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation. Bradycardia, VF, and VT are not characteristic of this valvular disorder.
13. The nurse is admitting a patient with complaints of dyspnea on exertion and fatigue. The patient's ECG shows dysrhythmias that are sometimes associated with left ventricular hypertrophy. What diagnostic tool would be most helpful in diagnosing cardiomyopathy? A) Cardiac catheterization B) Arterial blood gases C) Echocardiogram D) Exercise stress test
C Feedback: The echocardiogram is one of the most helpful diagnostic tools because the structure and function of the ventricles can be observed easily. The ECG is also important, and can demonstrate dysrhythmias and changes consistent with left ventricular hypertrophy. Cardiac catheterization specifically addresses coronary artery function and arterial blood gases evaluate gas exchange and acid balance. Stress testing is not normally used to differentiate cardiomyopathy from other cardiac pathologies.
15. A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse's interview is most suggestive of this valvular disorder? A) "I get chest pain from time to time, but it usually resolves when I rest." B) "Sometimes when I'm resting, I can feel my heart skip a beat." C) "Whenever I do any form of exercise I get terribly short of breath." D) "My feet and ankles have gotten terribly puffy the last few weeks."
C Feedback: The first symptom of mitral stenosis is often breathing difficulty (dyspnea) on exertion as a result of pulmonary venous hypertension. Patients with mitral stenosis are likely to show progressive fatigue as a result of low cardiac output. Palpitations occur in some patients, but dyspnea is a characteristic early symptom. Peripheral edema and chest pain are atypical.
18. The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient? A) Absence of complications B) Adherence to the self-care program C) Improved cardiac output D) Increased activity tolerance
C Feedback: The priority nursing diagnosis of a patient with cardiomyopathy would include improved or maintained cardiac output. Regardless of the category and cause, cardiomyopathy may lead to severe heart failure, lethal dysrhythmias, and death. The pathophysiology of all cardiomyopathies is a series of progressive events that culminate in impaired cardiac output. Absence of complications, adherence to the self-care program, and increased activity tolerance should be included in the care plan, but they do not have the priority of improved cardiac output.
34. The nurse is caring for a patient with acute pericarditis. What nursing management should be instituted to minimize complications? A) The nurse keeps the patient isolated to prevent nosocomial infections. B) The nurse encourages coughing and deep breathing. C) The nurse helps the patient with activities until the pain and fever subside. D) The nurse encourages increased fluid intake until the infection resolves.
C Feedback: To minimize complications, the nurse helps the patient with activity restrictions until the pain and fever subside. As the patient's condition improves, the nurse encourages gradual increases of activity. Actions to minimize complications of acute pericarditis do not include keeping the patient isolated. Due to pain, coughing and deep breathing are not normally encouraged. An increase in fluid intake is not always necessary.
30. A 17-year-old boy is being treated in the ICU after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. What type of cardiomyopathy is particularly common among young people who appear otherwise healthy? A) Dilated cardiomyopathy (DCM). B) Arrhythmogenic right ventricular cardiomyopathy (ARVC) C) Hypertrophic cardiomyopathy (HCM) D) Restrictive or constrictive cardiomyopathy (RCM)
C Feedback: With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people, including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy.
Physiological Integrity 17. During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.
C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated. DIF: Cognitive Level: Apply (application) REF: 826 TOP: Nursing Process: Implementation MSC:
Physiological Integrity 29. Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective? a. Assess for the presence of a paradoxical pulse. b. Monitor for changes in the patient's sedimentation rate. c. Assess for the presence of jugular venous distention (JVD). d. Check the electrocardiogram (ECG) for ST segment changes.
C Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST-segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis. DIF: Cognitive Level: Apply (application) REF: 817 TOP: Nursing Process: Evaluation MSC:
Physiological Integrity 19. When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of a. flank pain. b. splenomegaly. c. shortness of breath. d. mental status changes.
C Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves. DIF: Cognitive Level: Apply (application) REF: 812 TOP: Nursing Process: Planning MSC:
Physiological Integrity 14. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.
C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed. DIF: Cognitive Level: Apply (application) REF: 824-825 TOP: Nursing Process: Implementation MSC:
Physiological Integrity 30. Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been most effective? a. "I will avoid taking aspirin or other antiinflammatory drugs." b. "I will need to limit my intake of salt and fluids even in hot weather." c. "I will take antibiotics when my teeth are cleaned at the dental office." d. "I should begin an exercise program that includes things like biking or swimming."
C Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or NSAIDs. DIF: Cognitive Level: Apply (application) REF: 830 | 813 TOP: Nursing Process: Evaluation MSC:
Physiological Integrity 25. Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? a. Pulsus paradoxus 8 mm Hg b. Blood pressure (BP) of 168/94 c. Jugular venous distention (JVD) to jaw level d. Level 6 (0 to 10 scale) chest pain with a deep breath
C The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis. DIF: Cognitive Level: Apply (application) REF: 815 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
Health Promotion and Maintenance 13. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. b. peripheral edema. c. shortness of breath on exertion. d. right upper quadrant tenderness.
C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia. DIF: Cognitive Level: Apply (application) REF: 821 TOP: Nursing Process: Assessment MSC:
A nurse is teaching a client who is having a valuloplasty tomorrow. The client asks what the advantage is for having a tissue valve replacement instead of a mechanical valve. The correct answer by the nurse is which of the following? a) "A tissue valve is less likely to generate blood clots, and so long-term anticoagulation therapy is not required." b) "A tissue valve does not become infected as easily as mechanical valves." c) "A tissue valve is thought to be more durable and so requires replacement less often." d) "A tissue valve does not deteriorate as easily as mechanical valves."
a) "A tissue valve is less likely to generate blood clots, and so long-term anticoagulation therapy is not required." Tissue valves are less likely to generate thromoemboli, so long-term anticoagulation is not required. Mechanical valves do not deteriorate or become infected as easily as tissue valves. They are thought to be more durable than tissue valves and so require replacement less often.
The client teaching instructions for a 57-year-old male client with thrombophlebitis who is being discharged should include which of the following? Select all that apply. a) Ambulate as tolerated. b) Avoid elevating affected extremity. c) Take anticoagulant therapy when symptoms occur. d) Avoid sitting for too long. e) Perform leg exercises each hour.
a) Ambulate as tolerated. d) Avoid sitting for too long. e) Perform leg exercises each hour. Nurses instruct clients with thrombophlebitis to prevent recurrences by being active, avoiding knee bending or leg crossing, elevating legs periodically, and taking long-term anticoagulant therapy exactly as prescribed. Clients should also watch for and report signs that indicate impaired clotting: nosebleeds, bleeding gums, rectal bleeding, easy bruising, and prolonged oozing from minor cuts.
The nurse is performing a neurovascular assessment of a client's injured extremity. Which of the following would the nurse report? a) Dusky or mottled skin color b) Positive distal pulses c) Skin warm to touch d) Capillary refill of 3 seconds
a) Dusky or mottled skin color Normally, skin color would be similar to the color in other body areas. Pale or dusky skin color indicates an abnormality that needs to be reported. Presence of pulses, capillary refill of 3 seconds, and warm skin are normal findings.
The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood culture results. The client asks, "Where did I pick up these bacteria?"The nurse is most safe to speculate which of the following? a) From a break in the skin b) From ingestion of a food c) From droplets from a cough d) From the fecal-oral route
a) From a break in the skin The microorganisms that cause infective endocarditis include bacteria and fungi. Streptococci and staphylococci are the bacteria most frequently responsible for this disorder. Both bacteria are abundantly found on the skin. These organisms are not found in the other locations.
The nurse suspects a diagnosis of mitral valve regurgitation when what type of murmur is heard on auscultation? a) High-pitched blowing sound at the apex b) Diastolic murmur at the left sternal border c) Mitral click d) Low-pitched diastolic murmur at the apex
a) High-pitched blowing sound at the apex Mitral valve regurgitation is associated with a systolic murmur, which is a high-pitched, blowing sound at the apex.
A patient with a history of valvular disease has just arrived in the PACU after a percutaneous balloon valvuloplasty. Which intervention should the recovery nurse implement? a) Keep the patient's affected leg straight. b) Monitor the patient's chest drainage. c) Evaluate the patient's endotracheal lip line. d) Assess the patient's chest tube output.
a) Keep the patient's affected leg straight. Balloon valvuloplasty is performed in the cardiac catheterization laboratory. A catheter is inserted into the femoral artery. The patient must keep the affected leg straight to prevent hemorrhage at the insertion site. It is not an open heart surgery requiring chest tubes nor a chest dressing. ET tubes are placed when someone has general anesthesia, and this procedure is performed using light or moderate sedation.
Which of the following nursing interventions should a nurse perform to reduce cardiac workload in a patient diagnosed with myocarditis? a) Maintain the patient on bed rest. b) Elevate the patient's head. c) Administer a prescribed antipyretic. d) Administer supplemental oxygen.
a) Maintain the patient on bed rest. The nurse should maintain the patient on bed rest to reduce cardiac workload and promote healing. Bed rest also helps decrease myocardial damage and the complications of myocarditis. The nurse should administer supplemental oxygen to relieve tachycardia that may develop from hypoxemia. If the patient has a fever, the nurse should administer a prescribed antipyretic along with independent nursing measures such as minimizing layers of bed linen, promoting air circulation and evaporation of perspiration, and offering oral fluids. The nurse should elevate the patient's head to promote maximal breathing potential.
The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which of the following findings confirms a positive outcome?(Select all that apply.) a) No bleeding or bruising noted b) Right extremity pink c) Right extremity comparable in size to left d) Client denies pain e) Homan's sign positive f) Pedal pulse thready
a) No bleeding or bruising noted b) Right extremity pink c) Right extremity comparable in size to left d) Client denies pain Evaluation of the expected outcome of thrombolytic therapy includes restoring blood flow to the extremity. Findings include no pain from impaired circulation, a pink extremity of comparable size, and no bleeding from complications of the thrombolytic medication. A thready pulse would indicate impaired circulation, and a positive Homan's sign would indicate a continuing thrombus.
A patient was admitted to the hospital with a diagnosis of aortic regurgitation. On assessment, the nurse notes the following positive indicators for the disease process. Select all that apply. a) The pulse has a rapid upstroke, then collapses b) Systolic pressure in the lower extremities is lower than in the upper extremities c) Visible neck vein pulsations d) The presence of a diastolic murmur e) Shortened pulse pressure
a) The pulse has a rapid upstroke, then collapses c) Visible neck vein pulsations d) The presence of a diastolic murmur Pulse pressure widens and systolic blood pressure in the lower extremities is higher than in the upper extremities as a result of progressive left ventricular failure.
A patient with infective endocarditis of a prosthetic mitral valve returns to the emergency department with a second episode of left-sided weakness and visual changes. The nurse expects that collaborative management of the patient will include a) surgical valve replacement b) administration of anticoagulants c) higher than usual antibiotic dosages d) embolectomy
a) surgical valve replacement Aortic or mitral valve debridement, excision, or replacement is required in patients with more than one serious systemic embolic episode.
A patient with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. The graduate nurse discusses this development with the nurse preceptor. The preceptor is assured when the graduate nurse states: a) "I instructed the patient to do coughing and deep breathing and I will reassess in 30 minutes." b) "I anticipated this complication and I will call the doctor right now." c) "I placed the patient in a semi-Fowler's position and made him NPO." d) "I told the patient that this is a normal complication and to take deep breaths."
b) "I anticipated this complication and I will call the doctor right now." With right-sided heart endocarditis, the nurse assesses for signs and symptoms of organ damage such as stroke, meningitis, heart failure, myocardial infarction, glomerulonephritis, and splenomegaly. This requires further assessment and collaborative interventions to prevent further deterioration. The other actions are not appropriate at this time.
A 73-year-old male client is diagnosed with dilated cardiomyopathy. The nurse is aware that which of the following is the most likely cause of his condition? a) Scleroderma b) Chronic alcohol abuse c) Previous myocardial infarction d) Heredity
b) Chronic alcohol abuse Chronic alcohol ingestion is one of the main causes of dilated cardiomyopathy. Other causes include history of viral myocarditis, an autoimmune response, and exposure to other chemicals in addition to alcohol. Heredity is considered the main cause of hypertrophic cardiomyopathy. This a connective tissue disorder is thought to cause restrictive cardiomyopathy. Scar tissue that forms after a myocardial infarction is thought to be a cause of restrictive cardiomyopathy.
The nurse determines that a patient has a characteristic symptom of pericarditis. What symptom does the nurse recognize as significant for this diagnosis? a) Dyspnea b) Constant chest pain c) Uncontrolled restlessness d) Fatigue lasting more than 1 month
b) Constant chest pain The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. Pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning.
A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis? a) Race b) History of aortic valve replacement c) History of diabetes mellitus d) Age
b) History of aortic valve replacement A heart valve prosthesis such as an aortic valve replacement is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.
A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the nurse to clarify one of the last treatment options available that the physician mentioned earlier. After checking with the primary nurse, the nursing student would most likely discuss which of the following? a) Chordoplasty b) Left ventricular assist device c) Annuloplasty d) Open commissurotomy
b) Left ventricular assist device When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Because of the limited number of organ donors, many clients die waiting. In some cases, a left ventricular assist device is implanted to support the failing heart until a suitable donor becomes available. The other three choices have to do with failing valves and valve repairs.
A nurse is teaching a patient about valve replacement surgery. Which statement by the patient indicates an understanding of the benefit of an autograft replacement valve? a) "The valve is from a tissue donor, and I will not need to take any blood thinning drugs with I am discharged." b) "The valve is mechanical, and it will not deteriorate or need replacing." c) "The valve is made from my own heart valve, and I will not need to take any blood thinning drugs when I am discharged." d) "The valve is made from a pig tissue, and I will not need to take any blood-thinning drugs when I am discharged."
c) "The valve is made from my own heart valve, and I will not need to take any blood thinning drugs when I am discharged." Autografts (i.e., autologous valves) are obtained by excising the patient's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. Anticoagulation is unnecessary because the valve is the patient's own tissue and is not thrombogenic. The autograft is an alternative for children (it may grow as the child grows), women of childbearing age, young adults, patients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years.
The nurse is aware that statistics show an increase in the prevalence of infective endocarditis among older adults. Which of the following factors places older adults at risk for developing infective endocarditis? a) Higher rate of tuberculosis b) A greater incidence of a history of repaired congenital heart defects c) An increased use in the number of prosthetic valve replacements d) An increase in IV drug use
c) An increased use in the number of prosthetic valve replacements The prevalence of infective endocarditis among older adults has increased, due in part to the increased number of prosthetic valve replacements, including replacements for older adults, and an increase in hospital-acquired bacteremia. While history of a repaired congenital heart defect does place a client at greater risk for developing infective endocarditis in the future, it has not been shown as a contributing factor in the prevalence of infective endocarditis among older adults. IV drug use and IV drug abuse places individuals at greater risk for infective endocarditis. However, this risk has not been attributed to an increase in its prevalence among older adults. Tuberculosis is known to contribute to pericarditis among the general population and not specific to the older adult client.
The nurse is auscultating the heart sounds of a patient with mitral stenosis. The pulse rhythm is weak and irregular. What rhythm does the nurse expect to see on the electrocardiogram (ECG)? a) First-degree atrioventricular block b) Ventricular tachycardia c) Atrial fibrillation d) Sinus dysrhythmia
c) Atrial fibrillation In mitral stenosis, the pulse is weak and often irregular because of atrial fibrillation (caused by strain on the atrium).
A patient who has had a recent myocardial infarction develops pericarditis and complains of level 6 (on a scale of 0-10) chest pain with deep breathing. Which of these ordered pro re nata (PRN) medications will be the most appropriate for the nurse to administer? a) Morphine sulfate 6 mg IVP every 2-4 hours b) Acetaminophen (Tylenol) 650 mg per os (po) every 4 hours c) Ibuprofen (Motrin) 800 mg po every 8 hours d) Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours
c) Ibuprofen (Motrin) 800 mg po every 8 hours Pain associated with pericarditis is caused by inflammation, thus nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.
The nurse is caring for a client with manifestations of dilated cardiomyopathy. When planning care, which consideration would the nurse make? a) Assist client to bathroom every 2 hours. b) Assess abdominal girth daily. c) Place bed in a high or semi-high Fowler's position as needed. d) Instruct client to avoid strenuous activity.
c) Place bed in a high or semi-high Fowler's position as needed. Dilated cardiomyopathy has clinical manifestations of dyspnea on exertion and when lying down. Depending on level of dyspnea, placing the client in an upright Fowler's position is helpful. Clients with hypertrophic cardiomyopathy have syncopal episodes and can collapse following strenuous activity. Assistance with ambulation to avoid falls is helpful. Restrictive cardiomyopathy includes manifestations of ascites and assessment of abdominal girth.
Which of the following teaching interventions should the nurse include in the plan of care for a patient with valvular heart disease who is experiencing pulmonary congestion? a) Teaching patients to take nitroglycerin if shortness of breath develops b) Teaching patients to drink at least 2 L of fluid daily and monitor urine output c) Teaching patients to rest and sleep in a chair or sit in bed with head elevated d) Teaching patients to report a weight gain of 3 pounds in 1 week
c) Teaching patients to rest and sleep in a chair or sit in bed with head elevated Patients who experience symptoms of pulmonary congestion are advised to rest and sleep sitting in a chair or bed with the head elevated. In addition, the nurse educates the patient to take a daily weight and report gains of 3 pounds in 1 day or 5 pounds in 1 week to the primary provider. The nurse may assist the patient with planning activity and rest periods to achieve an acceptable lifestyle.
A patient with a recent myocardial infarction was admitted to the hospital with a new diagnosis of mitral valve regurgitation. Which of the following assessment data obtained by the nurse should be immediately communicated to the health care provider? a) The patient has a palpable thrill felt over the left anterior chest. b) The patient has 4+ peripheral edema in both legs. c) The patient has crackles audible throughout the lungs. d) The patient has a loud systolic murmur all across the precordium.
c) The patient has crackles audible throughout the lungs. Acute mitral regurgitation, resulting from a myocardial infarction, usually manifests as severe congestive heart failure. Dyspnea, fatigue and weakness are the most common symptoms. Palpitations, shortness of breath on exertion and cough from pulmonary congestion also occur. Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and need immediate interventions, such as diuretics.
The nurse understands that which of the following medications will be administered for 6 to 12 weeks following prosthetic porcine valve surgery? a) Aspirin b) Digoxin c) Warfarin d) Furosemide
c) Warfarin To reduce the risk of thrombosis in patients with porcine or bovine tissue valves, warfarin is required for 6 to 12 weeks, followed by aspirin therapy. Furosemide would not be given for 6 to 12 weeks following this type of surgery. Digoxin may be used for the treatment of arrhythmias, but not just for 6 to 12 weeks.
