Med Sure III Exam 1
A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect?
heart rate of 120 beats/min
The nurse is caring for a client on the medical surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor rhythm below: After calling for assistance and a defibrillator, what action would the nurse take next?
initiate cardiopulmonary resuscitation (CPR)
A nurse assesses female client who is experiencing a myocardial infarction. Which clincial manifestation would the nurse expect?
fatigue and shortness of breath
An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?
client who describes intense squeezing pressure across the chest.
A client is to receive a dopamine infusion. What does the nurse do to prepare for this infusion?
gather central line supplies
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
A nurse is caring for four clients. Which client should the nurse assess first?
Client who is 1 hour post angioplasty, has tongue swelling and anxiety
A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88. What action would the nurse take first?
Compare the results with the previous blood pressure readings
After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement?
Instruct the client to ask for assistance when rising from bed
A nurse assess a client who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
Location A
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
Maintain airway patency.
A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed?
dyspnea on excretion
A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure?
"Are you still able to walk upstairs without fatigue"
A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include?
"Avoid large crowds and people who are sick"
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate?
"Avoid straining while having a bowel movement"
A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching?
"Avoid using self substitutes"
A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching?
"Begin walking 200 feet a day three times a week"
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?
"Blood clots form more easily in artificial replacement valves."
A nurse supervises and AP applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure?
"Clean the skin and clip hairs if needed"
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" What is the nurse's best response?
"Client who use cocaine are at risk for fatal dysrhythmias."
A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching?
"Do not take this medication within 1 hour of taking an antacid"
A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I cant do it alone. Maybe I should die." What is the best response by the nurse?
"I can stay if you would like and talk more about this."
An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure?
"I get short of breath when I climb stairs"
A nurse prepare to discharge a client with a cardiac dysrhythmia who is prescribed home health care services. Which priority information would be communicated to the home health nurse upon discharge?
Medication orders for home
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left sided heart failure?
"I must stop halfway up the stairs to catch my breath"
After teaching a client who has an implantable cardioverter-defribrillator, a nurse assesses the client's understanding. Which statement by the client indicates correct understand of the teaching?
"I will avoid sources of strong electromagnetic fields"
After teaching a client who is being discharged home after mitral valve replacement surgery the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?
"I will have my teeth cleaned by my dentist in 2 weeks"
The provider requests the nurse start an infusion of an milrinone on a client. How does the nurse explain the action of these drugs to the client and spouse?
"It increases the force of the heart's contractions."
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this client's teaching?
"Minimize or abstain from caffeine"
A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right sided heart failure?
"My shoes fit really tight lately"
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema?
"My shoes fit tighter by the end of the day"
A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response?
"Tell me more about your concerns about the test"
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best?
"The heparin keeps that artery from getting blocked again."
A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I am sleeping at night." What is the nurses's best response?
"Use pillows to elevate your head and chest while you are sleeping"
A nurse assesses a client administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?
administer PRN acetaminophen
A nurse assesses clients on a medical surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease?
A 65 year old woman with diabetes mellitus
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure?
allergies to iodine-based agents
A nurse cares for a client with right sided heart failure. The client asks, "Why do I need to weight myself every day?" How would the nurse respond?
"Weight is the best indication that you are gaining or losing fluid"
A nurse teaches a client who has a history of heart failure. Which statement would the nurse in the client's discharge teaching?
"Weight yourself daily while wearing the same amount of clothing."
A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response?
"What do you understand about what happened to you?"
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond?
"Would you like information about advance directives?"
A nurse teaches a client with diabetes mellitus and body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in the client's teaching?
"You should balance weight loss with consuming necessary nutrients"
After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond?
"Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."
A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes?
. Give the client an aspirin.
A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation?
an 50 year old who is post coronary artery bypass graft surgery
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
Allow continued bathroom privileges.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?
Assess for any hemodynamic effects of the rhythm.
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next?
Assess for symptoms of left sided heart failure
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
Assess the IV site hourly.
A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?
Assess the clients respiratory status
what is the FIRST PRIORITY when a patient presents with chest pain?
EKG within 10 minutes
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client?
Ensure that everyone is clear of contact with the client and the bed
A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find?
Friction rub at the left lower sternal border
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. Which action would the nurse take?
Notify the primary HCP before scheduling the MRI
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
Poor peripheral pulses and cool skin
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
Prepare to administer a fluid bolus.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?
Pulse decreased from 100 to 80 beats/min
patients with unstable angina may present with what type of changes on a 12 lead EKG? but will not have changes in what lab?
ST changes; will not have troponin level changes. There is ischemia present but not enough to cause cell death
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What intervention would the nurse implement to address this client's concerns?
Schedule periods of exercise and rest during the day
A nurse assesses a client with atrial fibrillation. Which manifestations would alert the nurse to the possibility of a serious complication from this condition?
Speech alterations
A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use?
Standard precautions
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?
Stop the infusion and call the provider.
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How would the nurse interpret this observation?
Ventricular and atrial depolarizations are initiated from different sites
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication would the nurse expect to find on this client's medication administration record to prevent a common complication of this condition?
Warfarin
what percentage of occlusion does an artery need to reach for blood flow to be impaired to create myocardial ischemia when myocardial demand is increased
When an artery reaches 50% occlusion blood flow is impaired
A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at greatest risk for the development of left sided heart failure?
a 36 year old woman with aortic stenosis
A nurse performs an admission assessment on a 75 year old client with multiple chronic diseases. The clients blood pressure is 135/75 and oxygen saturation is 94% on 2L per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading below:
ask the client what medications he or her takes
A nurse cares for a client who is on a cardiac monitor. the monitors displayed rhythm: What action would the nurse take first?
assess airway, breathing, circulation
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first?
assess the clients medications
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next?
assess the color and temperature of the left leg
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing side but no ORS complex on the client's electrocardiogram. What action would the nurse take next?
assess vital signs and level of consciousness
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess?
atrial fibrillation
A nurse cares for a client who has an 80% blockage of the right coronary artery and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery?
initiation of an external pacemaker
A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete neck?
level of consciousness
A nurse assesses a client with tachycardia. Which client manifestation requires immediate intervention by the nurse?
midsternal chest pain
A nurse administers prescribed adenosine to a client. Which response would the nurse assess for as the expected therapeutic response?
short period of systole
A nurse assesses a clients ECG and observes:
sinus rhythm with premature ventricular contractions (PVCs)
A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?
sit the client up with a pillow to lean forward on.
After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: *CHART*
slow the amiodarone infusion rate
A nurse assesses a client who is receiving left sided cardiac catheterization. Which assessment finding requires immediate intervention?
slurred speech and confusion
A nurse assists with the cardio version of a client experiencing acute atrial fibrillation. What action would the nurse aka prior to the cardioversion?
turn off oxygen therapy
