Med surg exam 4
A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? "Consume foods high in potassium." "Monitor for irregular pulse." "Monitor for muscle cramping." "Avoid grapefruit juice."
"Avoid grapefruit juice."
The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? "Are you afraid you will not be able to work?" "If you control your diabetes, you can avoid amputation." "Your concerns are valid; we can review some steps to limit disease progression." "What about the situation concerns you most?"
"Your concerns are valid; we can review some steps to limit disease progression."
The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action would be taken by he nurse? No intervention is needed; this is a normal reading. Collaborate with the primary health care provider to administer a positive inotropic agent. Administer a STAT dose of metoprolol (Lopressor). Ask the client to perform the Valsalva maneuver.
Collaborate with the primary health care provider to administer a positive inotropic agent.
A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? Calls the family to lift the client's spirits Considers further assessment for depression Sedates the client to decrease myocardial oxygen demand Tells the client that things will get better
Considers further assessment for depression
The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are as follows: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action does the nurse take? Administer atropine. Administer digoxin. Administer clonidine. Continue to monitor.
Continue to monitor.
The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client would the nurse question? Enalapril (Vasotec) Sodium nitroprusside (Nipride) Dopamine (Intropin) Labetalol (Normodyne)
Dopamine (Intropin)
Which of these factors contribute to the risk for cardiovascular disease? Select all that apply. Consuming a diet rich in fiber Elevated C-reactive protein levels Low blood pressure Elevated high-density lipoprotein (HDL) cholesterol level Smoking
Elevated C-reactive protein levels Smoking
Which risk factors are known to contribute to atrial fibrillation? Select all that apply. Use of beta-adrenergic blockers Excessive alcohol use Advancing age High blood pressure Palpitations
Excessive alcohol use Advancing age High blood pressure
A client who is suffering from dyspnea on exertion and congestive heart failure (CHF) will most likely report which symptom during the health history? Fatigue Swelling of one leg Slow heart rate Brown discoloration of lower extremities
Fatigue
The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? ST segment Heart rate Troponin Myoglobin
HR
The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? Determines the client's physical limitations Encourages alternate rest and activity periods Monitors and documents heart rate, rhythm, and pulses Positions the client to alleviate dyspnea
Positions the client to alleviate dyspnea
The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the primary health care provider by the nurse for further instructions? Calcium 8.5 mEq/L (4.25 mmol/L) Potassium 3.0 mEq/L (3.0 mmol/L) Magnesium 2.1 mEq/L (1 mmol/L) International normalized ratio (INR) of 1.0
Potassium 3.0 mEq/L (3.0 mmol/L)
A patient admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? Prepare for defibrillation. Establish IV access. Place an oral airway and ventilate. Start cardiopulmonary resuscitation (CPR).
Prepare for defibrillation.
The nurse administers amiodarone (Cordarone) to a patient with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. Respiratory rate QT interval Heart rate Heart rhythm Urine output
QT interval Heart rate Heart rhythm
A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L (135 mmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L) Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) Serum magnesium level of 1.9 mEq/L (0.95 mmol/L)
Serum potassium level of 2.8 mEq/L (2.8 mmol/L)
A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and must be communicated immediately to the primary health care provider? White blood cell count Low-density lipoproteins Serum troponin I level C-reactive protein
Serum troponin I level
Which intervention provides safety during cardioversion? Setting the defibrillator at 220 joules Obtaining informed consent Setting the defibrillator to the synchronized mode Removing oxygen
Setting the defibrillator to the synchronized mode
Which symptom reported by a client who has had a total hip replacement requires emergency action? Localized swelling of one of the lower extremities Positive Homans' sign Shortness of breath and chest pain Tenderness and redness at the IV site
Shortness of breath and chest pain
Which vascular assessment by the student nurse requires intervention by the supervising nurse? Measuring capillary refill in the fingertips Assessing pedal pulses by Doppler Measuring blood pressure in both arms Simultaneously palpating the bilateral carotids
Simultaneously palpating the bilateral carotids
A patient's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? Normal sinus rhythm Sinus bradycardia Sinus tachycardia Sinus rhythm with premature ventricular contractions
Sinus tachycardia
The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? Friction rub auscultated at the left lower sternal border Pain aggravated by breathing, coughing, and swallowing Splinter hemorrhages Thickening of the endocardium
Splinter hemorrhages
The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? "I can use an electric razor or a regular razor." "Eating foods like green beans won't interfere with my Coumadin therapy." "If I notice I am bleeding a lot, I should stop taking Coumadin right away." "When taking Coumadin, I may notice some blood in my urine."
"Eating foods like green beans won't interfere with my Coumadin therapy."
Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? "I don't know how I am going to change my lifestyle." "I don't need to change. It hasn't killed me yet." "I don't think it is as bad as the doctors say." "I will have to change my diet and exercise more."
"I don't need to change. It hasn't killed me yet."
When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? "I feel my heart beating in my abdominal area." "I just started to feel a tearing pain in my belly." "I have a headache. May I have some acetaminophen?" "I have had hoarseness for a few weeks."
"I just started to feel a tearing pain in my belly."
The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? "I need to avoid eating hamburgers." "I must cut out bacon and canned foods." "I won't put the salt shaker on the table anymore." "I need to avoid lunchmeats but may cook my own turkey."
"I need to avoid eating hamburgers."
The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education? "I will be able to shower again soon." "I need to take my pulse every day." "I might trigger airport security metal detectors." "I no longer need my heart pills."
"I no longer need my heart pills."
The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? "I will call the provider if I have a cough lasting 3 or more days." "I will report to the provider weight loss of 2 to 3 pounds (0.9 to 1.4 kg) in a day." "I will try walking for 1 hour each day." "I should expect occasional chest pain."
"I will call the provider if I have a cough lasting 3 or more days."
The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? "I must stop taking my birth control pills." "I should drink lots of water so I don't get dehydrated." "I should exercise my legs when I have been sitting or standing for a long time." "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."
"If I wear pantyhose, I won't have to wear the stockings the hospital gives me."
A client who is to undergo cardiac catheterization must be taught which essential information by the nurse? "Monitor the pulses in your feet when you get home." "Keep your affected leg straight for 2 to 6 hours." "Do not take your blood pressure medications on the day of the procedure." "Take your oral hypoglycemic with a sip of water on the morning of the procedure."
"Keep your affected leg straight for 2 to 6 hours."
What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin? "It is important to consume a diet high in green leafy vegetables." "You would take aspirin or ibuprofen for headache." "Report nosebleeds to your provider immediately." "Avoid caffeinated beverages."
"Report nosebleeds to your provider immediately."
The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "This may be caused by a genetic trait." "Just imagine how bad it would be if you weren't in good shape."
"This may be caused by a genetic trait."
The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? "This is a noninvasive test performed to assess your heart rhythm." "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." "This is a painless test that is done to assess the structure of your heart using sound waves." "This test evaluates you for potentially fatal cardiac rhythms."
"This test evaluates you for potentially fatal cardiac rhythms."
In teaching patients at risk for bradydysrhythmias, what information does the nurse include? "Avoid potassium-containing foods." "Stop smoking and avoid caffeine." "Take nitroglycerin for a slow heartbeat." "Use a stool softener."
"Use a stool softener."
While performing an admission assessment on a client, the nurse assesses which of the following as risk factors for cardiovascular disease? (Select all that apply.) a. BMI of 22. b. Well-controlled diabetes mellitus. c. Exposure to second-hand cigarette smoke. d. BP of 128/54. e. History of repeated streptococcal tonsillitis. f. Family history of cardiovascular disease. g. Total cholesterol level is 140 mg/dl.
B, C, E, F
Which statement about diagnostic cardiovascular testing is correct? Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. The left side of the heart is catheterized first and may be the only side examined.
An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography
After receiving change-of-shift report about these four clients, which client would the nurse assess first? A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min
A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs)
Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness A 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C) A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic
A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic
Which waveform indicates proper function of the sinoatrial (SA) node? The QRS complex is present. The PR interval is 0.24 second. A P wave precedes every QRS complex. The ST segment is elevated.
A P wave precedes every QRS complex.
An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is most appropriate for the RN to assign to the LPN/LVN? A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging A client with acute coronary syndrome who has just been admitted and needs an admission assessment
A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index
A client is diagnosed with right-sided heart failure. Which assessment findings will the nurse expect the client to have? (Select all that apply.) a. Peripheral edema b. Crackles in both lungs c. Increased abdominal girth d. Ascites e. Tachypnea
A, C, D, E
Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? Serum potassium level of 3.2 mEq/L (3.2 mmol/L) Ejection fraction of 60% B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) Chest x-ray report showing right middle lobe consolidation
B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL)
The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? Assess leg ulcers for evidence of infection. Administer a clonidine patch for hypertension. Obtain a request from the health care provider for a dietary consult. Develop a plan for discharge, and assess home care needs.
Administer a clonidine patch for hypertension.
The home health nurse visits a client with heart failure who has gained 5 pounds (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Assess the client for peripheral edema. Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions.
Auscultate the client's posterior breath sounds.
A patient with atrial fibrillation (AF) with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? Synchronized cardioversion Electrophysiology studies (EPS) Anticoagulation Radiofrequency ablation therapy
Anticoagulation
Which statement reflects correct cardiac physical assessment technique? Auscultate the aortic valve in the second intercostal space at the right sternal border. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. Palpate the apical pulse over the third intercostal space in the midclavicular line. Assess for carotid bruit by auscultating over the anterior neck.
Auscultate the aortic valve in the second intercostal space at the right sternal border.
Which teaching is essential for a patient who has had a permanent pacemaker inserted? Avoid talking on a cell phone. Avoid operating electrical appliances over the pacemaker. Avoid sexual activity. Do not take tub baths.
Avoid operating electrical appliances over the pacemaker.
A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)? Partial thromboplastin time (PTT) 60 seconds Platelets 32,000/mm3 (32 × 109/L) White blood cells 11,000/mm3 (11 × 109/L) Hemoglobin 12.2 g/dL (122 mmol/L)
Platelets 32,000/mm3 (32 × 109/L)
A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The risk for hypotension The potential for bradycardia Liver function tests
The risk for hypotension
For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? Heart rate 52 beats/min Blood pressure (BP) 192/102 mm Hg Report of constipation Anxiety
Blood pressure (BP) 192/102 mm Hg
The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. Blurred vision Tachycardia Fatigue Serum digoxin level of 1.5 ng/ml (1.92 nmol/L) Anorexia
Blurred vison Fatigue Anorexia
The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? Defibrillation Cardiopulmonary resuscitation (CPR) Administration of epinephrine Administration of oxygen
Defibrillation
Which medication, when given in heart failure, may improve morbidity and mortality? Dobutamine (Dobutrex) Carvedilol (Coreg) Digoxin (Lanoxin) Bumetanide (Bumex)
Carvedilol (Coreg)
The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? Defibrillate the patient at 200 joules. Check the patient for a pulse. Cardiovert the patient at 50 joules. Give the patient IV lidocaine.
Check the patient for a pulse.
The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? Select all that apply. Chest discomfort or pain Tachycardia Expectorating thick, yellow sputum Sleeping on back without a pillow Fatigue
Chest discomfort or pain Tachycardia Fatigue
Which signs and symptoms are seen with suspected pericarditis? Select all that apply. Squeezing, vise-like chest pain Chest pain relieved by sitting upright Chest and abdominal pain relieved by antacids Sudden-onset chest pain relieved by anti-inflammatory agents Pain in the chest described as sharp or stabbing
Chest pain relieved by sitting upright Sudden onset chest pain relieved by anti-inflammatory agents Pain described as sharp or stabbing
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? Ejection fraction is 25%. Client states that she is able to sleep on one pillow. Client was hospitalized five times last year with pulmonary edema. Client reports that she experiences palpitations.
Client states that she is able to sleep on one pillow.
Which client would the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain Client who has many questions about the electrophysiology studies (EPS) scheduled for today
Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes
Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with heart failure who is receiving dobutamine (Dobutrex) Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea Client with pericarditis who has a paradoxical pulse and distended jugular veins Client with rheumatic fever who has a new systolic murmur
Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea
Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? Client with abdominal pain and belching Client with pressure in the mid-abdomen and profound diaphoresis Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows Client with claudication and fatigue
Client with pressure in the mid-abdomen and profound diaphoresis
A client with heart failure reports a 7.6-pound (3.4 kg) weight gain in the past week. What intervention does the nurse anticipate from the primary health care provider? Dietary consult Sodium restriction Daily weight monitoring Restricted activity
Daily weight monitoring
The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? Select all that apply. Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds (1.4 kg) since last seen in the clinic Cooks food in palm oil to save money Exercises once weekly Has cut down on caffeine
Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds (1.4 kg) since last seen in the clinic Has cut down on caffeine
The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse plan to administer? Heparin Atropine Dobutamine Magnesium sulfate
Heparin
The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8°F (37.7°C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action does the nurse take? Give the digoxin; reassess the heart rate in 30 minutes. Give the digoxin; document assessment findings in the medical record. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement.
Hold the digoxin, and obtain a prescription for a potassium supplement.
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? Ibuprofen (Motrin) Hydrochlorothiazide (HydroDIURIL) NPH insulin Levothyroxine (Synthroid)
Ibuprofen (Motrin)
The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the primary health care provider? Saline infusion Morphine sulfate No treatment, continue monitoring Intravenous furosemide
Intravenous furosemide
A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? Maintains NPO (nothing by mouth) until this resolves Calls in another nurse for a second opinion Performs a complete neurologic assessment and notifies the primary care provider Explains to the client and family that this is expected after sedation
Performs a complete neurologic assessment and notifies the primary care provider
Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Monitor pulse oximetry and cardiac rate and rhythm. Reassure the client that his distress can be relieved with proper intervention. Place the client in high-Fowler's position with the legs down. Ask a family member to remain with the client.
Place the client in high-Fowler's position with the legs down.
The nurse is caring for a patient with heart rate of 143 beats/min. For which manifestations does the nurse observe? Select all that apply. Palpitations Increased energy Chest discomfort Flushing of the skin Hypotension
Palpitations Chest discomfort Hypotension
A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? Ankle-brachial index Dye allergy Pedal pulses Gag reflex
Pedal pulses
Which client has the highest risk for cardiovascular disease? Man who smokes and whose father died at 49 of myocardial infarction (MI) Woman with abdominal obesity who exercises three times per week Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL (1.94 mmol/L) Man who is sedentary and reports four episodes of strep throat
Man who smokes and whose father died at 49 of myocardial infarction (MI)
Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? Peptic ulcer disease Deep vein thrombosis (DVT) Osteoarthritis Marfan syndrome
Marfan syndrome
The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? Right atrial pressure is 4 mm Hg. Mean arterial pressure (MAP) is 58 mm Hg. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. PO2 is reported as 78 mm Hg.
Mean arterial pressure (MAP) is 58 mm Hg
The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? Auscultate the client's precordium for murmurs. Teach the client about the reason for the TEE. Reassure the client that the test is painless. Validate that the client has remained NPO.
NPO
Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? Assess preprocedure medications the client took that day. Have the client sign the consent form before the procedure is performed. Educate the client about the need to remain on bedrest after the procedure. Obtain client vital signs and a resting electrocardiogram (ECG).
Obtain client vital signs and a resting electrocardiogram (ECG).
Which nursing action may be delegated to an unlicensed assistive personnel (UAP) working on the medical unit? Determine the usual alcohol intake for a client with cardiomyopathy. Monitor the pain level for a client with acute pericarditis. Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis.
Obtain daily weights for several clients with class IV heart failure.
The nurse receives a report that a patient with a pacemaker has experienced loss of capture. Which situation is consistent with this? The pacemaker spike falls on the T wave. Pacemaker spikes are noted, but no P wave or QRS complex follows. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. The patient demonstrates hiccups.
Pacemaker spikes are noted, but no P wave or QRS complex follows.
A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the primary health care provider (PCP) immediately? Swelling and tenseness in the affected area Incisional pain and tenderness at the surgical site Pink, mobile fingers An order for heparin infusion
Swelling and tenseness in the affected area
Which patient is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit? The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min The 71-year-old patient admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min The 88-year-old patient admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min The 92-year-old patient admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min
The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min
Which sign/symptom is essential for the nurse to report to the primary health care provider (PCP) when caring for a client with Raynaud's phenomenon? Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. The client's extremity became white, then red temporarily. The affected extremity becomes purple and cold. The client states that the digits are painful when they are white.
The affected extremity becomes purple and cold.
All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the primary care provider before the procedure begins? The client has had intermittent substernal chest pain for 6 months. The client develops wheezes and dyspnea after eating crab or lobster. The client reports that a previous arteriogram was negative for coronary artery disease. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.
The client develops wheezes and dyspnea after eating crab or lobster.
A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min. The client's weight decreases by 2.5 kg.
The client's weight decreases by 2.5 kg.
After a cardiac catheterization, the client needs to increase his or her fluid intake for which reason? NPO status will cause the client to be thirsty. The dye causes an osmotic diuresis. The dye contains a heavy sodium load. The pedal pulses will be more easily palpable.
The dye causes osmotic diuresis
How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia? The patient states he is dizzy and weak. The nurse notes dyspnea. The patient has a heart rate of 42 beats/min. The monitor shows an increase in heart rate.
The monitor shows an increase in heart rate.
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The client ambulates around the nursing unit with a walker. The nurse monitors the client's pulse and blood pressure frequently. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when the client becomes tachycardic.
The nurse obtains a bedside commode before administering furosemide.
The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? The patient is semi-recumbent in bed. Chest leads are placed as for the previous ECG. The patient is instructed to breathe deeply through the mouth. The patient is instructed to lie still.
The patient is instructed to breathe deeply through the mouth.
Which statement best reflects correct client education for a client with a blood pressure (BP) of 136/86 mm Hg? This blood pressure is good because it is a normal reading. This blood pressure indicates that the client has hypertension or high blood pressure. This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle. This blood pressure seems a little low; the client must be further assessed for orthostatic hypotension.
This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle.
Which laboratory finding is consistent with acute coronary syndrome (ACS)? Troponin 3.2 ng/mL (3.2 mcg/L) C-reactive protein 13 mg/dL (130 mg/L) Triglycerides 400 mg/dL (4.52 mmol/L) Lipoprotein-a 18 mg/dL (0.64 mcmol/L)
Troponin 3.2 ng/mL (3.2 mcg/L)
A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction (MI)? C-reactive protein of 1 mg/dL (10 mg/L) Homocysteine level of 13 mcmol/L Creatine kinase (CK) of 125 units/L Troponin of 5.2 ng/mL (5.2 mcg/L)
Troponin of 5.2 ng/mL (5.2 mcg/L)
The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? Urine output of 20 mL over 2 hours Blood pressure of 106/58 mm Hg Absent bowel sounds +3 pedal pulses
Urine output of 20 mL over 2 hours
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? Auscultation of crackles Pedal edema Weight loss of 6 pounds (2.7 kg) since the last visit Reports sucking on ice chips all day for dry mouth
Weight loss of 6 pounds (2.7 kg) since the last visit
The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information would be included? Men do not tend to report chest pain. Men are more likely than women to die after MI. Men more than women tend to deny the importance of symptoms. Women may experience extreme fatigue and dizziness as sole symptoms.
Women may experience extreme fatigue and dizziness as sole symptoms.
An 84-year-old client with heart failure presents to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning to the nurse? a. Digoxin (Lanoxin) therapy daily. b. Daily metoprolol (Lopressor). c. Furosemide (Lasix) twice daily. d. Currently taking an antacid for upset stomach.
a. Digoxin (Lanoxin) therapy daily.
Which statement made by the client on the way to the catheterization lab requires an immediate action by the nurse? a. "My allergies are bothering me so I took some Benadryl last night before bed." b. "I was nervous last night but I still remembered to take my warfarin last night." c. "I sure am hungry. I haven't had anything to eat since I went to bed last night." d. "I don't know what I will do if they find a blockage in my heart."
b. "I was nervous last night but I still remembered to take my warfarin last night."
During routine suctioning of a client with a tracheostomy, the client becomes diaphoretic, nauseous, and the heart rate decreases to 39 beats/minute. What is the nurse's best action at this time? a. Continue to clear the airway b. Stop suctioning the patient c. Administer atropine d. Call the heath care provider immediately
b. Stop suctioning the patient
The nurse is teaching a client with a newly diagnosed cardiovascular disorder. Which statement made by the client demonstrates health promotion? a. "My heart disease will go away when I cut down to one cigarette a day." b. "I'm glad I don't have to change my diet and continue to eat whatever I want." c. "I need to get at least 150 minutes of moderate exercise a week." d. "I finally have my blood pressure to a normal level of 150/85."
c. "I need to get at least 150 minutes of moderate exercise a week."
A client who recently had a heart valve replacement is preparing for discharge. What statement by the client indicates that the nurse will need to do additional health teaching? a. "I need to brush my teeth at least twice daily and rinse with water." b. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." c. "I need to take a full course of antibiotics prior to my colonoscopy." d. "I will take my blood pressure every day and call if it is too high or low."
c. "I need to take a full course of antibiotics prior to my colonoscopy."
The health care provider prescribes warfarin (Coumadin) for a client with atrial fibrillation. Which statement made by the client indicates additional education is needed? a. "I need to go to the clinical once a week to have my blood level checked." b. "If my stools turn black, I will be sure to call my healthcare provider" c. "I'm glad I do not need to change my diet. Salads are my favorite food." d. "I need to stop taking my herbal supplement"
c. "I'm glad I do not need to change my diet. Salads are my favorite food."
A client in the telemetry unit is on a cardiac monitor. The monitor technician notices there are no ECG complexes and the alarm sounds. What is the first action by the nurse? a. Suspend the alarm. b. Call the emergency response team. c. Press the record button to get an ECG strip. d. Assess the client and check lead placement.
d. Assess the client and check lead placement.
A client with chronic heart failure presents to the ED with a new onset of atrial fibrillation. Which of the following medications would the nurse question? a. Lasix (furosemide) b. Toprol XL (metoprolol succinate) c. Cardizem (diltiazem) d. Corlanor (ivabradine)
d. Corlanor (ivabradine)
The nurse is caring for a patient who has developed a bradycardia. Which possible causes does the nurse investigate? Select all that apply. Bearing down for a bowel movement Possible inferior wall myocardial infarction (MI) Patient stating that he just had a cup of coffee Patient becoming emotional when visitors arrived Diltiazem (Cardizem) administered 1 hour ago
earing down for a bowel movement Possible inferior wall myocardial infarction (MI) Diltiazem (Cardizem) administered 1 hour ago
