Med Surg I Exam 4

The nurse is caring for a client with heart failure in a cardiac clinic. What assessment data indicates that the client has demonstrated a positive outcome related to the addition of metoprolol to the medication regimen. 1. Client states, "I can sleep on one pillow." 2. Current ejection fraction is 25%. 3. Client reports feeling like her heart beats very fast at times. 4. Records indicate five episodes of pulmonary edema last year

1

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? 1. Potassium 2.8 mEq/L 2. Digoxin level 0.7 mg/mL 3. Hemoglobin 9.8 g/dL 4. Calcium 8.0 mg

1 Rationale: A flattened T wave or the development of U waves is indicative of a low potassium level.

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? 1. Weight gain of 1 kg (2.2 lb) in 1 day 2. Pitting edema +1 3. Client report of a nocturnal cough 4. B-type natriuretic peptide (BNP) level of 100 pg/mL

1 Rationale: A weight gain of 1 kg (2.2 lb) in 1 day indicates that the client is retaining fluid and is at risk for fluid volume overload. This suggests the client's heart failure is worsening.

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? 1. Elevated ST segments 2. Absent P waves 3. Depressed ST segments 4. Varying PP intervals

1 Rationale: Elevated ST segments can indicate hyperkalemia and pericarditis.

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? 1. Acidosis 2. Infection 3. Hypertension 4. Cardiac tamponade

1 Rationale: Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1 degree Celsius (1.8 degrees F) per hour.

The nurse is reviewing the medical record of the client admitted with heart failure. Which laboratory result warrants a call to the primary health care provider by the nurse for further instructions? 1. Potassium 3.0 mEq/L 2. Magnesium 2.1 mEq/L 3. International normalized ratio (INR) of 1.0 4. Calcium 8.5 mEq/L

1 Rationale: Normal potassium is 3.5 to 5.0 mEq/L. Hypokalemia may predispose the client to dysrhythmia, especially if the client is taking medications that deplete potassium (such as furosemide).

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? 1. Elevate the affected leg 2. Place the client on bed rest 3. Massage the affected leg 4. Administer aspirin for discomfort

1 Rationale: The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.

A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? 1. "I should remove the skin from poultry before eating it." 2. "I will eat seafood once per week." 3. "I should use margarine when preparing meals." 4. "I can use whole milk in my oatmeal."

1 Rationale: The nurse should identify the client understands the teaching when he states he will remove the skin from poultry before eating, as the skin contains the greatest amount of fat.

The nurse is teaching a client about the risk for brady dysrhythmias. What teaching will the nurse include? 1. "Use a stool softener." 2. "Stop smoking and avoid caffeine." 3. "Avoid potassium-containing foods." 4. "Take nitroglycerin for slow heartbeat."

1 Rationale: The nurse will advise the client to use stool softener. Patients at risk for brady dysrhythmias would avoid bearing down or straining during a bowel movement. The Valsalva maneuver associated with bearing down can cause bradycardia.

Which nursing statement reflects appropriate cardiac physical assessment technique? 1. "I will auscultate the aortic valve in the second intercostal space at the right sternal border." 2. "I will palpate the apical pulse over the third intercostal space in the midclavicular line." 3. "I will assess for orthostatic hypotension by moving the client from a standing to a reclining position." 4. "I will assess for carotid bruit by auscultating over the anterior neck."

1 Rationale: The statement that shows correct cardiac physical assessment technique is to auscultate the aortic valve in the second intercostal space at the right sternal border.

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? 1. "I would never have believed I could get used to enjoying my food without salt." 2. "My blood pressure device at home usually shows about 156/98 or so." 3. "I make sure I take my blood pressure medicine when I have headaches." 4. My blood pressure pills are very expensive. Could I take a cheaper medication?"

1 Rationale: This statement implies that the client has stopped adding salt to food. Sodium restriction is a single aspect of the treatment plan, but it does indicate dietary adherence by the client.

The nurse is caring for a client who experienced a recent cardiac event. Which client statement indicates maladaptive denial? 1. "I don't need to change. It hasn't killed me yet." 2. "I don't think it is bad as the doctors say." 3. "I don't know how I am going to change my lifestyle." 4. "I will have to change my diet and exercise more."

1 Rationale: This type of denial is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client does not adhere to the interprofessional plan of care.

The nurse is caring for a client with a heart rate of 143 beats/min. Which assessment data will the nurse anticipate? Select all that apply. 1. Chest discomfort 2. Hypotension 3. Flushing of the skin 4. Increased energy 5. Palpitations

1, 2, 5 Rationale: Tachycardia is a heart rate greater than 100 beats/min; the patient with a tachy dysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope ("blackout") from hypotension. Chest discomfort and palpitations may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time from ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue.

Which risk factors are known to contribute to atrial fibrillation? Select all that apply. 1. Advancing age 2. Palpitations 3. High blood pressure 4. Excessive alcohol use 5. Use of beat blockers

1, 3, 4 Rationale: Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and American Americans.

Which assessment data will the nurse associate with suspected pericarditis? Select all that apply. 1. Sudden-onset chest pain relieved by anti-inflammatory agents. 2. Chest and abdominal pain relieved by antacids. 3. Chest pain relieved by sitting upright 4. Squeezing vise-like chest pain. 5. Pain in the chest described as sharp or stabbing

1, 3, 5 Rationale: The chest pain of pericarditis is relieved when sitting upright, or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing.

The client asks the nurse about modifiable risk factors for heart disease. What nursing response is appropriate? Select all that apply 1. Cigarette smoking is one of the most significant modifiable risk factors. 2. Your personal health over the past 10 years a modifiable risk. 3. Your overall body mass index is nonmodifiable. 4. Increasing physical exercise is a method to modify your risk. 5. Diabetes mellitus is a modifiable risk factor.

1, 4 Rationale: Modifiable risk factors are hose risks that are controllable such as cigarette smoking, personal lifestyle, obesity, and psychological variables.

A client who is to undergo cardiac catheterization must be taught which essential information by the nurse? 1. "Take your oral hypoglycemic with a sip of water on the morning of the procedure." 2. "Keep your affected leg straight for 2 to 6 hours." 3. "Do not take your blood pressure medications on the day of the procedure." 4. "Monitor the pulses in your feet when you get home."

2 Rationale: The client will remain in bed and the affected leg kept straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding.

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which data is essential for the nurse to assess prior to administration? 1. Troponin 2. Heart rate 3. ST segment 4. Myoglobin

2 Rationale: The monitoring of the patient's heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.

A client with heart failure reports a 7.6 lb (3.4 kg) weight gain in the past week. What intervention does the nurse anticipate from the primary health care provider? 1. Sodium restriction 2. Daily weight monitoring 3. Restricted activity 4. Dietary consult

2 Rationale: The nurse expects that the primary health care provider will want the client's daily weights monitored.

A nurse is assisting a client who has peripheral vascular disease and venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity? 1. Absent pedal pulses 2. Ankle swelling 3. Hair loss 4. Skin atrophy

2 Rationale: The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.

Which client assessment data is most consistent with cardiac pain requiring the nurse to notify the primary health care provider? 1. Reports of abdominal pain and belching 2. Reports of pressure in the upper abdomen and sternum and diaphoresis 3. Apparent dyspnea on exertion (DOE) and an inability to sleep flat 4. Repots claudication with ambulation and fatigue

2 Rationale: Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety.

Which assessment data indicates proper function of the sinoatrial (SA) node? 1. The QRS complex is present 2. The ST segment 3. The PR interval is 0.24 seconds 4. A P wave precedes every QRS complex

4 Rationale: A P wave is generated by the SA node and represents atrial depolarization and needs to be followed by a QRS complex. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead.

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse anticipate administering? 1. Magnesium sulfate 2. Atropine 3. Dobutamine 4. Heparin

4 Rationale: AF is the loss of coordinated atrial contractions that can lead to pooling of blood, results in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? 1. Sudden hemoptysis 2. Acute diarrhea 3. Frontal headache 4. Acute confusion

4 Rationale: Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

A client recovering from cardiac angiography develops slurred speech. What will the nurse do first? 1. Assess the site of the procedure for bleeding. 2. Call in another nurse for a second opinion. 3. Maintain NPO status until the slurred speech resolves. 4. Perform a neurologic assessment and notify the primary care provider.

4 Rationale: Based on the assessment finding, the client probably is suffering a neurological event, possibly a stroke. Neurological changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness must be reported immediately for prompt intervention.

A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PCTA) with stent placement. Which of the following actions should the nurse anticipate in the sot-procedure plan of care? 1. Instruct the client about a long-term cardiac conditioning program 2. Administer scheduled doses of acetaminophen 3. Check for peak laboratory markers of myocardial damage 4. Monitor for bleeding

4 Rationale: Bleeding is a post-procedure complication of PCTA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. Manual pressure or a closure device is used to obtain hemostasis to the site. The client should remain on bed rest until hemostasis is assured.

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? 1. Decreased capillary refill 2. Dyspnea 3. Orthopnea 4. Dependent edema

4 Rationale: Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema.

A client admitted after using cocaine develops ventricular fibrillation. After determining unresponsiveness, which action will the nurse take next? 1. Place an oral airway and ventilate. 2. Start cardiopulmonary resuscitation (CPR). 3. Establish IV access 4. Prepare for defibrillation

4 Rationale: Defibrillating is the priority next action before any other resuscitation measures, according to advanced cardiac life support protocols. After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.

The cardiac care unit charge nurse is assigning clients to the oncoming shift. Which patient is appropriate to assign to a float RN from the medical-surgical unit? 1. A 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min. 2. An 88-year-old client admitted with elevated troponin level who is hypotensive with a heart rate of 96 beats/min. 3. A 71-year-old client admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min. 4. A 64-year-old client admitted for weakness with sinus bradycardia and heart rate of 58 beats/min.

4 Rationale: The 64-year-old client has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the patient develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This patient can be managed by a nurse with less cardiac dysrhythmia training.

Which assessment data is most important for the nurse to report to the primary car provider prior to a coronary arteriogram? 1. The client reports intermittent substernal chest pain for 6 months. 2. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate. 3. The client reports that a previous arteriogram was negative for coronary artery disease. 4. The client develops wheezes and dyspnea after eating crab or lobster.

4 Rationale: The contrast agent injected into the coronary arteries during the arteriogram is iodine based. The client with a shellfish allergy is likely to have an allergic reaction to the contrast and must be medicated with an antihistamine or a steroid before the procedure.

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE). Which nursing action is essential? 1. Reassure the client that they will not feel pain. 2. Teach the client about the reason for the TEE. 3. Auscultate the client's precordium for murmurs. 4. Validate that the client has remained NPO.

4 Rationale: The essential nursing action the nurse must take is to validate that the client scheduled for a TEE has remained NPO. Owing to the risk for aspiration, the client must be NPO before the procedure.

The nurse is caring for a patient on a telemetry unit who has regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 seconds. Additional vital signs are: BP 118/68 mmHg, respiratory rate 16 breaths/min and temp 98.8 degrees F. All of these medications are available on the medication record. What action will the nurse take? 1. Administer clonidine 2. Administer atropine 3. Administer digoxin 4. Continue to monitor

4 Rationale: The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs.

A client has been admitted to the hospital with chest pain radiating down the left arm. Which test result best confirms that the client sustained a myocardial infarction (MI)? 1. C-reactive protein of 1 mg/dL 2. Homocysteine level of 13 mcmol/L 3. Creatine kinase (CK) of 125 units/L 4. Troponin of 5.2 ng/mL

4 Rationale: The presence of elevated troponin indicates myocardial damage. Normal troponin would be less than 0.03 ng/mL.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which client statement indicates the need for further teaching? 1. "I won't put the salt shaker on the table anymore." 2. "I need to avoid eating hamburgers." 3. "I need to avoid lunchmeats but may cook my own turkey." 4. "I must cut out bacon and canned foods."

1

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? 1. Coarse crackles 2. Wheezes 3. Rhonchi 4. Friction rub

1 Rationale: client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds heard at the end of inspiration and are not cleared by coughing.

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? Select all that apply. 1. Nausea & vomiting 2. Diaphoresis & dizziness 3. Chest and left arm pain that subsides with rest 4. Anxiety and feelings of doom 5. Bounding pulse and bradypnea

1, 2, 4 Rationale: Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? Select all that apply. 1. Jugular vein distension 2. Moist crackles 3. Postural hypotension 4. Increased heart rate 5. Fever

1, 2, 4 Rationale: The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses.

The nurse is teaching a class on risk factors for cardiovascular disease. Which risk factors will the nurse include? Select all that apply. 1. Smoking history 2. Elevated HDL level 3. Decreased bone density 4. Low blood pressure 5. Family history of heart disease 6. Fiber-rich diet 7. Elevated C-reactive protein levels 8. Diabetes mellitus

1, 5, 7, 8 Rationale: Factors the contribute to the risk for cardiovascular disease include elevated C-reactive protein levels, smoking, diabetes mellitus, and family history of heart disease. Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation must also be emphasized. Smoking is a major modifiable risk factor for cardiovascular disease. Cardiovascular disease does have a genetic component and a history of diabetes mellitus increase the risk for heart disease.

The nurse is preparing to administer digoxin as prescribed to a client with heart failure and notes: Temp: 99.8 degrees F, Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, potassium level: 3.2 mEq/L. What action will the nurse take? 1. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. 2. Hold the digoxin, and obtain a prescription for a potassium supplement. 3. Give the digoxin; document assessment findings in the medical record. 4. Give the digoxin; reassess the heart rate in 30 minutes

2

A nurse is providing teaching about lifestyle changes to a client who experienced a myocardial infarction and has a new prescription for a beat blocker. Which of the following client statements indicates an understanding of the teaching? 1. "I should eat foods that are high in saturated fat." 2. "Before taking my medication, I will count my radial pulse rate." 3. "I will exercise once a week for an hour at the health club." 4. "I will stop taking my medication when my blood pressure is within a normal range."

2 Rationale: A beta blocker will induce bradycardia. The client should take the pulse rate for 1 minute before self-administration.

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? 1. Cardiogenic shock 2. Dysrhythmias 3. Heart failure 4. Pulmonary edema

2 Rationale: According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

Which action will the nurse delegate to experienced assistive personnel (AP) working in the cardiac catheterization laboratory? 1. Educate the client abut the need to remain on bedrest after the procedure. 2. Obtain client vital signs and a resting electrocardiogram (ECG). 3. Have the client sign the consent form before the procedure is performed. 4. Assess pre-procedure medications the client took that day.

2 Rationale: Checking vital signs and performing a 12-lead ECG can be delegated to the UAP.

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? 1. Vertigo 2. Epistaxis 3. Exophthalmos 4. Spondylolisthesis

2 Rationale: Epistaxis (a nosebleed) is a manifestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches, dizziness, facial flushing, and fainting.

The nurse is teaching a class on diagnostic cardiovascular testing. Which teaching will the nurse include? 1. The left side of the heart is catheterized first and may be the only side examined. 2. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. 3. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. 4. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism.

2 Rationale: Intravascular ultrasonography (IVUS) is performed when a flexible catheter with a miniature transducer is inserted at the distal tip to view the coronary arteries. The transducer emits sound waves, which reflect off the plaque and the arterial wall to create an image of the blood vessel. It is another option besides using the medium injection method of diagnostic cardiovascular testing.

A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse expect? 1. Pitting peripheral edema 2. Crackles in the lung bases 3. Jugular vein distention 4. Hepatomegaly

2 Rationale: Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs.

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? 1. "I should use salt sparingly while cooking." 2. "I can have yogurt as a dessert." 3. "I should use baking soda when I bake." 4. "I should use canned vegetables instead of frozen."

2 Rationale: The client understands the teaching when he selects yogurt as a dessert. Yogurt is low in fat and sodium and is a good source of calcium and protein.

A client with heart failure is prescribed furosemide. Which assessment data concerns the nurse with this new prescription? 1. Serum sodium level of 135 mEq/L 2. Serum magnesium level 1.9 mEq/L 3. Serum creatinine of 1.0 mg/dL 4. Serum potassium level of 2.8 mEq/L

4

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? Select all that apply. 1. Hypothyroidism 2. Hypertension 3. Diabetes Mellitus 4. Hyperlipidemia 5. Tobacco smoking

2, 3, 4, 5 Rationale: A client who has hypertension, diabetes mellitus, hyperlipidemia, or a history of smoking tobacco is at risk for coronary artery disease (CAD). Hypertension and hyperlipidemia can be controlled by diet and exercise, along with medication if needed. Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage. Diabetes mellitus can be managed by monitoring glucose levels and implementing diet and exercise recommendations. Cholesterol levels, such as total HDL and LDL levels, should be monitored since elevated total serum cholesterol levels increase the risk of a myocardial infarction.

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? 1. Bradycardia with ST-segment depression 2. Relief of chest pain with deep inspiration 3. Dyspnea with hiccups 4. Chest pain that increases when sitting upright

3 Rationale: A client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? 1. Cholesterol level 195 mg/dL 2. Elevated HDL levels 3. Elevated LDL levels 4. Triglyceride level 135mg

3 Rationale: AN elevated LDL level increases a client's risk of atherosclerosis. The client's desirable LDL level is <100 mg/dL.

A client who is suffering from dyspnea on exertion and heart failure (HF) will most likely report which symptom during the health history? 1. Brown discoloration of lower extremities 2. Swelling of one leg 3. Fatigue 4. Slow heart rate

3 Rationale: Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle.

The nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? 1. Increased BP and decreased pulse rate 2. Jugular vein distention and peripheral edema 3. Report of sudden, severe back pain 4. Report of retrosternal chest pain radiating to the left arm.

3 Rationale: An aortic aneurysm is a weak spot in the wall of the aorta (the primary artery that carries blood from the heart to the head and extremities) that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.

The nurse is teaching a client with atrial fibrillation about a new prescription for warfarin. What teaching will the nurse include? 1. "Avoid caffeinated beverages." 2. "You would take aspirin or ibuprofen for headache." 3. "Report bruising to your health care provider." 4. "It is important to consume a diet in green leafy vegetables."

3 Rationale: Bruising could be indicative of excessive dosing of warfarin. Warfarin is an anticoagulant and causes decreased ability for blood to clot.

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? 1. Dyspnea 2. Pain in the shoulder and left arm 3. Substernal chest pain 4. Palpitations

3 Rationale: Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? 1. Headache 2. Hemoptysis 3. Nausea 4. Diarrhea

3 Rationale: Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

Which laboratory finding is consistent with acute coronary syndrome (ACS)? 1. Triglycerides 400 mg/dL 2. C-reactive protein 13 mg/dL 3. Troponin 3.2 ng/mL 4. Lipoprotein-a 18 mg/dL

3 Rationale: Normal troponin would be less than 0.03 ng/mL.

The nurse is teaching a class about the mechanical properties of the heart. What teaching will the nurse include? 1. Body size does not affect overall cardiac output 2. Cardiac output is the amount of blood ejected by the ventricles during each contraction 3. Preload is the degree of stretch in the myocardial fibers 4. Stroke volume is the amount of blood pumped out of the heart each minute

3 Rationale: Preload refers to the degree of myocardial fiber stretch at the end of diastole and just before contraction.

Which client has the highest risk for cardiovascular disease? 1. Man who is sedentary and reports four episodes of strep throat 2. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL 3. Man who smokes and whose father died at 49 of myocardial infarction (MI) 4. Woman with abdominal obesity who exercises three time per week

3 Rationale: Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death.

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus women. Which teaching will the nurse include? 1. Men more than women tend to deny the importance of symptoms. 2. Men do not tend to report chest pain. 3. Women may experience extreme fatigue and dizziness as sole symptoms. 4. Men are more likely than women to die after MI.

3 Rationale: Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking strangling, tingling, squeezing, constricting, or vise-like.

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply. 1. Urine output 2. Respiratory rate 3. Heart rate 4. Heart rhythm 5. QT interval

3, 4, 5 Rationale: Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed.

A client begins therapy with lisinopril. What does the nurse consider at the start of therapy with this medication? 1. The client's ability to understand medication teaching 2. The potential for bradycardia 3. Liver function tests 4. The risk for hypotension

4

A client'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 seconds. Ho does the nurse interpret this rhythm strip? 1. Sinus rhythm with premature ventricular contractions 2. Normal sinus rhythm 3. Sinus bradycardia 4. Sinus tachycardia

4 Rationale: These are the characteristics of sinus tachycardia.