Med-surg: PrepU (test 2)

c) Dependent edema. Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: a) Intermittent claudication. b) Dyspnea. c) Dependent edema. d) Crackles.

b) vision changes. Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.

A nurse suspects that a client has digoxin toxicity. The nurse should assess for: a) hearing loss. b) vision changes. c) decreased urine output. d) gait instability.

c) myocardial necrosis. An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of: a) cerebral bleeding. b) I.M. injection. c) myocardial necrosis. d) skeletal muscle damage due to a recent fall.

d) monitor weight daily. People with heart failure are taught to maintain a target weight and to weigh themselves daily to monitor increasing fluid retention. Fluid retention can lead to decompensation and hospitalization. Monitoring daily urine output is not required of these clients. A week of bed rest is not indicated for most people with heart failure. Clients on potassium-wasting diuretics will be taught to include dietary sources of potassium or to take a potassium supplement. However, all clients with heart failure should weigh themselves daily to monitor fluid status.

The nurse is preparing the client with heart failure to go home. The nurse should instruct the client to: a) monitor urine output daily. b) maintain bed rest for at least 1 week. c) monitor daily potassium intake. d) monitor weight daily.

b) Store the tablets in a tight, light-resistant container. Clients should be instructed to keep nitroglycerin in a tightly closed, dark container and to replenish it frequently because it deteriorates rather rapidly. Nitroglycerin does not cause increased urine output. Clients should be instructed to use nitroglycerin at the first indication of chest pain and not to wait until pain becomes severe.

Which information about sublingual nitroglycerin tablets should the nurse include when instructing the client with angina? a) The drug will cause increased urine output. b) Store the tablets in a tight, light-resistant container. c) Use the tablets only when the pain is severe. d) The shelf life of nitroglycerin is up to 2 years.

b) 25 ml/hour The nurse should use the following formula to determine the infusion rate: ml/hour = (total volume (in ml) to be infused/total time of infusion in hours) ml/hour = (100 ml/4 hours) ml/hour = 25

A client with heart failure is receiving furosemide, 40 mg I.V. The physician orders [40 mEq (40 mmol/L)] of potassium chloride in 100 ml of dextrose 5% in water to infuse over 4 hours. The client's most recent serum potassium level is [3.0 mEq/L (3.0 mmol/L)]. At what infusion rate should the nurse set the I.V. pump? a) 10 ml/hour b) 25 ml/hour c) 50 ml/hour d) 100 ml/hour

a) "I sleep on three pillows each night." Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement? a) "I sleep on three pillows each night." b) "My feet are bigger than normal." c) "My pants don't fit around my waist." d) "I don't have the same appetite I used to."

d) avoids holding the breath during activity. Valsalva's maneuver, or bearing down against a closed glottis, can best be prevented by instructing the client to exhale during activities such as having a bowel movement or moving around in bed. Valsalva's maneuver is not prevented by having the client assume a side-lying position. Clenching the teeth will likely contribute to Valsalva's maneuver, not inhibit it. Drinking fluids through a straw has no effect on preventing or causing Valsalva's maneuver.

The client has had a myocardial infarction, and the nurse has instructed the client to prevent Valsalva's maneuver. The nurse determines the client is following the instructions when the client: a) assumes a side-lying position. b) clenches the teeth while moving in bed. c) drinks fluids through a straw. d) avoids holding the breath during activity.

b) Rheumatic fever Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? a) Croup b) Rheumatic fever c) Severe staphylococcal infection d) Medullary sponge kidney

a) cardiac arrhythmias. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in: a) cardiac arrhythmias. b) hypertension. c) seizure. d) hypothermia.

a) Atherosclerosis Atherosclerosis (plaque formation), is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related.

Which condition most commonly results in coronary artery disease (CAD)? a) Atherosclerosis b) Diabetes mellitus c) Myocardial infarction d) Renal failure

b) Blood pressure is 88/46 mm Hg. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain, and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range.

A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? a) Serum potassium is 3.5 mEq/L (3.5 mmol/L). b) Blood pressure is 88/46 mm Hg. c) ST elevation is present on the electrocardiogram. d) Heart rate is 61 bpm.

a) review the blood coagulation laboratory values. Before starting a heparin infusion, it is essential for the nurse to know the client's baseline blood coagulation values (hematocrit, hemoglobin, and red blood cell and platelet counts). In addition, the partial thromboplastin time should be monitored closely during the process. The client's stools would be tested only if internal bleeding is suspected. Although monitoring vital signs such as apical pulse is important in assessing potential signs and symptoms of hemorrhage or potential adverse reactions to the medication, vital signs are not the most important data to collect before administering the heparin. Intake and output are not important assessments for heparin administration unless the client has fluid and volume problems or kidney disease.

A client has acute arterial occlusion. The health care provider (HCP) has prescribed IV heparin. Before starting the medication, the nurse should: a) review the blood coagulation laboratory values. b) test the client's stools for occult blood. c) count the client's apical pulse for 1 minute. d) check the 24-hour urine output record.

d) electrocardiogram (ECG) results. Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

A client is taking spironolactone to control her hypertension. Her serum potassium level is [6 mEq/L (56mmol/L)]. For this client, the nurse's priority should be to assess her: a) neuromuscular function. b) bowel sounds. c) respiratory rate. d) electrocardiogram (ECG) results.

a) "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 3 to 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina. He may repeat the dose every 5 minutes for up to three doses; if this intervention doesn't bring relief, the client should seek immediate medical attention.

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and orders sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, which instruction should the nurse provide? a) "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." b) "Replace leftover sublingual nitroglycerin tablets every 9 months to make sure your pills are fresh." c) "A burning sensation after administration indicates that the nitroglycerin tablets are potent." d) "You may take a sublingual nitroglycerin tablet every 30 minutes, if needed. You may take as many as four doses."

c) Assessing troponin 1 levels Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority.

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority? a) Monitoring the platelet count b) Assessing B-type natriuretic peptide levels c) Assessing troponin 1 levels d) Monitoring the white blood cell count

c) Reduced cholesterol levels, progressive activity levels, and coping strategies Cardiac rehabilitation is designed to assist the client in regaining functioning gradually. It also includes heart-healthy information such as dietary changes, a progressive increase in activity, and effective coping strategies for stress reduction. The emphasis is on lifestyle changes and reducing the risk of recurrence. The information related to unsaturated fats and participation in burst training is inaccurate. There is no need to reduce calcium intake and sodium is not increased. Homocysteine levels should be decreased, not increased.

A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review? a) Ways to reduce the intake of unsaturated fats, regular participation in anaerobic burst training activity, and increase in fluid intake b) Ways to reduce the intake of calcium and increase the intake of sodium, and how to incorporate rest periods c) Reduced cholesterol levels, progressive activity levels, and coping strategies d) Increasing homocysteine levels, reducing weight, and a sedentary lifestyle

c) Blood pressure 84/52 mm Hg Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? a) Pulse rate of 84 beats/minute b) Respiration 26 breaths/minute c) Blood pressure 84/52 mm Hg d) Temperature of 100.2° F (37.9° C)

a) Decreased cardiac output related to depressed myocardial function For a client recovering from CABG surgery and experiencing these symptoms, decreased cardiac output is the most important nursing diagnosis. Complications of CABG include hemorrhage, dysrhythmias, and myocardial infarction (MI) leading to decreased cardiac output. Anxiety, activity intolerance, and acute pain may be relevant, but take lower priority at this time; maintaining cardiac output is essential to sustaining the client's life.

A client is recovering from coronary artery bypass graft (CABG) surgery and begins to experience chest pain, shortness of breath, and tachycardia. Further assessment reveals a widened QRS complex and an elevated ST segment. Which nursing diagnosis takes highest priority at this time? a) Decreased cardiac output related to depressed myocardial function b) Anxiety related to an actual threat to health status and pain c) Activity intolerance related to imbalance between oxygen supply and demand d) Acute Pain related to impaired electrical conduction

c) "Take your pulse and report any irregular heartbeats." Verapamil can cause irregular cardiac rhythms. Clients should be taught to take their pulse and report any irregular heartbeats to their health care provider. Diarrhea is not a problem; constipation is the most common adverse effect of verapamil. Verapamil does not cause bone marrow depression. The client does not need to restrict fluids. Instead, a normal fluid intake is encouraged to prevent constipation.

A client is taking verapamil hydrochloride as an antihypertensive. Which statement made by the nurse instructs the client about an adverse effect of verapamil? a) "A low-residue diet will help prevent the occurrence of diarrhea." b) "You should obtain a complete blood count routinely to monitor for potential bone marrow depression." c) "Take your pulse and report any irregular heartbeats." d) "Restrict your fluid intake to decrease the chance of developing fluid retention."

a) Within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? a) Within 6 hours b) Within 12 hours c) Within 24 to 48 hours d) Within 5 to 7 days

b) loss of hair on the lower leg The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected? a) edema around the ankle b) loss of hair on the lower leg c) thin, soft toenails d) warmth in the foot

b) Avoid eating foods high in potassium. Spironolactone is a potassium-sparing diuretic that causes excretion of sodium. When taking this drug, it is important that the client not eat foods high in potassium to avoid elevating serum potassium levels. The client does not need to restrict sodium intake as the drug promotes sodium excretion. Unless contraindicated, the client needs to maintain an adequate fluid intake; however, the client does not need to increase fluid intake to 3,000 mL/day. Spironolactone does not affect iron levels.

A client is taking spironolactone. Which change in the diet should the nurse teach the client to make when taking this drug? a) Restrict sodium intake. b) Avoid eating foods high in potassium. c) Maintain a fluid intake of 3,000 mL/day. d) Incorporate iron-rich foods into the diet.

a) gender, family history, and older age. The risk factors for coronary artery disease that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender, family history, and older age are risk factors that cannot be controlled.

A nurse is educating a client who is at risk for coronary artery disease (CAD). The nurse knows that the client needs more education when he states that the risk factors that can be controlled or modified include: a) gender, family history, and older age. b) inactivity, stress, gender, and smoking. c) obesity, inactivity, diet, and smoking. d) stress, family history, and obesity.

c) "I will need to change positions slowly so I will not get dizzy." Common adverse effects of isosorbide are light-headedness, dizziness, and orthostatic hypotension. Clients should be instructed to change positions slowly to prevent these adverse effects and to avoid fainting. Ankle swelling is not related to isosorbide administration. The client does not need to take his pulse before taking the medication. The client does not need to take the medication with food.

A client takes isosorbide dinitrate as an antianginal medication. Which statement indicates that the client understands the adverse effects of the drug? a) "I should take my pulse before taking the medication." b) "I should take isosorbide dinitrate with food." c) "I will need to change positions slowly so I will not get dizzy." d) "It is important that I report any swelling in my ankles."

c) assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the physician of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a physician's order. The nurse should notify the physician before holding a medication scheduled to be administered during another shift.

A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m. (0700), before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to: a) call the physician to request an increase in the warfarin dose. b) give the client an I.M. vitamin K injection and notify the physician of the results. c) assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. d) notify the next shift to hold the daily 5 p.m. dose of warfarin.

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

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission, what should the nurse assess first? a) blood pressure b) skin breakdown c) serum potassium level d) urine output

c) "Be sure to report skin irritation or other adverse reactions." Transdermal nitroglycerin can cause skin irritation; reporting this and other adverse reactions is the only correct instruction. The other options reflect incorrect teaching regarding transdermal nitroglycerin. The client should rotate the patch application site daily to prevent sensitization and tolerance; should avoid touching the medication-impregnated pad because touching it could cause drug absorption; and should store pads away from temperature and humidity extremes, which may inactivate the drug.

After receiving nitroglycerin, a client says his chest pain has diminished. The physician orders transdermal nitroglycerin, 0.2-mg/hour patch, as prophylaxis for angina pectoris. When teaching the client how to apply the transdermal system, which instruction should the nurse provide? a) "Use the same clean, hairless application site each day." b) "You may touch the medication pad after washing your hands." c) "Be sure to report skin irritation or other adverse reactions." d) "Store your supply of transdermal pads in the refrigerator."

c) digoxin toxicity. Nausea and vomiting, along with hypokalemia, are likely indicators of digoxin toxicity. Hypokalemia is a common cause of digoxin toxicity; therefore, serum potassium levels should be carefully monitored if the client is taking digoxin. The earliest clinical signs of digoxin toxicity are anorexia, nausea, and vomiting. Bradycardia, other dysrhythmias, and visual disturbances are also common signs. Chronic renal failure usually causes hyperkalemia. With persistent vomiting, the client is more likely to develop metabolic alkalosis than metabolic acidosis.

An 80-year-old client is admitted with nausea and vomiting. The client has a history of heart failure and is being treated with digoxin. The client has been nauseated for a week and began vomiting 2 days ago. Laboratory values indicate hypokalemia. Because of these clinical findings, the nurse should assess the client carefully for: a) chronic renal failure. b) exacerbation of heart failure. c) digoxin toxicity. d) metabolic acidosis.

b) the adequacy of the blood supply to the tissues The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply, the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.

The client asks the nurse, "Why will the health care provider not tell me exactly how much of my leg he is going to take off? Do you not think I should know that?" On which information should the nurse base the response? a) the need to remove as much of the leg as possible b) the adequacy of the blood supply to the tissues c) the ease with which a prosthesis can be fitted d) the client's ability to walk with a prosthesis

c) deep vein thrombosis (DVT). DVT is commonly associated with venous stasis in the legs when there is a lack of the skeletal muscle pump that enhances venous return to the heart. When a client is confined to bed rest, venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site. DVT increases the risk that a displaced plaque will become a pulmonary embolus. Arteriosclerosis is hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen, tortuous veins. These are not generally considered risk factors for pulmonary embolism.

Which client is at risk for pulmonary embolism? A client with: a) arteriosclerosis. b) a small abdominal aneurysms. c) deep vein thrombosis (DVT). d) varicose veins.

d) "Client walks 4 miles (6.4 kilometers) in 1 hour every day." Four weeks after an MI, a client's walking program should aim for a goal of 2 miles (3.2 kilometers) in less than 1 hour. Walking 4 miles (6.4 kilometers) in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. Performing relaxation exercises; following a low-fat, low-cholesterol diet; and seeking emergency help if the heart rate increases markedly at rest indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.

A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction? a) "Client performs relaxation exercises three times per day to reduce stress." b) "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." c) "Client verbalizes an understanding of the need to seek emergency help if his heart rate increases markedly while at rest." d) "Client walks 4 miles (6.4 kilometers) in 1 hour every day."

b) participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and resume activity when pain subsides. With arterial disease, extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. To avoid burns, heating pads should not be used by anyone with impaired circulation. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

A client has been diagnosed with peripheral arterial occlusive disease. In order to promote circulation to the extremities, the nurse should instruct the client to: a) keep the extremities elevated slightly. b) participate in a regular walking program. c) use a heating pad to promote warmth. d) massage calf muscles if pain occurs.

d) Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the physician before completing the initial assessment is premature.

A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? a) Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. b) Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician. c) Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. d) Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

d) "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." Telling the client that it is not a problem to rescind the order is the best response. The client is allowed to rescind a DNR order at any time. The client makes the decision about a DNR order with input from the physician; he does not need to talk to his family. The client needs to have more information regarding the specifics of the nurse's question, but has the right to either rescind or change it at any time.

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best? a) "Do you want to rescind the DNR, or just change it?" b) "You know that we will do everything needed to keep you comfortable even though you have the DNR in place." c) "Have you talked this over with your family?" d) "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."

c) dyspnea. Physical activity is gradually increased after a myocardial infarction while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When any of these symptoms appears, the client should reduce activity and progress more slowly. Edema suggests a circulatory problem that must be addressed but does not necessarily indicate overexertion. Cyanosis indicates reduced oxygen-carrying capacity of red blood cells and indicates a severe pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss indicates several factors but not overexertion.

A client whose condition remains stable after a myocardial infarction gradually increases activity. To determine whether the activity is appropriate for the client the nurse should assess the client for: a) edema. b) cyanosis. c) dyspnea. d) weight loss.

a) visual disturbances. Digoxin toxicity may cause visual disturbances (such as, flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (abnormal heart rate and arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.

A client with chronic heart failure is receiving digoxin, 0.25 mg by mouth daily, and furosemide, 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause: a) visual disturbances. b) taste and smell alterations. c) dry mouth and urine retention. d) nocturia and sleep disturbances.

a) Elevate the head of the bed to 30 to 45 degrees and reassess JVD Jugular vein distension should be measured when the head of the client's bed is at 30 to 45 degrees. The healthcare provider may or may not need to be notified, based on the assessment findings with the head of the bed elevated. Further assessment should be performed, but this further assessment does not include obtaining orthostatic blood pressure readings, since these readings do not affect JVD.

A client with heart failure has assessment findings of jugular vein distension (JVD) when lying flat in bed. Which of the following is the best nursing intervention? a) Elevate the head of the bed to 30 to 45 degrees and reassess JVD b) Notify the healthcare provider c) Document the finding as the only action d) Obtain orthostatic blood pressure readings

a) weigh daily. Monitoring daily weight will help determine the effectiveness of diuretic therapy. A client who gains weight without diet changes most probably is retaining fluids, so the diuretic therapy should be adjusted. Blood pressure monitoring is useful when diuretics are prescribed to control blood pressure. However, in clients with heart failure, the primary indication is to promote sodium and water excretion by the kidneys. While it may be useful to monitor intake and urinary output in the hospital, daily weights are a sensitive indicator of fluid status and more practical for home management. The client may be told to eat a potassium-rich diet; however, serum potassium levels are not used to determine the effectiveness of diuretic therapy.

A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to: a) weigh daily. b) take blood pressure daily. c) keep a daily record of urine output. d) have a serum potassium level drawn weekly.

b) acute pulmonary edema. Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of: a) right-sided heart failure. b) acute pulmonary edema. c) pneumonia. d) cardiogenic shock.

b) sumatriptan is contraindicated in clients with angina. Sumatriptan is contraindicated in clients with ischemic heart disease, such as angina, myocardial infarction, or coronary artery disease, because it is a vasoconstrictor. The cost of the medication is not the concern at this time; the drugs are contraindicated because of the client's history of angina. Sumatriptan is used for the abortive treatment of migraines, not prophylactic treatment, and it is effective in treating acute migraines with or without aura.

A client with migraine headaches and a history of angina asks the nurse why the physician does not prescribe one of the newer medications for migraine, such as sumatriptan. The nurse responds that: a) these drugs are very expensive. b) sumatriptan is contraindicated in clients with angina. c) sumatriptan is used only for prophylactic treatment of migraines. d) sumatriptan is used only for migraines with aura.

c) "I'll eat four servings of fresh, dark green vegetables every day." The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? a) "I'll watch my gums for bleeding when I brush my teeth." b) "I'll use an electric razor to shave." c) "I'll eat four servings of fresh, dark green vegetables every day." d) "I'll report unexplained or severe bruising to my doctor right away."

b) Potassium Diuretics, such as furosemide, are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin, and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? a) Platelet count b) Potassium c) Calcium d) White blood cell (WBC) count

d) she'll ask the dietitian to talk with him about modifying his diet. A dietitian can help the client decrease the fat in his diet and make other beneficial dietary modifications. This client's total cholesterol isn't within the recommended guidelines; it should be less than 200 mg/dl (5.172 mmol/L). LDL should be less than 79 mg/dl (2.043 mmol/L), and HDL should be greater than 40 mg/dl (1.034 mmol/L). Although this client should take his statin medication, he should still be concerned about his cholesterol level and make other lifestyle changes, such as dietary changes, to help lower it. The client should increase his activity level, but he doesn't need to run 2 miles (3.2 km) per day.

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. His cholesterol profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603 mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how to lower his cholesterol. The nurse should tell the client that: a) his cholesterol is within the recommended guidelines and he doesn't need to lower it. b) he should take his statin medication and not worry about his cholesterol. c) he should begin a running program, working up to 2 miles (3.2 km) per day. d) she'll ask the dietitian to talk with him about modifying his diet.

b) Control the pain and support breathing and oxygenation. Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention? a) Reduce the nausea and vomiting and stabilize the blood glucose. b) Control the pain and support breathing and oxygenation. c) Decrease the anxiety and reduce the workload on the heart. d) Monitor and manage potential complications.

a) The client demonstrates ability to tolerate more activity without chest pain. The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. A heart rate within the normal limits of 60-100 per minute does not necessarily indicate a favorable response to treatment. Smoking is a cardiovascular risk factor that the client would be wise to eliminate, but it does not indicate favorable response to treatment. Knowledge of prescribed meds is a good thing, but again does not impact response to treatment.

A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? a) The client demonstrates ability to tolerate more activity without chest pain. b) The client exhibits a heart rate within normal limits. c) The client requests information regarding smoking cessation. d) The client is able to verbalize the action of all his prescribed medications.

b) "Stress reduction techniques are helpful because stress stimulates the release of vasoconstricting catecholamines." The stress-induced release of vasoactive catecholamines, such as epinephrine, causes vasoconstriction, which directly aggravates peripheral vascular disease by intensifying the ischemic burden of the affected tissues. Vasoconstriction also indirectly aggravates atherogenesis by inducing hypertension. Stress-reduction techniques make it easier for clients to give up bad habits, such as smoking. However, this is not the only reason they are useful. Clients should not ignore claudication, which is a symptom of muscle ischemia. Stress reduction over time may help decrease the amount of medications for anxiety, but not for peripheral vascular disease.

A nurse is providing discharge instructions to a client with peripheral vascular disease that include stress-reduction techniques. The client asks the nurse, "Why is reducing stress so important?" What is the nurse's best response? a) "Reducing stress is helpful only because it will assist in smoking cessation." b) "Stress reduction techniques are helpful because stress stimulates the release of vasoconstricting catecholamines." c) "Stress reduction techniques will distract you from focusing on claudication pain." d) "Reducing stress will help decrease the amount of medication you take for peripheral vascular disease."

c) High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). The goal of treating hyperlipidemia is to decrease total cholesterol and LDL levels while increasing HDL levels. HDL levels should be greater than 35 mg/dl. This client's increased HDL levels indicate that he's followed his therapeutic regimen. Recommended total cholesterol levels are below 200 mg/dl. LDL levels should be less than 160 mg/dl, or, in clients with known coronary artery disease (CAD) or diabetes mellitus, less than 70 mg/dl. Triglyceride levels should be between 100 and 200 mg/d.

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following his therapeutic regimen? a) Total cholesterol level increases from 250 mg/dl to 275 mg/dl (6.48 mmol/L to 7.12 mmol/L). b) Low density lipoproteins (LDL) increase from 180 mg/dl (4.66 mmol/L to 190 mg/dl (4.92 mmol/L). c) High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). d) Triglycerides increase from 225 mg/dl (5.83 mmol/L) to 250 mg/dl (6.47 mmol/L).

d) "I have my wife look at the soles of my feet each day." A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? a) "I like to soak my feet in the hot tub every day." b) "I walk only to the mailbox in my bare feet." c) "I stopped smoking and use only chewing tobacco." d) "I have my wife look at the soles of my feet each day."

c) Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize? a) Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses. b) Store the drug in a cool, well-lit place. c) Lie down or sit in a chair for 5 to 10 minutes after taking the drug. d) Restrict alcohol intake to two drinks per day.

b) A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. The client whose cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation takes priority. This cardiac rhythm change may cause clots to shower from the atria, placing the client at risk for a stroke. The client whose cardiac monitor reveals sinus tachycardia with isolated premature ventricular contractions is not experiencing a life-threatening situation; therefore, he does not take priority. Frequent paced beats with capture is a normal finding for a client with a pacemaker. Sinus tachycardia with premature atrial contractions is not a priority situation.

A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority? a) A client's cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions. b) A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. c) A client's monitor shows frequent paced beats with capture. d) A client's monitor shows sinus tachycardia with frequent premature atrial contractions (PACs).

b) Take the blood pressure herself. A nurse is ultimately responsible for care she delegates to unlicensed personnel (unregulated care providers, UCP). The nurse shouldn't assume the assistant's (UCP's) documentation is incorrect. She should follow up on the care herself and take appropriate action. If the information is correct, the nurse should include it in her change-of-shift report. If the information is incorrect, the nurse should speak with the assistant about the importance of accurate documentation.

A nursing assistant (unregulated care provider, UCP) has finished taking routine vital signs of the clients assigned to her. While charting later in the shift, a nurse finds that the assistant (UCP) documented a client's blood pressure at 192/126 mm Hg. What is the most appropriate action for the nurse to take? a) Ask the assistant (UCP) to take the client's blood pressure again. b) Take the blood pressure herself. c) Assume the assistant (UCP) recorded the client's blood pressure incorrectly. d) Include the findings in her change-of-shift report.

d) Potassium level of 3.1 mEq/L (3.1 mmol/L) Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.

A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? a) Magnesium level of 2.5 mg/dl (0.1 mmol/L) b) Calcium level of 7.5 mg/dl (0.4 mmol/L) c) Sodium level of 152 mEq/L (152 mmol/L) d) Potassium level of 3.1 mEq/L (3.1 mmol/L)

b) Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. The nurse should intervene by asking a family member to fill a compliance aid each week with the client's weekly supply of medications in the appropriate time slots. Family members can't be expected to come to the client's house four times each day to administer medications. The physician shouldn't change the dosing regimen just for convenience. The home care nurse can't visit the client each morning to prepare the daily medication regimen.

A visiting nurse is teaching a client with heart failure about taking his medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? a) Ask the client's family to take turns coming to the house at each administration time to assist the client with his medications. b) Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. c) Ask the physician if the client can take fewer pills each day. d) Come to the client's house each morning to prepare the daily allotment of medications.

a) The client with heart failure who is having some difficulty breathing. The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. Although anxiety can be detrimental to a client with myocardial infarction, anxiety does not take precedence over another client's breathing difficulty. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. The coronary bypass client in pain needs her analgesic, but that does not take priority over a client with difficulty breathing.

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize her client care assignment. The nurse has an ancillary staff member available to help her care for her clients. Which of these clients should the registered nurse assess first? a) The client with heart failure who is having some difficulty breathing. b) The anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today. c) The coronary bypass client asking for pain medication for "11 of 10" pain in her donor site. d) The client admitted during the previous shift with new-onset controlled atrial fibrillation, who has her call light on.

c) "We will try to assign you the same nurse as often as possible." The charge nurse should try to accommodate the client's wishes by assigning him a familiar nurse whenever possible. Doing so should help decrease the client's anxiety. Preventing dependency shouldn't be a concern; allaying his anxiety should. The client shouldn't be concerned with evaluating the quality of care rendered by multiple nurses. Providing continuity of care helps ensure quality care.

An anxious client who suffered an acute myocardial infarction is transferred from the coronary care unit to the telemetry unit. The client asks the charge nurse if he can have the same nurse care for him every day. How should the charge nurse respond? a) "Different nurses will be assigned to you each day to avoid your becoming dependent on one nurse." b) "It's important for you to receive care from a variety of nurses so you can evaluate your care." c) "We will try to assign you the same nurse as often as possible." d) "It's our policy to rotate client care assignments to ensure quality care for everyone."

a) Notify the health care provider (HCP). Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client's change in mental status, tachypnea, and tachycardia indicates a possible pulmonary embolism. The nurse should promptly notify the HCP of the client's condition. Administering a sedative without further evaluation of the client's condition is not appropriate. There is no need to elicit a positive Homan's sign; the client is already diagnosed with deep vein thrombosis. Increasing the IV flow rate may be an appropriate action but not without first notifying the HCP.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? a) Notify the health care provider (HCP). b) Administer a sedative. c) Try to elicit a positive Homan's sign. d) Increase the flow rate of intravenous fluids.

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

The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. The client needs further education when the client states: a) "I know I should not drive after taking my furosemide." b) "I should be careful not to stand up too quickly when taking furosemide." c) "I should take the furosemide in the morning instead of before bed." d) "I need to be sure to also take the potassium supplement that the health care provider prescribed along with my furosemide."

d) "The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? a) "The pain lasted about 45 minutes." b) "The pain resolved after I ate a sandwich." c) "The pain got worse when I took a deep breath." d) "The pain occurred while I was mowing the lawn."

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

Which symptom should the nurse teach the client with unstable angina to report immediatelyto the health care provider (HCP)? a) a change in the pattern of the chest pain b) pain during sexual activity c) pain during an argument d) pain during or after a physical activity

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

A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The nurse should first: a) inquire about the onset, duration, severity, and precipitating factors of the heaviness. b) administer oxygen via nasal cannula. c) offer pain medication for the chest heaviness. d) inform the health care provider (HCP) of the chest heaviness.

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

As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: a) antispasmodic effects on the pericardium. b) causing an increased myocardial oxygen demand. c) vasodilation of peripheral vasculature. d) improved conductivity in the myocardium.

d) The client will be immobile during and shortly after surgery. Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? a) The client is 5 feet 9 inches (172.5 cm) tall and weighs 128 lb (58 kg). b) The client has been pregnant four times. c) The client usually walks 3 miles (4.8 kilometers) a day. d) The client will be immobile during and shortly after surgery.

c) blood pressure. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the health care provider (HCP) and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: a) pulse. b) respirations. c) blood pressure. d) temperature.

a) decrease in heart rate.

Metoprolol is added to the pharmacologic therapy of a woman with diabetes diagnosed with stage 2 hypertension and initially treated with furosemide and ramipril. An expected therapeutic effect is: a) decrease in heart rate. b) lessening of fatigue. c) improvement in blood sugar levels. d) increase in urine output.

c) gangrene. The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.

The nurse is assessing a cliet who has a history of peripheral vascular disease. The nurse observes that the left great toe is black. The discoloration is likely a result of: a) atrophy. b) contraction. c) gangrene. d) rubor.

c) stop smoking. Nicotine causes vasospasm and impedes blood flow. Stopping smoking is the most significant lifestyle change the client can make. The client should eat low-fat foods as part of a balanced diet. The legs should not be elevated above the heart because this will impede arterial flow. The legs should be in a slightly dependent position. Jogging is not necessary and probably is not possible for many clients with arterial occlusive disease. A rehabilitation program that includes daily walking is suggested.

One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: a) avoid eating low-fat foods. b) elevate the legs above the heart. c) stop smoking. d) begin a jogging program.

d) Heart Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.

A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol, 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located? a) Uterus b) Blood vessels c) Bronchi d) Heart

d) Leg edema Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? a) Cyanosis of the lips b) Bilateral crackles c) Productive cough d) Leg edema

d) Enroll in a supervised exercise training program. Decreased blood flow is a common characteristic of all PVD. When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. The nurse should suggest that the client enroll in a supervised exercise training program that will assist the client to gradually increase walking distances without pain. Not walking and resting will not increase blood flow to the legs. Support stockings may be prescribed, but the client should improve the capacity to walk and obtain exercise.

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do? a) Avoid walking when the pain occurs. b) Rest frequently with the legs elevated. c) Wear support stockings. d) Enroll in a supervised exercise training program.

d) blood pressure Nitroglycerin can cause hypotension. A priority nursing assessment after the administration of nitroglycerin is the client's blood pressure. Oxygen saturation, respiratory rate, and pulse rate are not priority nursing assessments after the administration of nitroglycerin.

The nurse has given a client a nitroglycerin tablet sublingually for angina. Which vital signs should be assessed following administration of nitroglycerin? a) pulse rate b) oxygen saturation c) respiratory rate d) blood pressure

d) coldness of the left foot and ankle Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction.

When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? a) aching pain in the left calf b) burning pain in the left calf c) numbness and tingling in the left leg d) coldness of the left foot and ankle

a) stop and assess the client further.

While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. The nurse should: a) stop and assess the client further. b) measure the client's blood pressure and heart rate. c) call for help and place the client in a wheelchair. d) administer nitroglycerin.

a) pulse rate The client who is on a progressive exercise program at home after a myocardial infarction should be taught to monitor the pulse rate. The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The client should also be taught to discontinue exercise if chest pain occurs.

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level? a) pulse rate b) blood pressure c) body temperature d) respiratory rate

a) Achieve adequate tissue perfusion. A primary outcome for the care of the client in shock is to achieve adequate tissue perfusion, thus avoiding multiple organ dysfunction. The lungs are susceptible to injury, especially acute respiratory distress syndrome. Vasoconstriction occurs as a compensatory mechanism until the client enters the irreversible stage of shock.

What is the primary goal for the care of a client who is in shock? a) Achieve adequate tissue perfusion. b) Preserve renal function. c) Prevent hypostatic pneumonia. d) Maintain adequate vascular tone.

a) "I already have my airline ticket, so I will not miss my meeting tomorrow." Leaving the hospital and immediately flying to a meeting indicate poor judgment by the client and little understanding of what she needs to change regarding her lifestyle. The other statements show that the client understands some of the changes she needs to make to decrease her stress and lead a healthier lifestyle.

Which statement would lead the nurse to determine that a client lacks understanding of her acute cardiac illness and the ability to make changes in her lifestyle? a) "I already have my airline ticket, so I will not miss my meeting tomorrow." b) "These relaxation tapes sound okay; I will see if they help me." c) "No more working 10 hours a day for me unless it is an emergency." d) "I talked with my husband yesterday about working on a new budget together."

c) retina The retina is especially susceptible to damage in a client with chronic hypertension. The arterioles supplying the retina are damaged. Such damage can lead to vision loss. The iris, cornea, and sclera are not affected by hypertension.

The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye? a) iris b) cornea c) retina d) sclera

c) verbalizes safety precautions needed to prevent pacemaker malfunction. Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb (1.35 kg) or stretching and bending. The client should know how to count the pulse and do so daily or as instructed by the health care provider (HCP). The client will not necessarily be placed on a low cholesterol diet. The client should resume activities, and does not need to remain on bed rest. The client should know signs and symptoms of a MI, but is not at risk because of the pacemaker.

The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The nurse knows that the client understands the discharge plan when the client: a) selects a low-cholesterol diet to control coronary artery disease. b) states a need for bed rest for 1 week after discharge. c) verbalizes safety precautions needed to prevent pacemaker malfunction. d) explains signs and symptoms of myocardial infarction (MI).

d) vasodilation. Diltiazem is a calcium channel blocker that blocks the influx of calcium into the cell. In this situation, the primary use of diltiazem is to promote vasodilation and prevent spasms of the arteries. As a result of the vasodilation, blood, oxygen, and nutrients can reach the muscle and tissues. Diltiazem is not an antianxiety agent and does not promote sedation. It also does not cause vasoconstriction, which would be contraindicated for the client with peripheral vascular disease.

The client with peripheral vascular disease has been prescribed diltiazem. The nurse should determine the effectiveness of this medication by assessing the client for: a) relief of anxiety. b) sedation. c) vasoconstriction. d) vasodilation.

b) left fifth intercostal space, midclavicular line. The correct landmark for obtaining an apical pulse is the left fifth intercostal space in the midclavicular line. This area is the point of maximum impulse and the location of the left ventricular apex. The left second intercostal space in the midclavicular line is where the nurse auscultates pulmonic sounds. The apical pulse isn't obtained at the midaxillary line or the seventh intercostal space in the midclavicular line.

The correct landmark for obtaining an apical pulse is the: a) left fifth intercostal space, midaxillary line. b) left fifth intercostal space, midclavicular line. c) left second intercostal space, midclavicular line. d) left seventh intercostal space, midclavicular line.

b) confusion, urine output 15 mL over the last 2 hours, orthopnea A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? a) BP 110/62 mm Hg, atrial fibrillation with HR 82 bpm, bilateral basilar crackles b) confusion, urine output 15 mL over the last 2 hours, orthopnea c) SpO2 92% on 2 L nasal cannula, respirations 20 breaths/min, 1+ edema of lower extremities d) weight gain of 1 kg in 3 days, BP 130/80 mm Hg, mild dyspnea with exercise

a) Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. Nitroglycerin tablets should be taken 5 minutes apart for three doses; if this is ineffective, 911 should be called to obtain an ambulance to take the client to the emergency department. The client should not drive or have a family member drive the client to the hospital.

The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin. The client has had 2 previous episodes of coronary artery disease. At the onset of chest pain, what should the client do? a) Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. b) Call 911 when five nitroglycerin tablets taken every 5 minutes are not effective. c) Take one tablet and then immediately call 911. d) Go to the emergency department if two nitroglycerin tablets taken 5 minutes apart are not effective.

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

The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet the client's needs? a) mixed green salad with blue cheese dressing, crackers, and cold cuts b) ham sandwich on rye bread and an orange c) baked chicken, an apple, and a slice of white bread d) hot dogs, baked beans, and celery and carrot sticks

d) Walking decreases venous congestion. Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs, which are all beneficial to a client with peripheral vascular disease. However, these changes do not have as significant an effect on the client's condition as decreasing venous congestion.

What is the most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program? a) Walking reduces stress. b) Walking aids in weight reduction. c) Walking increases high-density lipoprotein (HDL) level. d) Walking decreases venous congestion.

b) pedal pulses With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? a) IV fluid infusion rate b) pedal pulses c) nasal cannula flow rate d) capillary refill

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

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

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

When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to: a) promote hydration. b) dissolve clots. c) prevent kidney failure. d) treat dysrhythmias.

a) blood pressure. With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: a) blood pressure. b) hemoglobin level. c) temperature. d) heart rate.

d) forcing blood into the deep venous system. Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: a) encouraging ambulation to prevent pooling of blood. b) providing warmth to the extremity. c) elevating the extremity to prevent pooling of blood. d) forcing blood into the deep venous system.

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

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: a) control chest pain. b) reduce coronary artery vasospasm. c) control the arrhythmias associated with MI. d) revascularize the blocked coronary artery.

d) Explain to the client that the "ringing" may be related to the aspirin. Tinnitus (ringing in the ears) is an adverse effect of aspirin. Aspirin contains salicylate, which is an ototoxic drug that can induce reversible hearing loss and tinnitus. The nurse should explain this to the client and then encourage the client to inform the health care provider (HCP) of the symptom. Tinnitus is not a function of aging. The Weber test and audiometric testing are useful for determining hearing loss but are not necessarily helpful in the management or diagnosis of drug-induced tinnitus.

An older adult takes two 81-mg aspirin tablets daily to prevent a heart attack. The client reports having a constant "ringing" in both ears. How should the nurse respond to the client's comment? a) Tell the client that "ringing" in the ears is associated with the aging process. b) Refer the client to have a Weber test. c) Schedule the client for audiometric testing. d) Explain to the client that the "ringing" may be related to the aspirin.

c) Development of congestive heart failure Crackles probably signify pulmonary edema, which occurs when there is left-sided congestive heart failure. The client is very dyspneic, and the heart appears to be compensating (increased rate because of respiratory congestion). Initiation of measures to help strengthen the heartbeat is a very important priority. Signs and symptoms do not indicate hypoglycemic reaction or renal failure. Heart block would be indicated by bradycardia.

The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which of the following? a) A hypoglycemic reaction b) Cardiogenic shock associated with heart block c) Development of congestive heart failure d) Acute renal failure

b) To reduce the metabolic workload of digestion Acute care of the client with an MI is aimed at reducing the cardiac workload. Clear liquids are easily digested to help reduce this workload. Sympathetic nervous system involvement causes decreased peristalsis and gastric secretion, so limiting food intake helps prevent gastric distension and cardiac workload. A clear diet will not reduce gastric acidity or blood glucose, and fecal elimination will still occur, so these are incorrect choices.

The nurse is caring for a client post myocardial infarction (MI). Orders include strict bed rest and a clear, liquid diet. What is the nurse's best response to the client when inquiring about the purpose of the new diet? a) To improve the gastric acidity of the stomach b) To reduce the metabolic workload of digestion c) To address the fluctuation in blood sugar d) To reduce the amount of fecal elimination

d) hypokalemia Hypokalemia is one of the most common causes of digoxin toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digoxin to avoid toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

The nurse monitors the serum electrolyte levels of a client who is taking digoxin. Which electrolyte imbalance is a common cause of digoxin toxicity? a) hyponatremia b) hypomagnesemia c) hypocalcemia d) hypokalemia

a) headache The most common side effect of nitroglycerin is a headache. Additional cardiovascular side effects include tachycardia, hypotension, and dizziness. Nitroglycerin does not cause shortness of breath, bradycardia, or hypertension.

A client who has been experiencing angina has a new prescription for nitroglycerin. The nurse should instruct the client to report having which potential side effect of nitroglycerin? a) headache b) shortness of breath c) bradycardia d) hypertension

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

A client has a history of heart failure and has been prescribed furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of: a) hyperkalemia. b) digoxin toxicity. c) fluid deficit. d) pulmonary edema.

b) Protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? a) Phytonadione (vitamin K) b) Protamine sulfate c) Thrombin d) Plasma protein fraction