NCLEX Cardiac Nursing

The nurse has just completed education on myocardial infarction (MI) to a group of new nurses. Which statement made by one of the nurses indicates that the teaching has been effective? 1."Chest pain is caused by tissue hypoxia in the myocardium." 2."Chest pain is caused by tissue hypoxia in the vessels of the heart." 3."Chest pain is caused by tissue hypoxia in the parietal pericardium." 4."Chest pain is caused by tissue hypoxia in the visceral pericardium."

1. Chest pain is caused by tissue hypoxia in the myocardium

The nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do first? 1.Review intake and output records for the last 2 days. 2.Prescribe daily weights starting on the following morning. 3.Request a sodium restriction of 1 g/day from the cardiologist. 4.Change the time of diuretic administration from morning to evening.

1. Review intake and output records for the last 2 days ADPIE = assess before intervening. Gather info before calling the Dr.

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value comes back elevated? 1.Troponin 2.Myoglobin 3.C-reactive protein 4.Creatine kinase (CK)

1. Troponin Cardiac troponin elevations indicate myocardial injury or infarction

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1.Left atrium 2.Right atrium 3.Left ventricle 4.Right ventricle

3. Left Ventricle Rationale: Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels

A client with a history of hypertension has been prescribed triamterene. The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit? 1.Pears 2.Apples 3.Bananas 4.Cranberries

3. bananas Triamterene is a potassium-retaining diuretic

A client is brought to the emergency department complaining of substernal chest pain. To distinguish between angina and myocardial infarction, the nurse assesses for which characteristics of angina? (that it is angina, NOT an MI) Select all that apply 1.Chest pain that resolves with rest 2.Chest pain requiring an opioid for relief 3.Chest pain that is relieved by nitroglycerin 4.Chest pain that lasts longer than 30 minutes 5.Chest pain that is usually precipitated by exertion

1, 3, and 5!

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1.Emotional stress 2.Atrial fibrillation 3.Nutritional anemia 4.Peptic ulcer disease 5.Recent upper respiratory infection

1, 2, 3, 5

The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? 1.Urine output of 40 mL/hr 2.Heart rate of 110 beats/minute 3.Frequent premature ventricular contractions 4.Central venous pressure (CVP) of 15 mm Hg

1. Urine output of 40mL/hr Urine output of > 30mL/hr indicates adequate perfusion to the kidneys, so the other organs are most likely equally perfused. Classic cardiovascular signs of cardiogenic shock include low blood pressure and tachycardia. Dysrhythmias commonly occur as a result of decreased oxygenation to the myocardium and are not a favorable sign. The CVP rises as the effects of the backward blood flow caused by the left ventricular failure become apparent.

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education? 1."It is important that I limit protein intake." 2."I need to maintain a regular exercise program." 3."I understand that I need to avoid adding salt to foods." 4."It is important that I begin reducing and then maintaining weight."

1."It is important that I limit protein intake." Protein intake has no relationship to hypertension.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve? 1.Vagus (CN X) 2.Hypoglossal (CN XII) 3.Spinal accessory (CN XI) 4.Glossopharyngeal (CN IX)

1.Vagus (CN X) The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two-thirds of the tongue, pharyngeal sensation, and swallowing.

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1.Bradycardia 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

2.Ventricular dysrhythmias Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? 1.Ascites 2.Pedal edema 3.Bilateral lung crackles 4.Jugular vein distention

3. Bilateral lung crackles Left = L = LUNGS

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 1.Cardiac output of 5 L/min 2.Right atrial pressure of 9 mm Hg 3.Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg 4.Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

3.Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg Normal PCWP ranges from 8 to 15 mm Hg. A PCWP of 20 mm Hg is elevated and corresponds to volume overload of the left ventricle, such as occurs in heart failure. Options 1, 2, and 4 are normal values.

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the cardiac step-down unit. The client's blood pressure has been borderline low, and intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular vein for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy? 1.Hematoma 2.Air embolism 3.Systemic infection 4.Circulatory overload

4. Circulatory overload Circulatory (fluid) overload is a complication of IV therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure also increases. Hematoma is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Air embolism is characterized by tachycardia, dyspnea, hypotension, cyanosis, and decreased level of consciousness. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia.