NCLEX: Ch 49-50: Cardiovascular Disorders of the Adult Client & Medications

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse take? (Select all that apply.) 1. Call a code blue. 2. Contact the client's family. 3. Check the client's pain level. 4. Check the client's blood pressure. 5. Administer a second nitroglycerin, 0.4 mg, sublingually.

1. Check the client's pain level. 2. Check the client's blood pressure. 3. Administer a second nitroglycerin, 0.4 mg, sublingually. *The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain for a total dose of three tablets. The registered nurse is notified immediately if a client complains of chest pain. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would check the client's pain level and the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.

The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipate? (Select all that apply.) 1. The client should be placed on a cardiac monitor. 2. The PHCP massages the carotid artery for a full minute. 3. The head should be turned toward the side to be massaged. 4. Rhythm strips should be obtained before, during, and after the procedure. 5. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.

1. The client should be placed on a cardiac monitor. 2. Rhythm strips should be obtained before, during, and after the procedure. 3. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure. *Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm. The client's head should be turned away from the side to be massaged in order to provide better access to the carotid artery. The PHCP or cardiologist will massage only one carotid artery for a few seconds to determine whether a change in cardiac rhythm occurs. The client needs to be on a cardiac monitor throughout the procedure and obtain rhythm strips before, during, and after the procedure.

A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? (Select all that apply.) 1. Visual disturbances 2. Nausea and vomiting 3. Apical pulse rate of 63 beats per minute 4. Serum digoxin level of 2.3 ng/mL (2.93 nmol/L) 5. Serum potassium level of 3.9 mEq/L (3.9 mmol/L)

1. Visual disturbances 2. Nausea and vomiting 3. Serum digoxin level of 2.3 ng/mL (2.93 nmol/L) *Signs and symptoms of digoxin toxicity include gastrointestinal signs, bradycardia, visual disturbances, and hypokalemia. A therapeutic serum digoxin level ranges from 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). The serum potassium level should be between 3.5 mEq/L (3.5 mmol/L) and 5.0 mEq/L (5.0 mmol/L). The apical pulse must be greater than or equal to 60 beats per minute.

The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Hypokalemia, hyperglycemia, sulfa allergy 3. Hypokalemia, increased risk of osteoporosis 4. Hyperkalemia, hypoglycemia, penicillin allergy

Hypokalemia, hyperglycemia, sulfa allergy *Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement? 1. "Smoking cessation is very important." 2. "Moving to a warmer climate should help." 3. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine as prescribed will decrease vessel spasm."

"Moving to a warmer climate should help." *Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? 1. Dyspnea 2. Hacking cough 3. Dependent edema 4. Crackles on lung auscultation

Dependent edema *Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring? 1. Pneumonia 2. Pulmonary edema 3. Pulmonary embolism 4. Myocardial infarction

Pulmonary embolism *Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness

Status of airway *Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally? 1. Rhonchi 2. Crackles 3. Wheezes 4. Diminished breath sounds

Crackles *Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching? 1. "I will take my pills every day at the same time." 2. "I will be certain to avoid alcohol consumption." 3. "I have already called my family to pick up a MedicAlert bracelet." 4. "I will take enteric-coated aspirin for my headaches because it is coated."

"I will take enteric-coated aspirin for my headaches because it is coated." *Aspirin-containing products should be avoided while taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (9.95 mmol/L). The client is taking cholestyramine. Which statement made by the client indicates the need for further teaching? 1. "Constipation and bloating might be a problem." 2. "I'll continue to watch my diet and reduce my fats." 3. "Walking a mile each day will help the whole process." 4. "I'll continue my nicotinic acid from the health food store."

"I'll continue my nicotinic acid from the health food store." *Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications can also cause liver abnormalities so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. "It is not necessary to avoid the use of alcohol." 2. "The medication should be taken with meals to decrease flushing." 3. "Clay-colored stools are a common side effect and should not be of concern." 4. "Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing."

"Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing." *Rationale: Flushing is a side effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals; this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the PHCP.

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection

Acute kidney injury *The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.

The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first? 1. Go to the nurse's station quickly and call a code. 2. Run to get a defibrillator from an adjacent nursing unit. 2125 3. Call for help and initiate cardiopulmonary resuscitation (CPR). 4. Start oxygen by cannula at 10 L/minute and lower the head of the bed.

Call for help and initiate cardiopulmonary resuscitation (CPR). *When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. Options 1, 2, and 4 are incorrect.

A client is wearing a continuous cardiac monitor which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which action first? 1. Call a code blue. 2. Check the client status and lead placement. 3. Call the primary health care provider (PHCP). 4. Press the recorder button on the ECG console.

Check the client status and lead placement. *Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.

The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. Limiting movement and abduction of the left arm 2. Limiting movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm

Limiting movement and abduction of the right arm *In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.

A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available.

Monitor for signs of bleeding. *Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? 1. Provide the client with a walker. 2. Remove the telemetry equipment. 3. Encourage the client to cough and deep breathe. 4. Premedicate the client with an analgesic before ambulating.

Premedicate the client with an analgesic before ambulating. *The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item? 1. Smoking history 2. Recent exposure to allergens 3. History of recent insect bites 4. Familial tendency toward peripheral vascular disease

Smoking history *The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client? 1. Cut the dose in half. 2. Discontinue the medication. 3. Take the medication with food. 4. Contact the primary health care provider (PHCP).

Take the medication with food. *Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the client should be instructed to take the medication with food or meals. It is not necessary to contact the PHCP unless the headaches persist with therapy. It is not appropriate to instruct the client to discontinue therapy or adjust the dosages.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? (Select all that apply.) 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously *Pulmonary edema is a life-threatening event that can result from severe heart failure. During pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication associated with propranolol? 1. The development of complaints of insomnia 2. The development of audible expiratory wheezes 3. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication 4. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication

The development of audible expiratory wheezes *Audible expiratory wheezes may indicate a serious adverse reaction: bronchospasm. β-blockers may induce this reaction particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm? 1. Holding the defibrillator paddles firmly against the chest 2. Applying the adhesive patch electrodes to the skin and moving away from the client 3. Applying standard electrocardiographic monitoring leads to the client and observing the rhythm 4. Connecting standard electrocardiographic electrodes to a transtelephonic monitoring device

Applying the adhesive patch electrodes to the skin and moving away from the client *The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level? 1. Thrombocyte count of 100,000 mm3 2. Prothrombin time (PT) of 21 seconds 3. International normalized ratio (INR) of 2.3 4. Activated partial thromboplastin time (aPTT) of 55 seconds

Activated partial thromboplastin time (aPTT) of 55 seconds *The aPTT will assess the therapeutic effect of heparin sodium. The normal aPTT is 30 to 40 sec. To maintain a therapeutic level, the aPTT should be 1.5 to 2.5 times the normal value. The PT and INR will assess for the therapeutic effect of warfarin sodium. A decreased thrombocyte count can cause bleeding.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse should make which determination about the client's neurovascular status? 1. Moderately impaired, and the surgeon should be called 2. Normal, caused by increased blood flow through the leg 3. Slightly deteriorating, and should be monitored for another hour 4. Adequate from an arterial approach, but venous complications are arising

Normal, caused by increased blood flow through the leg *An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.