NUR 221 PrepU Cardiovascular Disorders.

A client is admitted to an acute care facility with pneumonia. When auscultating heart sounds, the nurse notes a fixed split of the second heart sound (S2) — a pathological split that doesn't vary with respirations. A fixed S2 split is the hallmark of

Atrial septal defect. Rationale: A fixed S2 split is the hallmark of atrial septal defect. This split, which is continuous and doesn't vary with respirations, results from prolonged emptying of the right ventricle. A right bundle-branch block causes a wide S2 split that's louder on inspiration than on expiration; this split results from delayed depolarization of the right ventricle and late pulmonic valve closure. Left bundle-branch block, aortic stenosis, and patent ductus arteriosus cause a paradoxical S2 split. Heard only on expiration, a paradoxical S2 split results from delayed aortic valve closure.

A client is taking spironolactone. Which change in the diet should the nurse teach the client to make when taking this drug?

Avoid eating foods high in potassium. Rationale: 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 admitted to the telemetry unit with newly diagnosed atrial fibrillation has been started on warfarin. What should the nurse instruct the client to do when taking this medication? Select all that apply.

Avoid injury to prevent bruising. Be careful using a razor or fingernail clippers. Report any change in color of urine or stool. Rationale: Warfarin is an anticoagulant used in clients with atrial fibrillation to reduce the risk of stroke or systemic embolization and, therefore, will put the client at risk for bleeding. The nurse should instruct the client to watch for signs of bleeding and prevent bruising. While good oral hygiene remains important, the nurse would advise against vigorous flossing and irritating the gums as it may increase the risk of bleeding. Warfarin does not affect the heart rate.

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:

Avoids holding the breath during activity. Rationale: 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.

A client has an International normalized ratio (INR) of 1.6, creatine kinase-MB (CK-MB) of 90 μ/L, troponin 2.1 ng/L, and myoglobin 90 μg/L. Which result requires the nurse to take action?

Troponin of 2.1 ng/L. Rationale: Troponins I and T are cardiac enzymes that are only released when the cardiac muscle is damaged. Elevation of these values above the respective reference ranges of 0-0.1 ng/L or 0-0.2 ng/L indicates a myocardial infarction. Myoglobin is released when muscle cells are damaged. Myoglobin may rise above the normal level of 0-90 μg/L with a myocardial infarction (MI) but is not a clear indicator of MI because it can also rise during strenuous exercise, traumatic injury, and intramuscular injections. CK-MB will rise following MI, but may be elevated by events that also raise myoglobin. A normal range for CK-MB is between 30 and 170 μ/L. The INR test is a measure of blood clotting. An INR value of 1.6 is within the normal range.

The nurse has been instructing the client about how to prepare meals that are low in fat. Which of these comments would indicate the client needs additional teaching?

"I will eat more liver with onions." Rationale: Liver and organ meats are high in cholesterol and saturated fat and should be limited.Water-packed tuna is one of the leanest types of fish available.Using a nonstick pan when cooking reduces the need for shortening or oil.Steak sauce and catsup are high in sodium and would likely accompany meals that include beef and other higher-fat meats.

A client who requested a do-not-resuscitate (DNR) order upon admission to the hospital now states a desire for the medical team to do everything possible to help the client get better. The client is concerned about the DNR order. Which response by the nurse is best?

"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." Rationale: 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 and does not need to talk to family members. The nurse should not imply with a question that perhaps revising the DNR would be more appropriate than rescinding it. The client has not expressed concern about feeling discomfort, so it would be inappropriate for the nurse to address that concern.

Which client statement should the nurse evaluate as indicating the client's correct understanding of the causes of coronary artery disease (CAD)?

"The leading cause of CAD is atherosclerosis." Rationale: Atherosclerosis (plaque formation) is the leading cause of CAD. Cigarette smoking is the leading cause of lung cancer. Telling the client to ask the healthcare provider is not appropriate.

When assessing a client with left-sided heart failure, the nurse expects to note

Air hunger. Rationale: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.

A client with a ventricular dysrhythmia is receiving intravenous lidocaine. For which assessment finding should the nurse suspect the client is experiencing toxicity from the medication?

Confusion and restlessness. Rationale: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine or tocainide — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.

The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance?

Hyperkalemia. Rationale: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.

A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral arterial disease. The health care provider (HCP) started the client on pentoxifylline once daily. Approximately 1 hour after receiving the initial dose of pentoxifylline, the client reports having chest pain. The nurse should first:

Inform the HCP. Rationale: Angina is an adverse reaction to pentoxifylline, which should be used cautiously in clients with CAD. The nurse should report the client's symptoms to the HCP , who may prescribe nitroglycerin and possibly discontinue the pentoxifylline. The client should rest until the chest pain subsides. It is not necessary at this point to initiate the rapid response team or start an intravenous infusion. The client's reports of symptoms should never be dismissed.

The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy?

Partial thromboplastin time, 1.5 to 2.5 times the normal control.

A client with deep vein thrombosis has been receiving warfarin for 2 months. The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do?

Return to laboratory for analysis of prothrombin times. Rationale: These symptoms suggest that the client is receiving too much warfarin; the client should return to the laboratory and have a blood sample drawn to determine the prothrombin levels and have the dosage of warfarin adjusted. The diet can influence clotting, but the client needs to first have the prothrombin levels checked. It is not necessary to contact the HCP; the client should return to the laboratory first, and the results of the prothrombin time will be reported to the HCP.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately?

The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. Rationale: Because the femoral artery is usually used as the access site during a cardiac catheterization, children are required to remain on bed rest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. A knee chest position is the correct position for an infant during a cyanotic episode as it will create peripheral resistance to the extremities, shunting blood to the heart. The apical heart rate is assessed prior to administering this medication; administration can be performed by an experienced LPN/VN, although medication is checked with the RN prior to administration. Because echocardiography is noninvasive, there is no need to withhold meals before this procedure.

The nurse is monitoring a client with a pacemaker. Which finding shows that the client's pacemaker is functioning correctly?

The nurse observed a spike on the electrocardiogram (EKG) with pacing initiated. Rationale: The client should have a spike on the EKG when pacing is initiated; this would come before the P wave if the pacemaker is initiating atrial contraction and before the QRS if the pacemaker initiates ventricular contraction instead. Finding the generator would be an indication of having a pacemaker, but not that it was working. The client should report any pacemaker problems, but it would not be an indication of the pacemaker's function at present. Having bilateral radial pulses does indicate heart function but does not specifically address pacemaker function.

The nurse's unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught?

The percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity. Rationale: The unit council needs to assess the number of clients diagnosed with an acute MI on the telemetry unit who were actually taught about resuming sexual activity. The unit council needs to identify the number of clients who were taught, not the quality of the teaching. Only education about resuming sexual activity is pertinent to this performance improvement study. The nurses' assessment of the quality of client education isn't pertinent to this study either.

What measure should the nurse take that will be most helpful in preventing wound infection when changing a client's dressing after coronary artery bypass surgery?

Wash hands before changing the dressing. Rationale: Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.

A client with aortic stenosis tells the nurse, "I have been feeling so tired lately that I take a nap in my recliner every afternoon." On assessment, the nurse notes apical heart sounds 2 cm left of the midclavicular line, crackles in lower lung fields during respiration, blood pressure 110/90 mm Hg, and weight gain of 2.5 kg (5.5 lb) in 24 hours. Which assessment requires further action?

Weight gain of 2.5 kg (5.5 lb) in 24 hours. Rationale: Aortic stenosis leads to left ventricular enlargement and eventually to heart failure. Signs of heart failure include rapid weight gain, a shift of the apical pulse to the left of the midclavicular line, narrowed pulse pressure, and adventitious lung sounds. The nurse must intervene for rapid weight gain of more than 1 kg in 24 hours, which indicates fluid retention from worsening heart failure.

The transducer system of an arterial line was disconnected from the monitoring cable. What is the best action by the nurse after reconnecting the transducer system to the monitoring cable?

Zero the transducer system. Rationale: The nurse should zero the transducer system to ensure the accuracy of the readings once the transducer system is reconnected to the monitoring cable. Changing the tubing is not needed. If the tubing needed to be changed, it should be changed prior to the transducer system being zeroed. Performing a square wave test can be completed after the transducer system is zeroed. "Dynamic response test" is merely another term for "square wave test."

The nurse prepares to administer digoxin to a client. For which reason should the nurse question the prescribed dose?

The client has chronic kidney disease (CKD). Rationale: After digoxin is metabolized, the kidneys eliminate remaining digoxin as an unchanged drug. Because of this, a client with CKD should be prescribed a lower dose of digoxin. Because digoxin is not eliminated through the lungs, gastrointestinal tract, or integumentary system, elimination will not be altered if the client has COPD, constipation, or eczema.

A nurse administers the first dose of nadolol to a client with a blood pressure of 180/96. During an assessment 4 hours later, which information indicates that the client needs immediate intervention?

The client has wheezing throughout the lung fields. Rationale: Wheezing indicates the client is experiencing bronchospasms, which are a common adverse effect of a noncardioselective beta blocker. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the healthcare provider. The other symptoms are all expected effects of nadolol.

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain. Rationale: Increased severe back pain and increased irritation to nerves are indicative of a potential rupture of an aneurysm. The client would be hypertensive and present with tachycardia, so the other choices are not correct. Nausea, although possible, or a missed dose of medication, do not indicate potential rupture.

A client comes to the emergency department complaining of visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension?

Untreated hypertension. Rationale: Untreated hypertension is the most common cause of malignant hypertension. Pyelonephritis, dissecting aortic aneurysm, and excessive catecholamine release (an effect of pheochromocytoma) are less common causes. Rarely, malignant hypertension results from eclampsia, ingestion of or exposure to drugs or toxic substances, and food and drug interactions (such as those that occur with monoamine oxidase inhibitors and aged cheeses).

A group has asked the nurse to discuss how lifestyle factors affect heart health. Which statements by members of the group would indicate that the teaching was effective? Select all that apply.

"Gradually increasing my exercise levels will help enhance circulation through the heart." "If I change my diet and lessen my intake of saturated fats and trans fatty acids, this may decrease my cholesterol levels." "As a borderline diabetic, if I lose weight and lessen my intake of simple carbohydrates, this should benefit my heart." "Walking is excellent exercise to strengthen my heart." Rationale: Increasing exercise levels, diet changes, losing weight, and walking are all important elements of heart health. Chewing tobacco is still harmful to the body.

The nurse is teaching a client how to apply nitroglycerin topical ointment. Which statement indicates that the client needs additional clarification of the instructions?

"I'll carefully massage the ointment into the skin." Rationale: The client should not rub or massage the ointment into the skin. The ointment should be allowed to absorb slowly. The client should use the applicator paper to measure the amount of ointment to apply. The client should rotate the application sites to avoid skin irritation. The client should remove any remaining ointment with a tissue before applying a new dose.

The nurse evaluates the client's understanding of nutritional modifications to manage hypertension. The nurse knows the teaching was successful when the client makes what statement?

"Limiting my salt intake to 2 grams per day will lower my blood pressure." Rationale: To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Chronic, moderate caffeine intake and fat intake do not affect blood pressure.

A client with chronic obstructive pulmonary disease (COPD) develops signs of cor pulmonale. What assessment data would alert the nurse to this condition?

Edema of the extremities and distended neck veins. Rationale: Cor pulmonale is right-sided heart failure caused by lung problems, so the symptoms outlined indicate edema and venous congestion, which are backup signs from right-sided failure. The other choices are incorrect.

A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Immediately following surgery, what should the nurse do as a priority to prevent infection?

Avoid using the arm for a venipuncture. Rationale: If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client?

Bed rest with the affected extremity elevated. Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.

The nurse is preparing to teach a client with iron deficiency anemia about the diet to follow after discharge. Which food should be included in the diet?

Eggs. Rationale: For the client with iron deficiency anemia, a rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green, leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.

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 condition?

Development of congestive heart failure. Rationale: 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.

A client with a cerebral embolus is receiving IV recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy?

Dissolved emboli. Rationale: Thrombolytic agents such as alteplase are used for clients with a history of thrombus formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic agents act by dissolving emboli. Thrombolytic agents do not directly improve perfusion or improve cerebral vascularization, nor do they prevent cerebral hemorrhage.

A nurse is awaiting the arrival of a client from the emergency department with a diagnosis of anterior wall myocardial infarction. In caring for this client, the nurse would be alert for which signs and symptoms of left-sided heart failure? Select all that apply.

Dyspnea. Crackles. Tachycardia. Rationale: The right side of the heart is where the body deposits deoxygenated blood from the systematic circulation. Blood is then pumped from the right side of the heart to the lungs, where it exchanges CO2 and picks up oxygen. Once the blood is oxygenated, it flows to the left side of the heart which pumps to the rest of the body. Signs and symptoms of left-sided heart failure include dyspnea, orthopnea, and paroxysmal nocturnal dyspnea; fatigue; nonproductive cough and crackles; hemoptysis; point of maximal impulse displaced toward the left anterior axillary line; tachycardia; S3 and S4 heart sounds; and cool, pale skin. Jugular vein distention, hepatomegaly, and right upper quadrant pain are all signs of right-sided heart failure. Skin tenting is a sign of dehydration.

A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances?

Early defibrillation in cases of ventricular fibrillation. Rationale: AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates.

Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease?

Enhance myocardial oxygenation. Rationale: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration is not the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.

Which signs and symptoms accompany a diagnosis of pericarditis?

Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR). Rationale: The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction lethargy, anorexia, heart failure and pitting edema do not result from acute renal failure.

An obese diabetic client has bilateral leg aching is to start a cardiac rehabilitation with an exercise program. Using which exercise equipment will be most helpful to the client?

Stationary bicycle. Rationale: The stationary bicycle is the most appropriate training modality because it is a non-weight-bearing exercise. The time that the individual exercises on the stationary bicycle is increased with improved functional capacity. The other exercise equipment requires exercising while standing.

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first?

The client with heart failure who is having some difficulty breathing. Rationale: 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 an analgesic, but that does not take priority over a client with difficulty breathing.

A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?

"I'll keep a log of each time my ICD discharges." Rationale: The client stating that they should keep a log of all ICD discharges indicates effective teaching. This log helps the client and physician identify activities that may cause the arrhythmias that make the ICD discharge. The client should also record the events right before the discharge. Clients with ICDs should avoid contact sports such as football. They must also avoid magnetic fields, which could permanently damage the ICD. Household appliances don't interfere with the ICD.

The nurse is assessing a client who is at risk for cardiac tamponade from chest trauma sustained in a motorcycle accident. What is the client's pulse pressure if the blood pressure is 108/82 mm Hg? Record your answer using a whole number.

26. Rationale: Pulse pressure is the difference between systolic and diastolic pressures. Normally, systolic pressure exceeds diastolic pressure by approximately 40 mm Hg. Narrowed pulse pressure, a difference of less than 30 mm Hg, is a sign of cardiac tamponade.

Which client is at greatest risk for Buerger's disease?

A 29-year-old male with a 14-year history of cigarette smoking. Rationale: Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men less than 40 years of age, and there is a very strong relationship with tobacco use.Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus.

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first?

Increase the oxygen flow rate from 2 to 4 L/min. Rationale: The first action is to increase the oxygen flow rate from 2 to 4 L/min to help ensure adequate oxygenation for the client. Although it is important to notify the HCP for additional prescriptions and to obtain further assessment data, such as arterial blood gas measurements, it is a priority to support the client's cardiopulmonary system. It would be appropriate to reassure the client while these other interventions are occurring.

A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client?

Stop smoking. Rationale: Buerger's disease is a nonatherosclerotic, recurrent inflammatory disorder of the small- and medium-sized arteries and veins of the upper and lower extremities. The disease occurs mostly in young men with a long history of tobacco use and chronic periodontal infection, but without other CVD risk factors such as hypertension, hyperlipidemia, and diabetes. Absolute cessation of nicotine is required to reduce the risk for amputation. Conservative management includes avoiding limb exposure to cold temperatures, a supervised walking program, antibiotics to treat any infected ulcers, and analgesics to manage the ischemic pain. Teach clients to avoid trauma to the extremities.

On a routine visit to the health care provider, a client with chronic arterial occlusive disease reports quitting smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?

Taking daily walks. Rationale: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.

A nurse is caring for a client with advanced heart failure. The client can't care for themself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses their desire for "nature to take its course." The client's family is pleading with the client to have a feeding tube inserted. What is the most appropriate action for the nurse to take?

Talk with the client's family about the client's right to decide for themself. Rationale: Advocating for a client's wishes is a key nursing role. It's especially important when a client's family disagrees with the client's wishes. The nurse should be sure that the client has all the information needed to make an informed decision. Then the nurse should support the client's decision. The nurse shouldn't contact a clergyman without the client's consent, call a family conference, or schedule intubation in violation of the client's wishes.

A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride, an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within

1 to 2 minutes after I.V. bolus administration. Rationale: Lidocaine exerts its antiarrhythmic effect in 1 to 2 minutes after I.V. bolus administration. A continuous I.V. infusion will maintain lidocaine's antiarrhythmic effect for as long as the drip is used. Lidocaine provides antiarrhythmic effects for only 15 minutes after the I.V. infusion is stopped.

The nurse is caring for a client with peripheral artery disease (PAD) who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediate attention from the nurse?

A change in the intensity of the pulse from the baseline. Rationale: A change in the intensity of a pulse maybe indicative of arterial closure and warrants immediate attention; the nurse should notify the health care provider (HCP) immediately. A pain level of 2 out of 10 it is not uncommon from the catheter insertion site especially after the placement of a stent. Shiny and hairless skin is expected in clients with PAD. A client undergoing a catheterization may experience pain at the catheterization site as large bore sheaths are place in the femoral artery. Because people with PAD have poor circulation in their lower extremities, it is possible for them to develop leg ulcers. However it is unlikely that the percutaneous transluminal balloon angioplasty caused this.

A client is started on digoxin. The health care provider (HCP) prescribes IV push doses of 0.5 mg now, 0.25 mg in 8 hr., and another 0.25 mg in another 8 hr. The client has a 1,000 mL bag of normal saline infusing at 25 mL/hr. What action should the nurse perform?

Administer each dose of medication over 5 minutes via IV push. Rationale: Digoxin is a potent cardiovascular drug that both slows conduction and increases contractility of the heart. Digoxin is administered slowly via IV push. Although each 1 mL can be diluted in 4 mL of SW, NS, D5W, or LR for injection, it is not added to the IV bag of solution or given over a 30-minute duration. There is no need to question the HCP's prescription at this time. Because digoxin is a new medication for this client and because it takes this type of dosing to reach a therapeutic level, dosing such as the one described is typical when the medication is first initiated. It is a type of loading dose protocol and for digoxin, sometimes referred to as digitalization.

A client with stage IV heart failure documents in an advance directive that no ventilatory support should be provided. What should the nurse do when the client begins experiencing severe dyspnea?

Administer oxygen, morphine, and a bronchodilator for comfort. Rationale: An advance directive identifies a client's wishes in the event that a life-threatening illness or injury occurs. The client's comfort should be paramount and the nurse should respect the client's wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will make breathing easier. The client will need more than coaching to take slow deep breaths. It is a violation of the client's advance directive to ask the family to consent to a ventilator. BIPAP is used to treat sleep apnea and not acute shortness of breath.

What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock?

Intra-aortic balloon pump. Rationale: Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.

The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. What evidence will indicate to the nurse that the client understands the discharge plan?

The client verbalizes safety precautions needed to prevent pacemaker malfunction. Rationale: 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.

What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine?

"Morphine decreases the heart's need for oxygen and also makes your heart not work as hard." Rationale: When given to treat acute MI, morphine eliminates pain, reduces preload and afterload, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine does not increase myocardial contractility, raise blood pressure, or increase preload or afterload.

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first?

Assess the client's orientation and vital signs. Rationale: The priority action is to assess the client and determine whether the rhythm is life threatening. More information, including vital signs, should be obtained and the nurse should notify the HCP. A bolus of lidocaine may be prescribed to treat this arrhythmia. This is not a code-type situation unless the client has been determined to be in a life-threatening situation.

The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hours ago. Which finding warrants further evaluation?

An arterial blood pressure of 80/50 mm Hg. Rationale: A blood pressure of 80/50 mm Hg in a client who has just had surgical repair of an abdominal aortic aneurysm warrants further evaluation as this indicates decreased perfusion to the brain, heart, and kidneys. A BUN of 26 and a creatinine of 1.2 are normal findings. While +1 pedal pulses may be an abnormal finding, it is not uncommon, and it is important to compare this finding to previous assessments and note if this is a change of the strength of the pedal pulses. Absent bowel sound and mild abdominal distension is expected for a client immediately following surgery. However this finding should be monitored as it could indicate a paralytic ileus.

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?

Assess respiratory status. Rationale: 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.

A client who has undergone a mitral valve replacement has had a mediastinal chest tube inserted. The client has persistent bleeding from the sternal incision during the early postoperative period. What actions should the nurse take? Select all that apply.

Check the postoperative CBC, INR, PTT, and platelet levels. Confirm availability of blood products. Monitor the mediastinal chest tube drainage. Rationale: The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding; therefore, availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should not be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). Their blood pressure is 104/68 mm Hg. Their pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the physician and report the findings. Rationale: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the physician immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect?

Pericardial tamponade. Rationale: A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (a pulse amplitude alteration from beat to beat, with a regular rhythm). Aortic regurgitation may cause a bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).

The correct landmark for obtaining an apical pulse is the

Left fifth intercostal space, midclavicular line. Rationale: 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 nurse is assessing the ankle-brachial index (ABI) for a client with peripheral vascular disease. The highest systolic pressure for each ankle is 80 mm Hg and the highest brachial pressure is 160 mm Hg. What does this client's ABI indicate?

Mild to moderate insufficiency. Rationale: ABI is calculated by dividing the highest systolic pressure for each ankle by the highest brachial pressure. For this client it would be 80/160 mm Hg = 0.50 ABI. This indicates that the client has mild to moderate insufficiency. Clients with ABI of about 1.0 have no arterial insufficiency; clients with ABI of less than 0.50 have ischemic rest pain; and clients with an ABI of 0.40 or less indicates severe ischemia or tissue loss.

A nurse is caring for a client taking diltiazem hydrochloride for arrhythmias. The nurse knows that diltiazem helps decrease arrhythmias by working during which phase of the cardiac action potential?

Phase 0. Rationale: Diltiazem, a calcium channel blocker, blocks the influx of calcium into the cells during phase 0 of the cardiac action potential. This action causes the sinoatrial node and atrioventricular (AV) node to slow their response times, which results in slowed AV conduction, decreased ventricular depolarization, and arrhythmias. Diltiazem doesn't work during phase 1, 2, or 3 of the cardiac action potential.

A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?

Potassium level of 3.1 mEq/L (3.1 mmol/L). Rationale: 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 client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. What is the nurse's primary goal at this time?

Prepare the client for emergency surgery. Rationale: The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circulation is maintained, unless the aneurysm ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about postoperative breathing exercises, and administer pain medication if prescribed.

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort?

Red, warm, palpable linear cord along the vein that is painful on palpation. Rationale: Superficial thrombophlebitis is associated with pain, warmth, and erythema. The nurse can request a prescription for warm packs to relieve the pain. Venous insufficiency causes edema and a brown discoloration of the lower leg. Varicose veins are dark, protruding veins, and symptoms of discomfort increase with standing. Pain on dorsiflexion of the foot indicates deep vein thrombosis; the client does not indicate having this pain.

The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply.

Reorient frequently to time, place and situation. Arrange for familiar pictures or special items at bedside. Spend time with the client, establishing a trusting relationship. Rationale: It is not unusual for the elderly client to become somewhat confused when "relocated" to the hospital, and this may be more difficult for those with known dementia. Frequent reorientation delivered patiently and calmly along with placing familiar items nearby so the client can see them may help decrease confusion related to hospitalization. Establishing a trusting relationship is important with every client but maybe more so with this client. Putting the client in a room further from the nursing station may decrease extra noise for the client, but will also make it more difficult to observe the client and maintain a safe environment. Procedures should be explained to the client prior to proceeding and should not be rushed. Visits by family and friends may help to keep the client oriented.

A client has peripheral artery disease of both lower extremities. The client tells the nurse, "I've really tried to manage my condition well." Which example indicates the client is using appropriate care management strategies?

The client walks slowly but steadily for 30 minutes twice a day. Rationale: Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute. Rationale: Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

The nurse is assessing a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. What should the nurse do immediately?

Assess vital signs. Rationale: The client should be evaluated for hemodynamic stability and extent of bleeding prior to calling the HCP. Direct pressure can be used prior to applying a tourniquet if there is significant bleeding. To avoid flexion contractures, which can delay rehabilitation, elevation of the surgical limb is contraindicated.