NUR 376 Exam #2
A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of PAD. The nurse knows that the teaching was effective based on which statement?
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following?
"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.)
-Avoid contracting garments -elevate the legs above the heart level for 30 minutes every 2 hours -sleep with the foot of the bed elevated about 6 inches
The nurse is teaching a client diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should the client consume per day?
2 or fewer
Which of the following does the nurse recognize as the therapeutic goal of radiofrequency catheter ablation for a client with cardiac dysrhythmias?
destruction of errant tissue
The nurse is assigned the following client assignment on the clinical unit. For which client does the nurse anticipate cardioversion as a possible medical treatment?
A client with atrial dysrhythmias
Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?
Monitor vital signs and cardiac rhythm
The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis?
RR interval
The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine
causes vasospasm
The nurse is admitting a client to a telemetry unit with an atrial dysrhythmia. What symptoms will the nurse further evaluate?
chest pain
The nurse is admitting a client to a telemetry unit with an atrial dysrhythmia. What symptoms will the nurse further evaluate?
chest pain ***Clients with atrial dysrhythmias may have chest pain, shortness of breath, and low blood pressure.
The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?
"Walk to the point of pain, rest until the pain subsides, then resume ambulation."
Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that apply.
-causes vasospasm -reduces circulation to the extremities -impairs transport and cellular use of oxygen -increases blood viscosity
A client is diagnosed with a dysrhythmia at a slower rate than 60bpm. What type of dysrhythmia does the client have? A. atrial bradycardia B. heart block C. none D. sinus bradycardia
D. sinus bradycardia
After evaluating a client for hypertension, a physician orders atenolol (Tenormin), 50 mg P.O. daily. Which therapeutic effect should atenolol have?
Decreased cardiac output and decreased systolic and diastolic BP
Nurses should implement measures to relieve emotional stress for clients with hypertension because the reduction of stress
Decreases the production of neurotransmitters that constrict peripheral arterioles.
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?
Demonstrate how to apply and remove elastic support stockings
Which is a characteristic of arterial insufficiency?
Diminished or absent pulses
What are the potential causes for Sinus Tachycardia?
Drinking too may caffeinated beverages Alcohol exercise fever High or low BP Imbalance of potassium or calcium Medication side effects Hyperthyroidism Smoking Sudden Stress
A diabetic client visits a walk-in clinic and asks the nurse to take a blood pressure (BP) reading. The measurements are 150/90 mm Hg. Which of the following would the nurse expect as the treatment to normalize the client's BP?
Drug therapy
The nurse is assessing a client with mitral regurgitation. The nurse expects to note what finding in this client?
Dyspnea, fatigue, and weakness
A client is being seen at the clinic for a routine physical when the nurse notes the client's BP is 150/97. The client is considered to be healthy, well-nourished young adult. What type of hypertension does this client have?
Essential (primary)
An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?
Fewer QRS complexes than P waves
The nurse is teaching a client who is experiencing dizziness to rise slowly from a sitting or lying position. What is the rationale for the teaching?
Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain.
A client with hypertension has been able to maintain a blood pressure of 130/70 mm Hg for 1 year while reducing dietary sodium and taking hydrochlorothiazide (HCTZ) and atenolol. What treatment plan will the nurse educate the client about?
Gradual reducing the HCTZ and the atenolol and continuing to reduce sodium intake
What are some causes of Afib/Aflutter?
HTN MI (past and present ) Coronary Artery Disease Abnormal Heart Valves Heart Defects (congenital) Exposure to stimulants Previous heart surgery Viral infections Stress
The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)?
Hypokalemia
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?
International normalized ratio (INR) is 2.5.
A client is being seen at the clinic on a monthly basis for assessment of blood pressure. The client has been checking blood pressure at home as well and has reported a systolic pressure of 158 and a diastolic pressure of 64. What does the nurse suspect this client is experiencing?
Isolated systolic hypertension
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?
It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node
A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?
Raynaud's disease
An older African American client is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do?
Recommend the client have blood pressure rechecked within 2 weeks.
Which term describes a situation in which blood pressure is very elevated but there is no evidence of impending or progressive target organ damage?
hypertensive urgency ***Hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage. A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage. Primary hypertension denotes high blood pressure from an unidentified source. Secondary hypertension is high blood pressure from an identified cause, such as renal disease.
The nurse is caring for a client who has had 25mg of oral hydrochlorothiazide added to the medication regimen for the treatment of hypertension. Which instruction should the nurse give the client?
increase the amount of fruits and vegetables you eat
Which terms refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieve by rest?
intermittent claudication
During the physical assessment of a client with hypertension, what would the nurse expect to be the most obvious finding?
sustained increase of either one or both systolic or diastolic measurements
On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped 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
The nurse is caring for a client with essential hypertension. The nurse reviews lab work and assesses kidney function. Which action of the kidney would the nurse evaluate as the body's attempt to regulate high blood pressure?
the kidney excretes sodium and water
A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?
venous insufficiency
The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what?
Atrial rate of 300 to 400
Which is not likely origination point for cardiac dysrhythmias?
Bundle of His
A client reports light headedness, chest pains, an SOB. The physician orders tests to ascertain what is causing the problems in cardiac rhythms? A. echocardiogram B. electrocautery C. electrocardiogram D. electroencephalogram
C. electrocardiogram
The nurse recognizes which as being true of cardioversion?
Defibrillator should be set to deliver a shock during the QRS complex.
A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD?
ankle-brachial index
Which condition contributes to secondary hypertension?
arterial vasoconstriction ***Elevated blood pressure in hypertensive urgency is associated with severe headache, epistaxis, and anxiety. An example of a hypertensive emergency is a myocardial infarction, intracranial hemorrhage, or dissecting aortic aneurysm.
The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?
in 3 to 5 days
The nurse and student nurse are observing a cardioversion procedure. The nurse is correct to tell the student that electrical current will be initiated at which time?
During ventricular depolarization
The nurse is evaluating the types of medications prescribed for a client's hypertension. Which of the following medication classifications establishes an action on vasoconstrictive hormones in the blood stream?
ACE inhibitor
Which diagnostic method is recommended to determine whether left ventricular hypertrophy has occurred?
Echocardiography
The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the dysrhythmia?
Elective cardioversion
The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?
Heart and blood vessels
What are the potential causes of Sinus Bradycardia?
Heart tissue damage related to aging Damage to heart tissues from heart disease or MI Heart disorder present at birth (congenital heart defect) Infection of heart tissue (myocarditis) complication of heart surgery imbalance of potassium or calcium Hypothyroidism
A client is taking 50 mg of oral spironolactone twice a day to assist with blood pressure control. While the nurse is performing the morning assessment, the client reports nausea, general muscle cramps, and weakness. The ECG strip shows a peaked, narrow T-wave, which is a change. What electrolyte imbalance does the nurse suspect?
Hyperkalemia
A patient arrives at the clinic for a follow-up visit for treatment of hypertension. The nurse obtains a blood pressure reading of 180/110 but finds no evidence of impending or progressive organ damage when performing the assessment on the patient. What situation does the nurse understand this patient is experiencing?
Hypertensive urgency
The nurse assesses a client with a HR of 120 BPM. What are the known causes of sinus tachycardia?
Hypovolemia
A client informs the nurse, "I can't adhere to the dietary sodium decrease that is required for the treatment of my hypertension." What can the nurse educate the client about regarding this statement?
It takes 2 to 3 months for the taste buds to adapt to changes in salt intake.
The nurse is assessing a patient with severe hypertension. When performing a focused assessment of the eyes, what does the nurse understand may be observed related to the hypertension?
Papilledema
A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours.
Peripheral pulses every 15 min after surgery
The nurse in an oncology clinic notes that the client being treated has hypertension. What tumor is a predisposing condition for secondary hypertension?
Pheochromocytoma
The nurse is instructing a student on the proper technique for measuring blood pressure (BP). Which student action indicates a need for further teaching?
Positions the arm at waist level
When the nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II and observes a bizarre, abnormal shape to the QRS complex, the nurse has likely observed which of the following ventricular dysrhythmias?
Premature ventricular contraction (PVC)
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?
Protamine sulfate
A 35-year-old client has been diagnosed with hypertension. The client is a stock broker, smokes daily, and has diabetes. During a follow-up appointment, the client states that regular visits to the doctor just to check blood pressure (BP) are cumbersome and time consuming. As the nurse, which aspect of client teaching would you recommend?
Purchasing a self-monitoring BP cuff
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle?
QRS complex
What is Normal Sinus Rhythm?
RATE: 60-100 bpm Rhythm: Regular P-wave: Yes PRI: 0.12-0.2 seconds QRS: Normal, less than or equal to 0.12 sec
Which finding indicates that hypertension is progressing to target organ damage?
Retinal blood vessel damage
The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V1?
Right side of sternum, fourth intercostal space
The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. What order does the nurse describe?
Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers
Which of the following are alterations noted in Virchow's triad? Select all that apply.
Stasis of blood Vessel wall injury Altered coagulation
The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client?
Stroke
The nurse is preparing to administer adenosine for a patient diagnosed with atrial flutter. How should the nurse administer this medication?
The dose is administered rapid IV push
The client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse?
The rhythm has a normal beat, then a premature beat pattern
The nurse documents that a client is having a normal sinus rhythm. What characteristics of this rhythm has the nurse assessed?
The sinoatrial (SA) node initiates the impulse.
The nurse is obtaining a health history from a client with a blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering blood pressure. Which medication classification does the nurse anticipate first?
Thiazide diuretic
Which condition(s) indicates target organ damage from untreated/undertreated hypertension? Select all that apply.
heart failure retinal damage stroke
A client with dilated cardiomyopathy is having frequent episodes of ventricular fibrillation. What medical treatment does the nurse anticipate the client will have to terminate the episode of ventricular fibrillation?
internal cardioverter defibrillator insertion
The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V1?
right side of sternum, fourth intercoastal space
A nurse is teaching a client with severe hypertension about the damage this condition can cause to the body. What system/organs will the nurse note are particularly targeted for damage due to severe hypertension?
sensory
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give?
50%
A 1-minute electrocardiogram (ECG) tracing of a client with a regular heart rate reveals 25 small, square boxes within an RR interval. The nurse correctly identifies the client heart rate as:
60 bpm ***A client's HR can be obtained from the electrocardiogram (ECG) tracing by several methods. A 1-minute strip contains 300 large boxes and 1500 small boxes. Therefore, an easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide by 1,500. In this instance, 1,500/25 = 60.
A nurse is caring for a client who has hypertension and diabetes mellitus. The client's blood pressure this morning was 150/92 mm Hg. When the client asks the nurse what his or her blood pressure should be, what is the nurse's most appropriate response?
"Clients with diabetes should have a lower blood pressure goal. You should strive for 120/80 mm Hg."
A 66-year-old client presents to the emergency department reporting severe headache and mild nausea for the past 6 hours. Upon assessment, the client's BP is 210/120 mm Hg. The client has a history of hypertension and takes 1.0 mg clonidine twice daily. Which question is most important for the nurse to ask the client next?
"Have you taken your prescribed clonidine today?"
The nurse is caring for a client newly diagnosed with hypertension. Which statement by the client indicates the need for further teaching?
"If I take my blood pressure and it is normal, I don't have to take my blood pressure pills."
Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?
"Limiting my salt intake to 2 grams per day will improve my blood pressure."
A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification?
"Shoes made of synthetic material are best for my feet." ***The client should wear leather shoes with an extra-depth toe box. Synthetic shoes do not allow air to circulate.
A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?
"The Enoxaparin will work immediately, but the warfarin takes several day to achieve its full affect."
A patient is being treated for hypertensive emergency. When treating this patient, the priority goal is to lower the mean arterial BP by up to which percentage in the first hour?
25%
A client with second-degree atrioventricular heart block Type II, is admitted to the coronary care unit. How will the nurse explain the need to monitor the client's ECG strip to the spouse?
"The small box will transmit the heart rhythm to the central monitor all the time."
Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply.
-Direct vasodilators may cause headache and tachycardia. -With thiazide diuretics, monitor serum potassium concentration. ***Thiazide diuretics may deplete potassium; many clients will need potassium supplementation. Direct vasodilators may cause headache and increased heart rate. Adrenergic inhibitors can cause sedation and fatigue. Beta-blockers may induce decreased heart rate; pulse rate should be assessed before administration. Angiotensin-converting enzyme inhibitors can induce a mild to severe dry cough.
Heparin Therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value?
1.5-2.5
A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the nurse specify about this client's target blood pressure?
130/80
The nurse is monitoring a client with hypertension and chronic kidney disease. What is the target blood pressure for the client?
140/90 mmHg
The nurse is explaining the DASH diet to a client diagnosed with hypertension. The client inquires about how many servings of fruit per day can be consumed on the diet. What is the nurse's best response?
4 or 5 servings per day ***The client can consume 4 or 5 servings of fruit per day on the DASH diet. The servings for grains and grain product is 7 or 8. Two or 3 servings of low-fat or fat-free dairy foods can be consumed per day. Meat, fish, and poultry servings are 2 or fewer per day.
A nurse is discussing with a nursing student how to accurately measure blood pressure. What statement by the student indicates an understanding of the education?
A cuff that is too small will give a false high blood pressure.
The licensed practical nurse is setting up the room for a client arriving at the emergency department with ventricular arrhythmias. The nurse is most correct to place which of the following in the room for treatment?
A defibrillator
The nurse is assessing the blood pressure for a patient who has hypertension and the nurse does not hear an auscultatory gap. What outcome may be documented in this circumstance?
A high diastolic or low systolic reading
A client's electrocardiogram (ECG) tracing reveals an atrial rate between 250-400, with saw toothed P waves. The nurse correctly identifies this dysrhythmia as?
Atrial flutter
A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete?
Attempt to palpate the dorsal is pedis and posterior tibial pulses
The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?
Avoid situation that contribute to ischemic episodes.
Which of the following assessment results is considered a major risk factor for PAD?
BP of 160/110 mm Hg
Health teaching includes advising patients on ways to reduce PAD. The nurse always emphasizes that the strongest risk factor for the development of atherosclerotic lesions is:
Cigarette smoking
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?
Constant, intense back pain and falling blood pressure
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?
Elevate the legs periodically for at least 15 to 20 minutes
A nurse is caring for a client with atrial fibrillation. What procedure would the nurse educate the patient about for termination of the dysrhythmia?
Elective cardioversion ***Pacemakers are implanted for Sinus Bradycardia.
A client will be undergoing elective electrical cardioversion. Which nursing intervention will be included in the client's plan of care?
Ensure the client has not eaten or drunk before the procedure.
A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?
Epinephrine
The nurse explains to the patient with PACs that there are many causes, some of which are modifiable. Select all that apply.
Hypoxemia, Anxiety, Alcohol
A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching?
Ill keep a log of each time my ICD discharges
A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:
Keep the affected leg level, or slightly dependent
The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position?
Left 5th intercoastal space at midclavicular line
The nurse is developing a teaching plan for a client diagnosed with hypertension. What would be important for the nurse to emphasize as part of the plan of care?
Limiting sodium intake in the diet
A client has just received a diagnosis of hypertension after the completion of diagnostics. What can the client do to decrease the consequences of hypertension? Select all that apply.
Lose weight, Manage stress effectively.
The nurse is planning the care of a patient admitted to the hospital with hypertension. What objective will help to meet the needs of this patient?
Lowering and controlling the blood pressure without adverse effects and without undue cost
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:
Lowering the limb so that it is dependent
The nurse teaches the client which guidelines regarding lifestyle modifications for hypertension?
Maintain adequate dietary intake of fruits and vegetables
A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply.
P-R Interval P wave T wave
A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat. Is this normal?" What is the nurse's best response?
Premature Atrial Complex (PAC)
The nurse analyzes the electrocardiogram (ECG) tracing of a client newly admitted to the cardiac step-down unit with a diagnosis of chest pain. Which finding indicates the need for follow-up?
QT interval that is 0. 46 seconds long
A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next?
Question the client about alcohol and illicit drug use.
What is Sinus Bradycardia?
RATE: <60 BPM Rhythm: Regular P-wave= YES PRI: 0.12-0.2 secs QRS: Normal, less than or equal to 0.12 sec
What is Sinus Tachycardia?
RATE: >100bpm Rhythm: Regular P-Wave= YES PRI: 0.12-0.2 seconds QRS: Normal, less than or equal to 0.12 sec
A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension?
Secondary
The nurse is caring for a client prescribed bumetanide for the treatment of stage 2 hypertension. Which finding indicates the client is experiencing an adverse effect of the medication?
Serum potassium value of 3.0 mEq/L
The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that which risk factors and cardiovascular problems are related to hypertension? Select all that apply.
Smoking, Overweight/obesity Age ≥65 in women
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?
Stop smoking
The nurse is employed in a physician's office and is caring for a client present for an annual exam. A blood pressure of 124/84 mm Hg is documented. Following revised guidelines for identifying hypertension, which educational pamphlet is help?
Stress reduction to lower prehypertensive state
The nursing student asks the nurse to describe the difference between sinus rhythm and sinus bradycardia on the electrocardiogram strip. What is the nurse's best reply?
The only difference is the HR
A client in a clinic setting has just been diagnosed with hypertension. When the client asks what the end goal is for treatment, what is the nurse's best response?
To prevent complications/death by achieving and maintaining a blood pressure of 140/90 or less
Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply.
Using a BP cuff that is too small will give a higher BP measurement. The client's arm should be positioned at the level of the heart. The client should sit quietly while BP is being measured.
A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?
arterial insufficiency
A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms?
atrial fibrillation
The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor of the client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record?
bigeminy
A client has severe coronary artery disease (CAD) and hypertension. Which medication order should the nurse consult with the health care provider about that is contraindicated for a client with severe CAD?
clonidine
When measuring blood pressure in each arm of a healthy adult, the nurse recognizes that the pressures:
differ no more than 5 mm Hg between arms.
The nurse assesses a client returning from the post anesthesia unit with a new onset of sinus tachycardia with a heart rate of 138 beats per minute and a blood pressure of 128/80mmHg after elevating the head of the bed. What intervention does the nurse consider?
evaluating lab values
A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What other conditions can cause this response in a healthy heart?
fever, shock, strenuous exercise
A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?
moderate to severe arterial insufficiency
The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)?
hypokalemia ***PVCs can be caused by cardiac ischemia or infarction, increased workload on the heart (e.g., exercise, fever, hypervolemia, heart failure, tachycardia), digitalis toxicity, acidosis, or electrolyte imbalances, especially hypokalemia.
A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?
ineffective peripheral tissue perfusion
The nurse is discussing aging and the incidence of hypertension with an older adult. What lifestyle change will lower blood pressure for the older adult?
keep weight stable
A client with a history of hypertension is receiving client education about structures that regulate arterial pressure. Which structure is a component of that process?
kidneys
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:
left calf circumference 1" (2.5 cm) larger than the right. *Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.
A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction?
pallor
A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat." The nurse believes that the client is experiencing what condition?
premature atrial complex (PAC)
It is important for the nurse to encourage the client to rise slowly from a sitting or lying position because gradual changes in position:
provide time for the heart to increase the rate of contraction to resupply oxygen to the brain.
Which dysrhythmia is common in older clients?
sinus bradycardia
Which of the following are alterations noted in Virchow's triad? Select all that apply.
stasis of blood altered coagulation vessel wall injury
Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low?
u wave
The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities?
ulceration
A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be?
ventricular fibrillation
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?
ventricular fibrillation ***Ventricular fibrillation is called the rhythm of a dying heart. It is the rhythm that needs attention first because there is no cardiac output, and it is an indication for CPR and immediate defibrillation. Sustained asystole either is from death, or the client is off of the cardiac monitor. Supraventricular tachycardia and atrial fibrillation is monitored and reported to the physician but is not addressed first.
