Practice EXAM 3 CHA
After teaching a patient who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the patient's understanding. Which statement by the patient indicates a correct understanding of the teaching?
"I will avoid sources of strong electromagnetic fields." The patient being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Patients should avoid tight clothing, which could cause irritation over the ICD generator. The patient should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The patient should continue all prescribed medications.
15. After teaching a patient who is being discharged home after mitral valve replacement surgery, the nurse assesses the patient's understanding. Which patient statement indicates a need for additional teaching?
"I will have my teeth cleaned by my dentist in 2 weeks." Patients who have defective or repaired valves are at high risk for endocarditis. The patient who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the patient needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Patients on anticoagulant therapy would be instructed on bleeding precautions, including using an electric razor. If the patient is prescribed warfarin, the patient should avoid foods high in vitamin K. Patients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.
A nurse is preparing to discharge a patient that developed rheumatic fever after having strep throat. Which statement by the patient requires further education?
"I will have to take antibiotics after any dental procedure that exposes the nerve."
2. After teaching a patient with congestive heart failure, the nurse assesses the patient's understanding. Which patient statements indicate a correct understanding of the teaching related to nutritional intake? Select all that apply.
"I'll read the nutritional labels on food items for salt content." "I will eat oatmeal for breakfast instead of ham and eggs." "Substituting fresh vegetables for canned ones will lower my salt intake." Nutritional therapy for a patient with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The patient would be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day.
The provider requests the nurse start an infusion of an inotropic agent on a patient. How does the nurse explain the action of this drug to the patient and spouse?
"It increases the force of the heart's contractions."
4. A nurse teaches a patient who experiences occasional premature ventricular contractions (PVC's) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this patient's teaching?
"Minimize or abstain from caffeine." PACs usually have no hemodynamic consequences. For a patient experiencing infrequent PACs, the nurse would explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the patient first should try lifestyle changes to control them.
11. A nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure?
"My shoes fit really tight lately." Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.
A nurse teaches a patient with a new permanent pacemaker. Which instructions would the nurse include in this patient's teaching? Select all that apply.
"Until your incision is healed, do not submerge your pacemaker. Only take showers." "Report any pulse rates lower than your pacemaker settings." "Do not lift your left arm above the level of your shoulder for 8 weeks." The patient should not submerge in water until the site has healed; after the incision is healed, the patient may take showers or baths without concern for the pacemaker. The patient should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The patient should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The patient should never apply pressure over the generator and should avoid tight clothing. The patient should never have MRI because, whether turned on or off, the pacemaker contains metal. The patient should be advised to inform all healthcare providers that he or she has a pacemaker.
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication?
Aspirin
8. A nurse cares for a patient who is on a cardiac monitor. The monitor displayed the rhythm shown below. (VTACH)What action would the nurse take first?
Assess airway, breathing, and circulation. Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse would first assess if the patient is alert, breathing, and has a pulse. If this patient is pulseless, then the nurse would call a Code Blue and begin CPR. The treatment of choice for pulseless ventricular tachycardia is defibrillation. If the patient has a pulse, then cardioversion would be indicated. Amiodarone is the antidysrhythmic of choice, but it is not the first action.
List "normal" vital signs you would expect to see for a newborn.
HR: 120-160 RR: 30-60 BP: 60-100/30-60
Describe specific administration guidelines for Digoxin for infants.
Hold digoxin if HR <100. Monitor for hyperkalemia and potential dig toxicity. Give 20-30 minutes before feeding, if possible.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? Select all that apply.
Hypertension Obesity Smoking Stress Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect?
I have trouble breathing when I walk rapidly
In babies with cyanotic heart disease such as Tetralogy of Fallot, explain what you will do when the baby has a "hypercyanotic episode" or "choking spell."
If heart is unable to maintain cardiac output, fluid backs up into lungs causing pulmonary congestion. Hypercyanotic episode caused by acute spasm of right ventricle, resulting in decreased pulmonary blood flow, which can lead to hypoxia and metabolic acidosis. Symptoms: rapid, deep respirations, cyanosis, irritability after crying, feeding or after BM Be calm in approach, knee- chest position to help with blood flow Administer oxygen and possibly morphine to increase air exchange Often develop polycythemia to help correct hypoxia At risk for anemia because normal RBCs pushed out. Risk for CNS injury due to increased viscosity of blood - risk for CVA
A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse?
In case to too slow of a heart rate, the epicardial leads are attached to a pacemaker to maintain a normal rate
When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect?
Increased contractile force of the myocardium
Nitroglycerin may be an appropriate intervention for which of the following conditions affecting the myocardial tissue? Select all that apply.
Infarction Ischemia
6. The nurse is caring for a patient on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm (VFIB) below. After calling for assistance and a defibrillator, what action would the nurse take next?
Initiate cardiopulmonary resuscitation (CPR). The patient's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse would start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the patient does not already have an IV, other members of the team can insert one after defibrillation. The patient's code status would already be known by the nurse prior to this event.
After administering newly prescribed captopril (Capoten) to a patient with heart failure, the nurse implements interventions to decrease complications. Which priority intervention would the nurse implement for this patient?
Instruct the patient to ask for assistance when rising from bed. Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse would instruct the patient to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The patient would be encouraged to complete activities of daily living as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the patient has renal insufficiency secondary to heart failure.
9. A telemetry nurse assesses a patient who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next?
Level of consciousness A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The patient is at risk for inadequate cerebral perfusion. The nurse would assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the patient's level of consciousness is the priority.
The nurse is caring for a patient with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important?
Notify the provider immediately. If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse would notify the provider immediately. The nurse would not independently increase the suction, reposition the chest tube, or take the tubing apart.
A client presents to the ED with a fever, new regurgitant murmur and splinter hemorrhages in the nail bed. The client underwent valve replacement surgery 2 months prior. Which intervention should the nurse implement first?
Obtain blood cultures
patent ductus venosus
Opening in the liver to shunt blood to the inferior vena cava
A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective?
Pain subsides as a result of arteriole and venous dilation.
13. A nurse is in charge of the coronary intensive care unit. Which patient would the nurse see first?
Patient who is 1 day post coronary artery bypass graft, with blood pressure 180/100 mm Hg Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse would see this patient first. The patient who became dizzy earlier would be seen next. The patient on the nitroglycerin drip is stable. The patient going home can wait until the other patients are cared for.
4. A nurse is caring for four patients. Which patient would the nurse assess first?
Patient who is 1 hour post-angioplasty, and has tongue swelling and anxiety The post-angioplasty patient with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse would assess this patient first. The patient with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two postcoronary artery bypass patients are stable.
10. A patient had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
Poor peripheral pulses and cool skin Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and would be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.
ACE inhibitors
Prevents L ventricular remodeling & HF after MI
Clopidogrel
Prevents fibrinogen from attaching to platelets- prevents additional clots from forming
5. A nurse is assessing a patient with left-sided heart failure. For which clinical manifestations would the nurse assess? Select all that apply.
Pulmonary crackles Confusion, restlessness Cough that worsens at night Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided heart failure occurs with problems from the pulmonary vasculature onward including pulmonary hypertension. Signs will be noted before the right atrium or ventricle including dependent edema.
Which of the following statements is an accurate description of fetal circulation?
Pulmonary vascular resistance is high because the lungs are collapsed
A common complication of congenital heart defects is congestive heart failure. What manifestations are commonly seen in an infant with HF?
Shunting occurring during heart defects. Greater pressures on left side of heart, so pressures shunt blood to right side, which results in volume overload on right side and pulmonary artery. This increases the workload of the heart, and leads to CHF. Symptoms: tachycardia, tachypnea, grunting while breathing due to respiratory distress, JVD, cyanosis, irritability (r/t difficulty feeding), decreased peripheral perfusion, decreased UO (decreased circulation to kidneys).
A nurse is caring for a patient with acute pericarditis who reports substernal pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?
Sit the patient up with a pillow to lean forward on. Pain from acute pericarditis may worsen when the patient lays supine. The nurse would position the patient in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain.
3. A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the clients question?
Slows and strengthens cardiac contractions
A patient with a Creatinine level of 1.2 is safe to have a coronary angiogram.
TRUE This creatinine level is at the upper end of normal. With elevated creatinine levels, the risk of kidney damage must be weighed against the benefits of the coronary angiogram.
A nurse is conducting discharge teaching to parents about care of their infant after cardiac surgery. The nurse instructs the parents to notify the provider if what condition occurs? Select all that apply.
Temperature at or above 38 C (100.4 F) The infant's lips are bluer than normal New, frequent coughing
In your own words, describe fetal circulation and explain how this changes with the "normal" neonate's first breath.
Umbilical vein carries richly oxygenated blood from placenta to liver. Liver has ductus venosus, where blood goes into inferior vena cava. From inferior vena cava into right atrium. Blood from upper part of fetus body goes through superior vena cava into right atrium. Goes through foramen ovale from right atrium to left atrium, or into right ventricle Right ventricle to pulmonary artery OR left atrium to left ventricle to aorta. Very little of blood in pulmonary artery goes into lungs, because lungs are collapsed. Most blood goes through ductus arteriosus from pulmonary artery into descending aorta From aorta to periphery of body then through umbilical arteries back to placenta for oxygenation. With first breath, all shunts (ductus venosus, foramen ovale, and ductus arteriosus) close/constrict due to change in pressure. Lungs expand, pulmonary resistance decreases, resulting in increased blood flow). Process starts with first breath, may take days to fully close.
16. A nurse teaches a patient who has a history of heart failure. Which statement would the nurse include in this patient's discharge teaching?
Weigh yourself daily while wearing the same amount of clothing." Patients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The patient would be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.
4. A nurse cares for a patient recovering from prosthetic valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?
"Blood clots form more easily in artificial replacement valves." Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.
1. A client with angina pectoris is scheduled for stress echocardiogram. What should the nurse tell the client that an echocardiogram is?
A noninvasive approach to assess cardiovascular status
How can the nurse best describe heart failure to a client?
AN inability of the heart to pump blood in proportion to metabolic needs
When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve?
Pulmonic
A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade?
Pulsus paradoxus Correct! Muffled heart sounds Correct! Jugular vein distention
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? Select all that apply.
Accompanied by shortness of breath Feelings of fear or anxiety No relief from taking nitroglycerin Pain occurs without known cause The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.
13. A nurse assesses a patient after administering isosorbide mononitrate (Imdur). The patient reports a headache. What action would the nurse take?
Administer PRN acetaminophen. The vasodilating effects of isosorbide mononitrate frequently cause patients to have headaches during the initial period of therapy. Patients would be told about this side effect and encouraged to take the medication with food. Some patients obtain relief with mild analgesics, such as acetaminophen. The patient's headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The patient needs to take the medication as prescribed to prevent angina; the medication would not be held.
Before giving a dose of digoxin (Lanoxin), the nurse checked an infant's apical heart rate and it was 122 bpm. What should the nurse do next?
Administer the dose as ordered
Describe ethical implications for an infant who needs to undergo cardiopulmonary transplant as a result of a congenital heart defect.
Adult making decision for the child: surrogate decision maker Relgion/beliefs What's best for the child Benefits outweighing risks
9. A nursing student planning to teach patients about risk factors for coronary artery disease (CAD) would include which topics? Select all that apply.
Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.
The parents of a baby with a congenital heart defect tell you that their baby "has a hard time eating." How will you explain the cause of the difficulty in eating to them?
Airway, hard to breath; but because it takes energy to eat and the baby is working hard at keeping organs perfused; body chooses perfusion over eating when it comes to energy consumption.
What client response must the nurse monitor to determine the effectiveness of amiodarone?
Decrease in cardiac dysrhythmias
A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply
Dependent edema Urinating at night Distended abdomen
Nitro
Dilates coronary arteries to increase perfusion to myocardium
An electrocardiogram is prescribed for a client complaining of chest pain. The nurse recognizes which as an early finding of an infarcted area of the heart?
Elevated ST segments
A 10-year-old child undergoes open heart surgery to repair a cardiac defect. The healthcare provider informs the parents that antibiotics are required before any dental work is performed. Later the parents ask the nurse why this is necessary. When responding, the nurse explains that this is done to prevent what type of infection?
Endocarditis
A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client?
Hematoma formation
Which is the priority nursing action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation?
Initiating defibrillation
The parents of a baby with a congenital heart defect tell you that their baby "has a hard time eating." What interventions will you utilize, and teach the parents, to improve this baby's nutritional status?
Maintain relaxed, calm environment Feed baby before activities when they have energy to eat Keep upright while eating Feed at least Q3H Need increased caloric intake (e.g. 27kcal/oz) Weekly weights Monitor growth and development RN implement lavage feeding - if suck not strong enough for nutrition
A nurse is auscultating a client's heart; closure of what structures produces the first heart sound (S1)?
Mitral and tricuspid valves
patent ductus arteriosus
Opening between the aorta and the pulmonary artery
1. A nurse cares for a patient with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions would the nurse implement to address this patient's concerns?
Schedule periods of exercise and rest during the day. Patients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse would schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the patient with self-care activities.
12. A nurse assesses a patient who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? Select all that apply.
Shortness of breath Abdominal bloating New-onset bradycardia Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.
The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis?
Shunting of blood from right to left
While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings?
Subacute bacterial endocarditis
A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?
The signs and symptoms of heart failure
10. A nurse assists with the cardioversion of a patient experiencing acute atrial fibrillation. What action would the nurse take prior to the initiation of cardioversion?
Turn of oxygen therapy. For safety during cardioversion, the nurse would turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The patient would be placed in a supine position.
A nurse observes the following dysrhythmia on a client's cardiac monitor. Which rhythm does the nurse identify?
Ventricular fibrillation
A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.
Weight Smoking
A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of?
Cardiac irritability
1. A patient presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3pm). The facility has a 24-hour catheterization laboratory abilities. To improve patient outcomes, by what time would the patient have a percutaneous coronary intervention performed?
1630 Percutaneous coronary intervention would be performed within 90 minutes of diagnosis of myocardial infarction. Therefore, the patient would have a percutaneous coronary intervention performed no later than 16:30 (4:30 PM).
18. A nurse admits a patient who is experiencing an exacerbation of heart failure. What action would the nurse take first?
Assess the patient's respiratory status. Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.
Umbilical vein
Carries oxygenated blood from the placenta to the liver
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?
Check for a pulse
The patient with a health concern of Aortic Regurgitation, which could be the possible cause?
Bicuspid Valve Rheumatic fever Aortic aneurysm
A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding?
Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta.
Which of the following strategies are appropriate to implement when feeding an infant with congestive heart failure. Select all that apply.
Consider administering digoxin prior to feedings Consider feeding the infant when they are calm and rested Limit feeding time to no more than 30 minutes The infant should be fed every 2-3 hours. Keep infant upright during feedings
The nurse is caring for a client with a diagnosis of Pericarditis. The patient hits his call light and alerts the nurse that he is experiencing chest pain. What type of chest pain is commonly associated with pericarditis?
Constant pain that is relieved with sitting up.
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic?
Continues after rest and nitroglycerin
What is the difference between cyanotic and acyanotic congenital heart defects? Give examples of each.
Cyanotic (R to L shunting) - blood is not oxygenated, goes from R side of heart to L side, bypassing the lungs, therefore not picking up oxygen Pulmonary valve stenosis Ventricular septal defect Overriding aorta Acyanotic (L to R shunting) -usually L side is strong pump but blood backed up to R side = volume overload = increased heart workload, which can lead to CHF Patent ductus arteriosus Atrial septal defect Ventricular septal defect
After a discussion with the primary healthcare provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?
It is a connection between the pulmonary artery and the aorta
A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse?
This test will reflect any heart damage
A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Select all that apply.
foramen ovale and ductus arteriosus
7. A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?
"I must stop halfway up the stairs to catch my breath." Patients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.
6. A nurse cares for a patient with right-sided heart failure. The patient asks, "Why do I need to weigh myself every day?" How would the nurse respond?
"Weight is the best indication that you are gaining or losing fluid." Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 lbs (1 kg). The other responses do not address the importance of monitoring fluid retention or loss.
The parents of a baby with a congenital heart defect tell you that their baby "has a hard time eating." What specific questions will you ask them about the baby's feeding patterns and behavior?
How long does it take to eat? How much is consumed? Hungry or irritable after feeding? What is their growth or weight gain over time?
The spouse of a patient who had emergency coronary artery bypass surgery asks why there is a dressing on the patient's left leg. How should the nurse explain the dressing?
A vein in the leg was used to bypass the coronary artery
14. While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next?
Assess for symptoms of left-sided heart failure. The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.D: The vasodilating effects of isosorbide mononitrate frequently cause patients to have headaches during the initial period of therapy. Patients would be told about this side effect and encouraged to take the medication with food. Some patients obtain relief with mild analgesics, such as acetaminophen. The patient's headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The patient needs to take the medication as prescribed to prevent angina; the medication would not be held.
A patient is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the patient to the bathroom and notes the patient's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
Allow continued bathroom privileges This patient's physiologic parameters did not exceed normal during and after activity, so it is safe for the patient to continue using the bathroom. There is no indication that the patient needs oxygen, a commode, or a bedpan.
8. A nurse assesses a patient who has a history of heart failure. Which question would the nurse ask to assess the extent of the patient's heart failure?
Are you able to walk upstairs without fatigue?" Patients with a history of heart failure generally have negative findings, such as shortness of breath and fatigue. The nurse needs to determine whether the patient's activity is the same or worse, or whether the patient identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the patient's heart failure.
8. A patient has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the patient's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
Assess the patient for bleeding. A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse would assess the patient for any bleeding associated with the arterial line. The nurse would document the findings after a full assessment. The patient may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.
2. A patient had a myocardial infarction (MI). The nurse notes the patient's cardiac rhythm as shown below. What action by the nurse is most important?
Assess the patient's blood pressure and level of consciousness. Patients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse would first assess the patient's hemodynamic status, including vital signs and level of consciousness. The patient may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.
6. A patient is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this patient? Select all that apply.
Assist the patient into a position of comfort in bed. Provide complementary therapies such as music. Remind the patient to splint the incision when coughing. Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.
17. A nurse assesses a patient who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess?
Atrial fibrillation Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in patients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.
A client with a history of heart failure and hypertension is admitted with reports of syncope. Which prescribed medication should the nurse prepare to administer based on the electrocardiogram (ECG) rhythm strip image? SINUS BRADY
Atropine
3. A nurse assesses a patient with pericarditis. Which assessment finding would the nurse expect to find?
Friction rub at the left lower sternal border. The patient with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.
Umbilical artery
Carries deoxygenated blood from the fetal body to the placenta
An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply.
Dyspnea Crackles Hacking cough
10. A nurse assesses a patient with mitral valve stenosis. What clinical manifestation would alert the nurse to the possibility that the patient's stenosis has progressed?
Dyspnea on exertion Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.
A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period?
Dysrhythmias, especially atrial fibrillation
3. A nurse prepares to defibrillate a patient who is in ventricular fibrillation. Which priority intervention would the nurse perform prior to defibrillating this patient?
Ensure that everyone is clear of contact with the patient and the bed. To avoid injury, the rescuer commands that all personnel clear contact with the patient or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a patient is defibrillated because this is an emergency procedure; equipment would be checked on a routine basis. Epinephrine should be administered after defibrillation.
Which nursing intervention should the nurse consider to be a priority for clients with fluid overload?
Ensuring client safety
It is okay for a patient to have a cup of coffee with their breakfast the morning of an exercise stress test.
FALSE Coffee contains caffeine, which is a stimulant and contraindicated prior to a cardiac stress test as it can interfere with results.
TPA (activase)
Fibrinolytic used to break up/ dissolve clots that have already formed
Occlusion of which coronary artery often causes sudden death due to impairing the heart's ability to pump blood to the body?
Left Anterior Descending Artery
Patent foramen ovale
Opening between the right and left atrium
Aspirin
Platelet aggregate inhibitor prevents platelets from sticking together & keeps blood "slippery
Metoprolol
Slows heart rate & decreases contractility to decrease the size of the infarct
A nurse evaluates prescriptions for a patient with chronic atrial fibrillation. Which medication would the nurse expect to find on this patient's medication administration record to prevent a common complication of this condition?
Warfarin (Coumadin) Atrial fibrillation puts patients at risk for developing emboli. Patients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.
The nurse is caring for a client who is on a cardiac rhythm monitor. The nurse notes that the client's P waves are of normal configuration and that each P wave is followed by a QRS complex. All intervals are normal as well, but the client's heart rate is 112 beats per min. How will the nurse interpret this rhythm?
sinus tachycardia
