RN Targeted Med-Surg : Cardio
A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Identify the area of the strip the nurse should examine to observe for atrial depolarization. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)
A. P wave B) QRS complex = ventricular depolarization C) T wave - ventricular repolarization
A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. Which of the following client findings should the nurse report to the provider? A. Mediastinal drainage 100 ml/hr b. Blood pressure 160/80 mm Hg C. Temperature 37.1° C (98.8° F) D. Potassium 3.8 meq/L
B. Blood pressure 160/80 mm Hg R: increased vascular pressure can cause bleeding at the incision site A) drainage up to 150 mL/hr is expected C) within expected range following CABG D) desired goal following CABG
A nurse is caring for a client who is being treated for HF and has prescriptions for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication? A. SOB b. Lightheadedness c. Dry cough d. Metallic taste
B. Lightheadedness R: Furosemide can cause a substantial drop in BP resulting in lightheadedness A) used to manage SOB secondary to HF, not adverse reaction C,D) not adverse reaction
A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following? A. Tendon pain b. Persistent cough c. Frequent urination d. Constipation
B. Persistent cough R: adverse effect of ACE inhibitors, report and D/C A) adverse effect of fluoroquinolone antibiotics C) expected outcome of med D) adverse effect of ACE inhibitors but no need to report or D/C
A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? A. Obtain clients current weight B. Review serum electrolyte values C. Determine the time of the last digoxin dose D. Check the clients urine output
B. Review serum electrolyte values R: weakness and irregular HR indicate greatest risk for electrolyte imbalance, adverse effect of loop diuretic A,C,D) not priority
A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions? A. Delivery of precordial thump b. Vagal stimulation c. Administration of atropine IV d. Defibrillation
B. Vagal stimulation R: it can help the clients heart return to a normal sinus rhythm temporarily A) used in witnessed Vtach if defibrillator is unavailable C) used to treat badydysrhythmias D) cardioversion rather than defibrillation is used to treat SVT, defibrillation is used for Vfib or pulseless Vtach
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a MI? A. Myoglobin b. C-reactive protein c. Creatine kinase- MB d. Homocysteine
C. Creatine kinase- MB R: it is the isoenzyme specific to the myocardium and is elevated when that muscle is injured A) not specific to cardiac muscle, elevated following MI and skeletal muscle injury B) increases soon after beginning of inflammatory process such as RA, not specific to cardiac muscle C) always present in blood, increase indicates risk factor for CV disease
A nurse is caring for a client who presents to the ER with a BP of 254/138 mmhg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Obtain blood samples for laboratory testing B. Tell the client to report vision changes C. Place the head of the bed at 45 degrees D. Initiate an IV
C. Place the head of the bed at 45 degrees R: this improves respiratory status and promotes venous return to reduce workload on the heart A B, D) not the 1st actions
A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? A. Hemoglobin 14 g/dl B. Minimal bruising of extremities C. Reduced circumference of affected extremity D. INR 2.0
D. INR 2.0 R: within the desired therapeutic range A,B) not evidence of effective warfarin therapy C) decrease BP is a manifestation of bleeding, adverse effect of warfarin
A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)
located in the 5th ICS, Left midclavicular line
A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect? A. Confusion B. Friction Rub C. Hypertension D. Dry Skin
A) Confusion Rationale: it can cause decreased tissue perfusion, which can lead to confusion. monitor the clients mental status B) friction rub is expended in pericarditis C) monitor a client who has bradydysrhythmia for hypotension D) Bradydysrhythmia -> monitor for diaphoresis
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? A. "I can't get rid of these hiccups." b. "I feel dizzy when I stand." c. "My incision site stings." d. "I have a headache."
A. "I can't get rid of these hiccups." R: may indicate pacemaker is stimulating the chest wall or diaphragm (lead wire perforation) B) not a complication, expected initially C) not a complication, monitor insertion site for manifestations of infection. D) not a complication
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately? A. Slurred speech B. Irregular pulse C. Dependent edema D. Persistent fatigue
A. Slurred speech R: it can indicated inadequate circulation to the brain because of an embolus. report immediately B) expected finding in Afib, at risk for inadequate CO C) expected finding in HF, at risk for inadequate circulation D) expected finding in HF, at risk for inadequate CO
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find? A. Inc abdominal girth b. Weak peripheral pulses c. Jugular vein distention d. Dependent edema
B. Weak peripheral pulses R: related to decreased CO A, C, D) result of right-sided HF
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? A. "My arthritis is really bothering me because I haven't taken my aspiring in a week." b. "My blood pressure shouldn't be high because I took my BP medication this morning." c. "I took my warfarin last night according to my usually schedule." d. "I will check my BP because I took a reduced dose of insulin this morning."
C. "I took my warfarin last night according to my usually schedule." R: CABG should not take anticoagulants, for 5-7 days prior to surgery to prevent excessive bleeding A) Aspirin may have been ordered to be discontinued to reduce risk of bleeding B) BP meds may be ordered to reduce risk of HTN D) may have been instructed to take reduced dose of insulin to regulate BG
A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the clients family history of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection
C. Inquire about the presence or absence of claudication R: Experiencing claudication helps differentiate venous from arterial ulcers. (arterial ulcers experience claudication) A) important but doesn't differentiate between arterial and venous ulcers B) both cause varying degrees of pain or discomfort D) both have potential to become infected
A nurse is caring for a client who has a history of angina and is schedules for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I'm still hungry after the bowl of cereal I ate at 7am." b. "I didn't take my heart pills this morning because the doctor told me not to." c. "I have had chest pain a couple of times since I saw my doctor in the office last week." d. "I smoked a cigarette this morning to calm my nerves about having this procedure."
D. "I smoked a cigarette this morning to calm my nerves about having this procedure." R: Smoking prior can change the outcome and places the client at additional risk A) not necessary to be NPO B) provider may withhold CV meds to effectively monitor CV response to stress C) not a contraindication to test
A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? A. Administering IV morphine sulfate B. Administering oxygen at 2:/min via nasal cannula C. Helping the client to the bedside commode D. Assisting with thrombolytic therapy
D. Assisting with thrombolytic therapy R: Major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy A) should admin IV morphine to relieve pain and reduce myocardial oxygen demand B) should administer supplemental oxygen to increase myocardial tissue perfusion C) BSC is less stressful than using a bedpan
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Ventricular depolarization B. Guillain-Barre syndrome C. Myelodysplastic syndrome D. Valvular disease
D. Valvular disease R: valvular disease or damage often occurs as a result of inflammation or infection of the endometrium A) occurs during normal cardiac cycle B) associated with certain bact or viral infections but not endocarditis C) disorder of bone marrow
A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of deep-vein thrombosis. Which of the following interventions should the nurse anticipate taking if the client's aptt is 96 seconds? A. Increase the heparin infusion flow rate by 2 ml/hr B. Continue to monitor the heparin infusion as prescribed C. Request a prothrombin time D. Stop the heparin infusion
D. stop the heparin infusion R: aPTT level is above the critical value/therapeutic range of 1.5 to 2x the control value(25-36 sec). A) aPTT of 96 sec indicates excessive heparin, do not increase B) heparin is excessive, take corrective action C) should monitor PT for oral anticoagulant, not necessary to order before taking corrective action.
A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching? A. "you may no longer be able to feel chest pain." b. "your level of activity tolerance will not change." c. "after 6 months, you will no longer need to restrict your sodium intake." d. "you will be able to stop taking immunosuppressants after 12 months."
A. "you may no longer be able to feel chest pain." R: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart B) should improve gradually C) permanently maintain sodium and fat restrictions D) will remain on immunosuppressants for life
A nurse is assessing a client who has pulmonary edema related to hear failure. Which of the following findings indicates effective treatment of the client's condition? A. Absence of adventitious breath sounds B. Presence of a nonproductive cough C. Decrease in respiratory rate at rest D. Sao2 86% on room air
A. Absence of adventitious breath sounds R: indications pulm edema is resolving B) not indicative of resolution C) RR usually decreases at rest D) abnormal finding
A nurse is caring for a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? A. Dyspnea on exertion B. Tracheal deviation C. Pericardial rub D. Weight loss
A. Dyspnea on exertion R: due to ventricular compromise and reduced CO B) manifestation of tension pneumothorax C) manifestation of pericarditis D) not a manifestation but wt gain is
A nurse is providing discharge teaching for a client who has HF. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 2 lb. in 24 hr b. Inc of 10 mmhg in systolic BP c. Dyspnea with exertion d. Dizziness when rising quickly
A. Weight gain of 2 lb in 24 hr R: weight gain of 0.5-0.9 (1-2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening HF B, C, D) nonurgent finding
A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values? A. Cholesterol 180 mg/dl, HDL 70 mg/dl, LDL 90 mg/dl b. Cholesterol 185 mg/dl, HDL 50 mg/dl, LDL 120 mg/dl c. Cholesterol 190 mg/dl, HDL 25 mg/dl, LDL 160 mg/dl d. Cholesterol 195 mg/dl, HDL 55 mg/dl, LDL 125 mg/dl
C. Cholesterol 190 mg/dl, HDL 25 mg/dl, LDL 160 mg/dl R: Total chol <200, HDL >45 men/ >55 women, LDL <130
A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? A. Serosanguinous drainage on dressing B. Severe pain with coughing C. Urine output of 20 ml/hr D. Increase in temp from 36.C (98.2F)- 37.5C (99.5F)
C. Urine output of 20 ml/hr R: urine output less than 30ml/hr can indicate shock because it reflects decreased blood flow to the kidneys possible from graft rupture and hemorrhage A) expected and not a manifestation of shock, should decrease over 1st few days and d/c after 5 B) expected D) within reference range
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? A. Hemoglobin 14.4 g/dl b. History of peripheral arterial disease c. Urine output 200 ml/4 hr d. Previous allergic reaction to shellfish
D. Previous allergic reaction to shellfish R: Contrast medium use is iodine-based A) within expected range B) access is through large arteries or veins, not peripheral arteries C) within expected range
A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include? (Select all that apply.) A. Limited alcohol intake B. Regular exercise program C. Decreased magnesium intake D. Reduced potassium intake E. Smoking cessation
A, B, E. Limited alcohol intake, Regular exercise program, Smoking cessation C,D) low mag and K intake associated with HTN
A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? A. A client who has hypothyroidism b. A client who has DM c. A client whose daily caloric intake consists of 25% fat d. A client who consumes two bottles of beer a day
B. A client who has DM R: DM places the client at risk for microvascular damage and progressive PAD A) not a risk factor for PAD C) within recommended range for daily fat intake D) considered moderate alcohol intake
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? A. Apply the new patch to the same site as the previous patch. B. Place the patch on an area of skin away from skin folds and joints. C. Keep the patch on 24 hr per day. D. Replace the patch at the onset of angina.
B. Place the patch on an area of skin away from skin folds and joints. R: it should be applied to an area of skin that is not prone to movement or wrinkling A) rotating patch site prevents skin irritation C) should be patch-free 10-12 hrs/day to prevent tolerance to med D) nitro patches offer ongoing prevention and don't treat angina attacks
