Silvestri Cardiovascular (HTN, HF, Vascular)
A client seeks treatment in a vascular surgeon's office for unsightly varicose veins, and radiofrequency ablation (RFA) is recommended. Before leaving the examining room, the client says to the nurse, "Can you tell me again how this is done?" Which statement should the nurse make? - "The varicosity is surgically removed." - "A heating element is used to occlude the vein." - "The vein is tied off at the upper end to prevent stasis from occurring." - "The vein is tied off at the lower end to prevent stasis from occurring."
"A heating element is used to occlude the vein." Radiofrequency ablation (RFA) is a treatment for varicose veins that uses a radiofrequency heat element to ablate (occlude) the affected vessel. This procedure is less invasive than a ligation and removal of veins procedure. Using ultrasound guidance, the clinician advances a catheter into a vein and injects an anesthetic agent around it. Then the vessel is ablated while the catheter is slowly removed. This causes collapse and sclerosis of the vein causing the occlusion.
The nurse educator is teaching the new registered nurse (RN) how to care for clients with a decrease in blood pressure. Which statement by the new RN indicates the need for further instruction? - "Decreased contractility occurs." - "Decreased heart rate is not a side effect." -"Decreased myocardial blood flow is not a concern." - "Increased resistance to electrical stimulation often occurs."
"Decreased myocardial blood flow is not a concern." The primary effect of a decrease in blood pressure is reduced blood flow to the myocardium. This in turn decreases oxygenation of the cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase, not decrease, in response to this change. The effects of tissue ischemia lead to decreased contractility over time.
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? - "I need to be sure not to go barefoot around the house." - "If I cut my toenails, I need to be sure that I cut them straight across." - "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4."I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."
"I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements and indicate that the teaching has been effective.
The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? - "I'll need to become a strict vegetarian." - "I should use polyunsaturated oils in my diet." - "I need to substitute eggs and whole milk for meat." - "I should eliminate all cholesterol and fat from my diet."
"I should use polyunsaturated oils in my diet." The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? - "I'm not supposed to eat cold cuts." - "I can have most fresh fruits and vegetables." - "I'm going to weigh myself daily to be sure I don't gain too much fluid." - "I'm going to have a ham and cheese sandwich and potato chips for lunch."
"I'm going to have a ham and cheese sandwich and potato chips for lunch." When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.
The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking? - "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." - "Because most of the damage has already been done, it will be all right to cut down a little at a time." - "If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." - "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."
"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. The statements in the remaining options are incorrect.
A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective? - "It involves tying off the veins so that circulation is redirected in another area." - "It involves surgically removing the varicosity, so anesthesia will be required." - "It involves tying off the veins to prevent sluggishness of blood from occurring." - "It involves injecting an agent into the vein to damage the vein wall and close it off."
"It involves injecting an agent into the vein to damage the vein wall and close it off." Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with the use of a hook and wires applied through multiple small incisions in the leg. Other treatments include the application of radiofrequency (RF) energy, in which the vein is heated from the inside by the RF energy and shrinks; collateral veins nearby take over. Laser treatment is another alternative to surgery; in this treatment, a laser fiber is used to heat and close the main vessel that is contributing to the varicosity.
An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education? - "It is important that I limit protein intake." - "I need to maintain a regular exercise program." - "I understand that I need to avoid adding salt to foods." - "It is important that I begin reducing and then maintaining weight."
"It is important that I limit protein intake." Obesity and sodium intake are modifiable risk factors for hypertension. These are of the utmost importance because they can be changed or modified by the individual through a regular exercise program and careful monitoring of sodium intake. Protein intake has no relationship to hypertension.
The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? - "Pulse rate will increase." - "Blood pressure will decrease." - "Edema will be present in the legs." - "Crackles in the lungs will be present."
"Pulse rate will increase." The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid overload.
The registered nurse (RN) is listening to a lecture on pulmonary edema. Which statement by the RN indicates that the teaching has been effective? - "The client may have mild anxiety." - "The client will not experience anxiety." - "The client will experience extreme anxiety." - "The client will only experience anxiety in a stressful environment."
"The client will experience extreme anxiety." Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering. Therefore, the client will experience extreme anxiety.
A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective? - "The peripheral arteries and veins; when stimulated they cause vasoconstriction." - "Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." - "The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." - "Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation."
"The peripheral arteries and veins; when stimulated they cause vasoconstriction." Found in the peripheral arteries and veins, alpha-adrenergic receptors cause a powerful vasoconstriction when stimulated. The remaining options are incorrect statements.
A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? - "Apply warm packs to the leg." - "Keep the leg elevated as much as possible." - "Your primary health care provider needs to be contacted to report this problem." - "This normally occurs after surgery and will subside when the edema goes down."
"Your primary health care provider needs to be contacted to report this problem." A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. The remaining options are inaccurate responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential complications include bruising, tightness along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy the varices and then removes the pieces via aspiration.
The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. - Soak the feet in hot water daily. - Be careful not to injure the legs or feet. - Use a heating pad on the legs to aid vasodilation. - Walk each day to increase circulation to the legs. - Cut down on the amount of fats consumed in the diet.
- Be careful not to injure the legs or feet. - Walk each day to increase circulation to the legs. - Cut down on the amount of fats consumed in the diet. Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity are contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.
The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse anticipate the physician to most likely prescribe? Select all that apply. - Strict bedrest - Elevation of the right leg - Administration of acetaminophen - Application of moist heat to the right leg - Monitoring for signs of pulmonary embolism
- Elevation of the right leg - Administration of acetaminophen - Application of moist heat to the right leg - Monitoring for signs of pulmonary embolism Standard management for the client with DVT includes maintaining the activity level as prescribed by the physician; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Strict bedrest is not likely to be prescribed; recent research is showing that ambulation does not cause pulmonary embolism and does not cause the existing DVT to worsen. Additionally, bedrest can cause complications such as skin integrity problems, weakness due to immobility, and respiratory problems.
The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. - Emotional stress - Atrial fibrillation - Nutritional anemia - Peptic ulcer disease - Recent upper respiratory infection
- Emotional stress - Atrial fibrillation - Nutritional anemia - Recent upper respiratory infection Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. Peptic ulcer disease is not an exacerbating factor.
The primary health care provider prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. - Encourage coughing with deep breathing. - Place in high-Fowler's position for eating. - Encourage increased oral intake of water daily. - Place thigh-length elastic stockings on the client. - Place sequential compression boots on the client. - Encourage the intake of dark green, leafy vegetables.
- Encourage coughing with deep breathing. - Encourage increased oral intake of water daily. - Place thigh-length elastic stockings on the client. The client with DVT may require bed rest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bed rest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with high-Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.
The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? - 1+ edema - 2+ edema - 3+ edema - 4+ edema
1+ edema Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.
A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin, which laboratory result should the nurse review as the priority? - Sodium level - Digoxin level - Creatinine level - Potassium level
Potassium level Diuretic therapy can cause hypokalemia. The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.
The nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin notes that the heart rate is 52 beats/min. The nurse should make which interpretation of this information? - Normal, because of the client's age - Abnormal, requiring further assessment - Normal, as a result of the effects of digoxin - Normal, because this is the reason the client is receiving digoxin
Abnormal, requiring further assessment The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would report the finding to the primary health care provider for further instruction. The remaining options are incorrect interpretations because the heart rate of 52 beats/min is not normal.
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? - Hypovolemia - Acute kidney injury - Glomerulonephritis - Urinary tract infection
Acute kidney injury The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine, male, 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.
A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? - Ambulates 10 feet (3 meters) farther each day - Verbalizes the benefits of increasing activity - Chooses a healthy diet that meets caloric needs - Sleeps without awakening throughout the night
Ambulates 10 feet (3 meters) farther each day Each of the options indicates a positive outcome on the part of the client. Both option 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more action-oriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping.
A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? - A stage 1 ulcer - A vascular ulcer - An arterial ulcer - A venous stasis ulcer
An arterial ulcer Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? - Bananas - Broccoli - Antacids - Cantaloupe
Antacids The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.
Endovenous laser treatment (EVLT) is done on a client with varicose veins. Which interventions should the nurse include in the postprocedure plan of care? - Inform the client that the EVLT procedure ensures closure of the treated vein. - Assess color and temperature of the affected limb to determine vascular status. - Teach the client the importance of using graduated compression stockings (GCSs) during the day. - Inform the client that circulation impairment and nerve damage is expected to occur following the procedure.
Assess color and temperature of the affected limb to determine vascular status. Endovenous laser treatment (EVLT) is a treatment for varicose veins that uses laser heat to ablate (occlude) the affected vessel. This procedure is less invasive than a ligation and removal of veins procedure. Using ultrasound guidance, the clinician advances a catheter into a vein (most commonly the saphenous vein) and injects an anesthetic agent around it. Then the vessel is ablated while the catheter is slowly removed. After the procedure, the client is taught the importance of using a GSC or other form of compression such as elastic compression bandages as prescribed for 24 hours a day (not just during the day), except for showers for at least the first week. A follow-up ultrasonography is done to ensure closure, so it is not appropriate to tell the client that the EVLT ensures closure; this needs to be verified. Circulation impairment is not expected. Nerve damage is not expected but can occur; if it does occur, it is usually temporary and minimal and resolves within a few months. The nurse needs to assess the vascular status of the affected limb and check for changes in color or temperature of the limb. The nurse would also monitor for pain, edema, and paresthesias that could indicate complications such as deep vein thrombosis or nerve damage.
The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect? - Asymptomatic - Shortness of breath - Visual disturbances - Frequent nosebleeds
Asymptomatic Hypertensive clients often have no symptoms until target organ involvement, which happens with very high blood pressure. This is why it is often noted as the "silent killer." The remaining options are incorrect because those clinical manifestations occur with severely high hypertension.
A client with a history of hypertension has been prescribed triamterene. The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit? - Pears - Apples - Bananas - Cranberries
Bananas Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, fresh oranges, mangos, nectarines, papayas, and prunes.
A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? - Ascites - Pedal edema - Bilateral lung crackles - Jugular vein distention
Bilateral lung crackles The client with heart failure may present with different symptoms, depending on whether the right side or the left side of the heart is failing. Adventitious breath sounds, such as crackles, are an indicator of decreased left-sided heart function. Peripheral edema, jugular vein distention, and ascites all can be present because of insufficiency of the pumping action of the right side of the heart.
The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? - Breath sounds - Peripheral edema - Hepatojugular reflux - Jugular vein distention
Breath sounds The client with heart failure may present with different signs and symptoms according to whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all indicators of impaired right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function.
A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? - Rhonchi - Wheezes - Crackles in the bases - Crackles throughout the lung fields
Crackles in the bases Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields.
A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? - Left atrium - Right atrium - Left ventricle - Right ventricle
Left ventricle Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. The remaining options are not the chambers that are primarily responsible for this disease process, although these chambers may be affected as the disease becomes more chronic.
The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? - Keep the legs aligned with the heart. - Elevate the legs higher than the heart. - Clean the skin with alcohol every hour. - Position the client onto the side during every shift.
Elevate the legs higher than the heart. In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.
The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? - Restricting fluids - Placing a pillow under the knees - Encouraging active range-of-motion exercises - Applying a heating pad to the lower extremities
Encouraging active range-of-motion exercises Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a primary health care provider's prescription.
The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? - Age - Hypertension - Hyperlipidemia - Glucose intolerance
Glucose intolerance Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors for CAD. Age is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.
A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? - Bilateral edema - Increased calf circumference - Diminished distal peripheral pulses - Coolness and pallor of the affected limb
Increased calf circumference The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.
Spironolactone is prescribed for a client with heart failure. In providing dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which electrolyte? - Calcium - Potassium - Magnesium - Phosphorus
Potassium Spironolactone is a potassium-retaining diuretic, and the client should avoid foods high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could develop. The client does not need to avoid foods that contain calcium, magnesium, or phosphorus while taking this medication.
The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? - Walk for as long as possible each day. - Cross the legs at the ankle only, not at the knee. - Sit in a chair 3 times a day for 3 hours at a time. - Lie down with the legs elevated and avoid sitting.
Lie down with the legs elevated and avoid sitting. The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless performing a specific activity for the first few days after the procedure. Prolonged standing or sitting increases the risk of edema in the legs by decreasing blood return to the heart. The client should avoid crossing the legs at any level for the same reason.
The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? - Listening to lung sounds - Palpating for organomegaly - Assessing for jugular vein distention - Assessing for peripheral and sacral edema
Listening to lung sounds The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.
The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan? - Maintain activity level as prescribed. - Maintain the affected leg in a dependent position. - Administer an opioid analgesic every 4 hours around the clock. - Apply cool packs to the affected leg for 20 minutes every 4 hours.
Maintain activity level as prescribed. Standard management for the client with DVT includes maintaining the activity level as prescribed by the PHCP; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse should maintain the prescribed activity level. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? - Glipizide - Metformin - Repaglinide - Regular insulin
Metformin Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of a contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.
A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? - Apnea monitor - Oxygen flowmeter - Telemetry cardiac monitor - Oxygen saturation monitor
Oxygen saturation monitor
The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? - Checking for a rash on the digits - Observing for softening of the nails or nail beds - Palpating for a rapid or irregular peripheral pulse - Palpating for diminished or absent peripheral pulses
Palpating for diminished or absent peripheral pulses Raynaud's disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit? - 4+ edema noted in lower extremities - Crackles auscultated from lung bases to apices - Blood pressure rises from 116/68 to 118/74 mm Hg - Pulse rate increases from 100 beats/min to 136 beats/min
Pulse rate increases from 100 beats/min to 136 beats/min The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for decreases in fluid volume. Options 1 and 2 may be noted in fluid overload. A low blood pressure is expected in a postoperative client who lost a significant amount of blood.
A client is having a follow-up primary health care provider (PHCP) office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which would be an appropriate action by the nurse based on evaluation of the client's comment? - Report the complaint to the PHCP. - Instruct the client to apply warm packs. - Reassure the client that this is only temporary. - Advise the client to take acetaminophen until it is gone.
Report the complaint to the PHCP. Hypersensitivity or a sensation of pins and needles in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Although complications from this surgery can occur, they are relatively rare so this symptom should be reported. The actions in the remaining options are incorrect and could be harmful; in addition, they delay the possible need for intervention about the client's complaint. Although nerve damage can occur and is usually temporary and minimal and resolves within a few months, it is not appropriate to tell the client that this occurrence is only temporary. The complaint needs to be further assessed.
A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? - Oxygen saturation decreased from 96% to 91%. - Pulse rate increased from 80 to 104 beats per minute. - Blood pressure decreased from 140/86 to 112/72 mm Hg. - Respiratory rate increased from 16 to 19 breaths per minute.
Respiratory rate increased from 16 to 19 breaths per minute. Vital signs that remain near baseline indicate good cardiac reserve with exercise. Only the respiratory rate remains within the normal range. In addition, it reflects a minimal increase. A pulse rate increase to a rate more than 100 beats per minute during mild exercise does not show tolerance, nor does a 5% decrease in oxygen saturation levels. In addition, blood pressure decreasing by more than 10 mm Hg is not a sign indicating tolerance of activity.
The nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do first? - Review intake and output records for the last 2 days. - Prescribe daily weights starting on the following morning. - Request a sodium restriction of 1 g/day from the cardiologist. - Change the time of diuretic administration from morning to evening.
Review intake and output records for the last 2 days. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Therefore, the nurse should review intake and output records for the last 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.
The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? - Use nail polish to protect the nail beds from injury. - Wear gloves for all activities involving the use of both hands. - Stop smoking because it causes cutaneous blood vessel spasm. - Always wear warm clothing, even in warm climates, to prevent vasoconstriction.
Stop smoking because it causes cutaneous blood vessel spasm. Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. It is not necessary to wear gloves for all activities, nor should warm clothing be worn in warm climates.
After instruction on the application of antiembolism stockings, the nurse determines that the client requires further teaching if which of these actions is performed? - The client puts on the stockings before getting out of bed. - The client bunches up the stockings for easier application. - The client ensures that stockings are pulled up all the way. - The client ensures that the rough seams of the stockings are on the outside.
The client bunches up the stockings for easier application. When applying antiembolism stockings, the client should not bunch up the stockings. Instead, the client should place the hand inside the stocking and pull the heel out. The foot of the stocking should then be placed over the client's foot and the rest of the stocking pulled up the leg. This will help to prevent wrinkling and twisting of the stocking. The remaining options demonstrate correct application of the stockings.
A client's total cholesterol level is 344 mg/dL (8.6 mmol/L), low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL (4.25 mmol/L), and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL (1.2 mmol/L). Based on analysis of the data, how should the nurse direct client teaching? - The client should maintain the current dietary regimen but increase activity level. - Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time. - The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught. - The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen.
The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught. In the absence of documented cardiovascular disease, the desired goal is to have the total cholesterol level lower than 200 mg/dL (<5 mmol/L). A desired LDL-C level for all individuals is lower than 100 mg/dL (<2.59 mmol/L), and a desirable HDL-C level is higher than 40 mg/dL (>1.55 mmol/L). Because the client's levels are outside the range to a significant degree for all three values, the client is at high risk for developing cardiovascular disease and requires teaching on risk factor reduction.
The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving intravenous doses of furosemide. The client is attached to cardiac telemetry, and the nurse is monitoring the client's cardiac status. The nurse notes that the client's cardiac rhythm has changed to this pattern. The nurse determines that the most likely cause of this cardiac rhythm in the client is which problem? - Pacemaker dysfunction - The presence of hypokalemia - The effectiveness of the furosemide - An impending myocardial infarction (MI)
The presence of hypokalemia This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs). PVCs may be insignificant, or they may occur with myocardial ischemia or MI; heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, a diuretic that causes the excretion of potassium. The most likely cause of the PVCs in this client is hypokalemia. Option 3 is an incorrect interpretation. The question presents no data indicating that this client has a pacemaker or has signs or symptoms of an impending MI.
The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? - Using a bedside commode - Sleeping in the supine position - Elevating the legs when in bed - Using seasonings to improve the taste of food
Using a bedside commode Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. The supine position increases respiratory effort and decreases oxygenation. Elevating the client's legs increases venous return to the heart thus increasing cardiac workload. Seasonings may be high in sodium and promote further fluid retention.
A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? - Eat breakfast just before the procedure. - Wear firm, rigid shoes, such as work boots. - Wear loose clothing with a shirt that buttons in front. - Avoid cigarettes for 30 minutes before the procedure.
Wear loose clothing with a shirt that buttons in front. The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that buttons in the front. The client should receive nothing by mouth after bedtime or for a minimum of 2 hours before the test. The client should wear rubber-soled, supportive shoes, such as athletic training shoes. The client should avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with the potential for a false-positive result.
A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? - Weigh self on a daily basis. - Sleep with the head of the bed flat. - Take a double dose of the diuretic if peripheral edema is noted. - Withhold prescribed digoxin if slight respiratory distress occurs.
Weigh self on a daily basis. The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported to the primary health care provider (PHCP). The client should sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the PHCP.
