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.) graphic INCORRECT The nurse should inspect this location to assess for pulsations of the tricuspid area of the heart, which is located in the fifth intercostal space to the left of the sternal border.
A nurse is caring for a client who has dilated cardiomyopathy. The client reports increasing difficulty completing her daily 1-mile walks. The nurse should recognize that this is a finding of which of the following? graphic •Left ventricular failure Activity intolerance is a finding of left ventricular failure and is associated with dilated cardiomyopathy. Peripheral vasodilation INCORRECT Peripheral vasodilation is not a finding associated with dilated cardiomyopathy. Pericardial effusion INCORRECT Pericardial effusion is not a finding associated with dilated cardiomyopathy. Decreased vascular volume INCORRECT Decreased vascular volume is not a finding associated with dilated cardiomyopathy.
A nurse is caring for a client who presents to the emergency department with a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? graphic •Obtain blood samples for laboratory testing. INCORRECT The nurse should obtain blood samples for laboratory testing, such as cholesterol and glucose. However, this is not the first action the nurse should take. Tell the client to report vision changes. INCORRECT The nurse should tell the client to report vision changes as part of monitoring for the complications of hypertension. However, this is not the first action the nurse should take. Place the head of the bed at 45°. CORRECT The first action the nurse should take when using the airway, breathing, circulation approach to client care is to place the head of the client's bed at 45°. This improves respiratory status and promotes venous return to reduce workload on the heart. Initiate an IV. INCORRECT The nurse should initiate an IV to provide access for medication administration. However, this is not the first action the nurse should take.
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find? graphic •Increased abdominal girth INCORRECT Increased abdominal girth is a finding related to systemic congestion resulting from right-sided heart failure. Weak peripheral pulses CORRECT Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. Jugular venous neck distention INCORRECT Jugular venous neck distention is a finding related to systemic congestion resulting from right-sided heart failure. Dependent edema INCORRECT Dependent edema is a finding related to systemic congestion resulting from right-sided heart failure.
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? graphic •Serosanguineous drainage on dressing INCORRECT Serosanguineous drainage during the first postoperative hours is expected and is not a sign of shock. Severe pain with coughing INCORRECT Coughing is painful after an aortic aneurysm repair. However, it is not associated with shock. Urine output of 20 mL/hr CORRECT Urine output less than 30 mL/hr can indicate shock because it reflects decreased blood flow to the kidneys, possibly from graft rupture and hemorrhage. Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F) INCORRECT A moderate change in temperature is not associated with shock.
A nurse is caring for a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? graphic •Hemoglobin 14 g/dL INCORRECT The nurse should recognize a hemoglobin level of 14 g/dL is within the expected reference range and is desired. However, this is not the best evidence of effective warfarin therapy. Minimal bruising of extremities INCORRECT The nurse should recognize that minimal bruising or no bruising is desired. However, this is not the best evidence of effective warfarin therapy. Reduced circumference of affected extremity INCORRECT The nurse should recognize that decreased circumference of the affected extremity is a desired effect. However, this is not the best evidence of effective warfarin therapy. INR 2.5 CORRECT The nurse should determine that an INR of 2.5 is within the desired therapeutic range and is the best evidence of effective warfarin therapy.
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 of the following laboratory values? graphic •Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL INCORRECT These laboratory values do not indicate the need for dietary teaching. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL INCORRECT These laboratory values do not indicate the need for dietary teaching. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL CORRECT The expected reference range of cholesterol is less than 200 mg/dL, HDL above 40 mg/dL, and LDL less than 100 mg/dL. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL INCORRECT These laboratory values do not indicate the need for dietary teaching.
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? graphic •Mediastinal drainage 100 mL/hr INCORRECT Mediastinal drainage of up to 150 mL/hr is expected during this time. Blood pressure 160/80 mm Hg CORRECT The nurse should report an elevated blood pressure following a CABG procedure because increased vascular pressure can cause bleeding at the incision sites. Temperature 37.1° C (98.8° F) INCORRECT A body temperature within the expected reference range is anticipated following a CABG procedure. Potassium 3.8 mEq/L INCORRECT A potassium level of 3.8 mEq/L is within the expected reference range.
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? graphic •"My arthritis is really bothering me because I haven't taken my aspirin in a week." INCORRECT Clients scheduled for a CABG should not take aspirin for 5 to 7 days prior to the surgery to prevent excessive bleeding. "My blood pressure shouldn't be high because I took my blood pressure medication this morning." INCORRECT Medication to treat high blood pressure may be given prior to surgery if indicated by the provider. "I took my warfarin last night according to my usual schedule." CORRECT Clients scheduled for a CABG should not take anticoagulants, such as warfarin, for 5 to 7 days prior to the surgery to prevent excessive bleeding. "I will check my blood sugar because I took a reduced dose of insulin this morning." INCORRECT Clients scheduled for a CABG who take insulin can be given a reduced dose of insulin the morning of surgery to regulate blood glucose.
A nurse in the emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals she is 1 week postoperative open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? graphic •Administering IV morphine sulfate INCORRECT Administering IV morphine is an appropriate intervention for pain management. Administering oxygen at 2 L/min via nasal cannula INCORRECT Supplemental oxygen can increase myocardial tissue perfusion and is an appropriate intervention to assist the client. Helping the client to the bedside commode INCORRECT Using a bedside commode is less stressful than using a bedpan, and most clients are allowed to use a commode following a myocardial infarction. Assisting with thrombolytic therapy CORRECT The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
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? graphic •Slurred speech The greatest risk to this client is injury from an embolus caused by the atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. The nurse should report this finding to the provider immediately. Irregular pulse INCORRECT An irregular pulse, an expected finding for a client who has atrial fibrillation, indicates the client is at risk for inadequate cardiac output, but another finding is the priority. Dependent edema INCORRECT Dependent edema, an expected finding for a client who has heart failure, indicates the client is at risk for inadequate circulation, but another finding is the priority. Persistent fatigue INCORRECT Fatigue, an expected finding for a client who has heart failure, indicates the client is at risk for inadequate cardiac output, but another finding is the priority.
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? graphic •Tendon pain INCORRECT Tendonitis is not an adverse effect of ACE inhibitors. Persistent cough CORRECT A persistent cough is an adverse effect of ACE inhibitors, and the client should discontinue the medication if it occurs. Frequent urination INCORRECT Frequent urination is an expected outcome of this medication. Constipation INCORRECT Constipation is a common adverse effect of calcium-channel blockers, but it is not an adverse effect of ACE inhibitors.
A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect? graphic •Confusion Bradydysrhythmia can cause decreased tissue perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status. Friction rub INCORRECT The nurse should expect to hear a friction rub during cardiac auscultation on a client who has pericarditis. Hypertension INCORRECT The nurse should monitor the client who has a bradydysrhythmia for hypotension. Dry skin INCORRECT The nurse should monitor the client who has a bradydysrhythmia for diaphoresis.
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? graphic •Increase the heparin infusion flow rate by 2 mL/hr. INCORRECT Increasing the heparin infusion flow rate is not the appropriate action to take. Continue to monitor the heparin infusion as prescribed. INCORRECT Continuing to monitor the heparin infusion as prescribed is not the appropriate action to take. Request a prothrombin time (PT). INCORRECT Although the nurse should monitor PT in a client who is taking warfarin, it is not appropriate to request a PT level before taking any corrective action. Stop the heparin infusion. CORRECT The aPTT level is above the therapeutic range of 1.5 to 2 times the control value. The nurse should discontinue the heparin infusion immediately and notify the provider to prevent harm to the client.
A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? graphic •A client who has hypothyroidism INCORRECT Hypothyroidism is not associated with peripheral arterial disease. A client who has diabetes mellitus CORRECT Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease. A client whose daily caloric intake consists of 25% fat INCORRECT Twenty-five percent is within the recommended range for daily fat intake and diet does not place the client at risk for development of peripheral arterial disease. A client who consumes two bottles of beer a day INCORRECT Two bottles of beer a day is considered moderate alcohol intake and does not place the client at risk for development of peripheral arterial disease.
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 heart rate of 200 to 210/min and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions? graphic •Delivery of a precordial thump INCORRECT Supraventricular tachycardia does not require a precordial thump. Vagal stimulation CORRECT Vagal stimulation can help the client's heart return to a normal sinus rhythm temporarily. Administration of atropine IV INCORRECT Supraventricular tachycardia does not require atropine. Defibrillation INCORRECT Supraventricular tachycardia does not require defibrillation.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? graphic •Ventricular depolarization INCORRECT Ventricular depolarization occurs during a normal cardiac cycle and is not a potential complication of endocarditis. Guillain-Barré syndrome INCORRECT Guillain-Barré syndrome is not a potential complication of endocarditis. Myelodysplastic syndrome INCORRECT Myelodysplastic syndrome is not a potential complication of endocarditis. Valvular disease CORRECT Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is caring for a client who is being treated for heart failure and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications? graphic •Shortness of breath INCORRECT Digoxin and furosemide are used to manage shortness of breath secondary to heart failure. This is not an adverse reaction to these medications. Lightheadedness CORRECT Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness. Dry cough INCORRECT A dry cough is not an adverse reaction to digoxin and furosemide. Metallic taste INCORRECT A metallic taste is not an adverse reaction to digoxin and furosemide.
A nurse is caring for a client who has a history of angina and is scheduled for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? graphic •"I'm still hungry after the bowl of cereal I ate at 7 a.m." INCORRECT It is not necessary for the client to be NPO prior to this procedure. "I didn't take my heart pills this morning because the doctor told me not to." INCORRECT It is appropriate for the client to be instructed not to take cardiac medication prior to this procedure. "I have had chest pain a couple of times since I saw my doctor in the office last week." INCORRECT Episodes of chest pain are not a contraindication to this test. "I smoked a cigarette this morning to calm my nerves about having this procedure." CORRECT Smoking prior to the test can change the outcome and places the client at additional risk, so the test should be rescheduled.
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? graphic •"I can't get rid of these hiccups." Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can indicate a complication such as lead wire perforation. "I feel dizzy when I stand." INCORRECT Dizziness is not a complication of the insertion procedure and can be expected initially as the client adjusts to the pacemaker. "My incision site stings." INCORRECT Pain or stinging at the incision site is an expected finding after insertion of a permanent pacemaker. "I have a headache." INCORRECT Headache is not a complication of the insertion procedure. However, it might be related to other disease processes.
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? graphic •Weight gain of 0.9 kg (2 lb) in 24 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately. Increase of 10 mm Hg in systolic blood pressure INCORRECT An increase of 10 mm Hg in systolic blood pressure is a nonurgent finding. Although the client should note the increase in blood pressure, the client does not need to report this finding immediately. Dyspnea with exertion INCORRECT Dyspnea with exertion is a nonurgent finding, and the client does not need to report it immediately. Dizziness when rising quickly INCORRECT Dizziness when rising quickly is a nonurgent finding that is expected for a client who is taking medications to treat heart failure. The client does not need to report this finding immediately.
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.) graphic CORRECT The nurse should examine this area of the rhythm strip to evaluate for atrial depolarization.
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.) graphic ✓Limited alcohol intake ✓Regular exercise program Decreased magnesium intake Reduced potassium intake Smoking cessation INCORRECT Limited alcohol intake is correct. Clients who have hypertension should limit alcohol intake. Regular exercise program is correct. A regular exercise program will help reduce blood pressure. Decreased magnesium intake is incorrect. Low magnesium intake is associated with hypertension. Reduced potassium intake is incorrect. Low potassium intake is associated with hypertension. Smoking cessation is correct. Smoking exacerbates hypertension.
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? graphic •Hemoglobin 14.4 g/dL INCORRECT A hemoglobin level of 14.4 g/dL is within the expected reference range. History of peripheral arterial disease INCORRECT This procedure involves access through large arteries or veins into the heart and is not affected by peripheral arterial disease. Urine output 200 mL/4 hr INCORRECT An output of 200 mL in 4 hr is within the expected reference range. Previous allergic reaction to shellfish CORRECT The contrast medium used is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine.
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? graphic •Apply the new patch to the same site as the previous patch. INCORRECT Rotating the patch site can help prevent skin irritation. Place the patch on an area of skin away from skin folds and joints. CORRECT The client should apply the patch to an area of skin that is not prone to movement or wrinkling. Keep the patch on 24 hr per day. INCORRECT The client should have a patch-free interval of 10 to 12 hr per day to help prevent tolerance to the medication. Replace the patch at the onset of angina. INCORRECT The nurse should emphasize that nitroglycerin patches offer ongoing prevention of angina attacks. The patches do not treat angina attacks because they do not take effect immediately.
A nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade? graphic •Sternal instability INCORRECT Sternal instability is an expected finding because of the incision through the sternum during surgery. Increased WBC count INCORRECT An increased WBC count can indicate an infection. Blood pressure 140/82 mm Hg on inspiration and 154/90 mm Hg on expiration CORRECT Pulsus paradoxus, when the systolic blood pressure is 10 mm Hg or higher on expiration than on inspiration, is an indicator of cardiac tamponade. Sinus rhythm with occasional premature atrial contractions and heart rate 88/min INCORRECT Premature atrial contractions with a heart rate within the expected reference range can be caused by caffeine intake and lack of sleep.
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? graphic •Explore the client's family history of peripheral vascular disease. INCORRECT Family history is important, but it does not help to differentiate between arterial and venous ulcers. Note the presence or absence of pain at the ulcer site. INCORRECT Both arterial and venous ulcers cause varying degrees of pain or discomfort. Inquire about the presence or absence of claudication. CORRECT Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not. Ask if the client has had a recent infection. INCORRECT Both arterial and venous ulcers have the potential to become infected.
A nurse is caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client? graphic •Neck vein distention INCORRECT The client is at risk for neck vein distention because of hypervolemia, but it is not the priority assessment. Bowel sounds INCORRECT The client is at risk for reduced bowel sounds because of reduced perfusion, but it is not the priority assessment. Peripheral edema INCORRECT The client is at risk for peripheral edema because of reduced cardiac output, but it is not the priority assessment. Urine output CORRECT The greatest risk to this client is graft occlusion or rupture. Therefore, monitoring urine output, which reflects blood flow to the kidneys, is the priority assessment.
A nurse providing teaching for a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching? graphic •"You may no longer be able to feel chest pain." Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart. "Your level of activity intolerance will not change." INCORRECT The client's activity tolerance should gradually improve as the healing process progresses. "After 6 months, you will no longer need to restrict your sodium intake." INCORRECT The client will need to permanently maintain a diet that is restricted in sodium and fat. "You will be able to stop taking immunosuppressants after 12 months." INCORRECT The client will remain on immunosuppressants for the remainder of his life to help prevent rejection of the heart.
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 myocardial infarction (MI)? graphic •Myoglobin INCORRECT Elevated myoglobin is found after an MI, but it is not specific to the cardiac muscle and can increase if other muscles are injured. C-reactive protein INCORRECT C-reactive protein increases soon after the beginning of an inflammatory process, such as rheumatoid arthritis, and is not specific to cardiac muscle. Creatine kinase-MB CORRECT Creatine kinase-MB is the isoenzyme specific to the myocardium and is elevated when that muscle is injured. Homocysteine INCORRECT Homocysteine is always present in the blood. An increased level can be a risk factor marker for the development of cardiovascular disease.