MED SURG chapters 36,38 & 40
Terms in this set (103)
A client's cardiac status is being observed by telemetry monitoring. The nurse observes a P wave that changes shape in lead II. What conclusion does the nurse make about the P wave?
a. It originates from an ectopic focus.
b. The P wave was replaced by U waves.
c. It is from the sinoatrial (SA) node.
d. Multiple P waves are present.
The nurse is assessing the client's electrocardiography (ECG). What does the P wave on the ECG tracing represent?
a. Contraction of the atria
b. Contraction of the ventricles
c. Depolarization of the atria
d. Depolarization of the ventricles
A nurse notes that the PR interval on a client's electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take?
a. Assess serum cardiac enzymes.
b. Administer 1 mg epinephrine IV.
c. Administer oxygen via nasal cannula.
d. Document the finding in the client's chart.
When analyzing a client's electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The client's chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites.
The nurse observes a prominent U wave on the client's electrocardiograph (ECG) tracing. What is the most appropriate action for the nurse to take?
a. Document the finding as a normal variant.
b. Review the client's daily electrolyte results.
c. Move the crash cart closer to the client's room.
d. Call for an immediate electrocardiogram.
The client's heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take?
a. Evaluate for a respirator disorder.
b. Assess the client for chest pain.
c. Document the finding in the chart.
d. Administer antidysrhythmic drugs.
A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse?
a. Mid-sternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave
A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer?
a. Atropine (Atropine)
b. Digoxin (Lanoxin)
c. Lidocaine (Xylocaine)
d. Metoprolol (Lopressor)
A client experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. What instruction does the nurse include in the client's teaching plan?
a. "Minimize or abstain from caffeine."
b. "Lie on your side until the attack subsides."
c. "Use your oxygen when you experience PACs."
d. "Take quinidine (Cardioquin) daily to prevent PACs."
The nurse identifies a client's rhythm to be a sustained supraventricular tachycardia. What medication does the nurse administer?
a. Atropine (Atropine)
b. Epinephrine (Adrenalin)
c. Lidocaine (Xylocaine)
d. Diltiazem (Cardizem)
A client has a heart rate averaging 56 beats/min with no adverse symptoms. What activity modifications does the nurse suggest to avoid further slowing of the heart rate?
a. "Make certain that your bath water is warm (100° F)."
b. "Avoid bearing down or straining while having a bowel movement."
c. "Avoid strenuous exercise, such as running, during the late afternoon."
d. "Limit your intake of caffeinated drinks to no more than 2 cups per day."
The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation?
a. Middle-aged client who takes an aspirin daily
b. Client who is dismissed after coronary artery bypass surgery
c. Older adult client after a carotid endarterectomy
d. Client with chronic obstructive pulmonary disease
The nurse is caring for a client on a cardiac monitor. The monitor shows a rapid rhythm with a "saw tooth" configuration. What physical assessment findings does the nurse expect?
a. Presence of a split S1 and wheezing
b. Anorexia and gastric distress
c. Shortness of breath and anxiety
d. Hypertension and mental status changes
The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
d. Dyspnea with activity
The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition?
a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Atropine)
d. Lidocaine (Xylocaine)
The nurse is caring for a client admitted for myocardial infarction. The client's monitor shows frequent premature ventricular contractions (PVCs). What dysrhythmia does the nurse remain alert for?
a. Sinus tachycardia
b. Rapid atrial flutter
c. Ventricular tachycardia
d. Atrioventricular junctional rhythm
A client with myocardial ischemia is having frequent early, wide ventricular complexes seen on the cardiac monitor. Which medication does the nurse administer?
a. Lanoxin (Digoxin)
b. Amiodarone (Cordarone)
c. Dobutamine (Dobutamine)
d. Atropine sulfate (Atropisol)
The nurse has administered adenosine (Adenocard). What is the expected therapeutic response?
a. Increased intraocular pressure
b. A brief tonic-clonic seizure
c. A short period of asystole
d. Hypertensive crisis
A client's electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurse's first action?
a. Assess airway, breathing, and level of consciousness.
b. Administer an amiodarone bolus followed by a drip.
c. Cardiovert the client with a biphasic defibrillator.
d. Begin cardiopulmonary resuscitation (CPR).
A client with unstable ventricular tachycardia is receiving amiodarone by intravenous infusion. The nurse notes that the client's heart rate has decreased from 68 to 50 beats/min. The client is asymptomatic. What is the nurse's priority intervention?
a. Stop the infusion and flush the IV.
b. Slow the amiodarone infusion rate.
c. Administer a precordial thump.
d. Place the client in a side-lying position.
A client with ischemic heart disease has an electrocardiograph (ECG) tracing that shows a PR interval of 0.24 second. What is the nurse's best action?
a. Document the finding in the chart.
b. Measure blood pressure.
c. Notify the health care provider.
d. Administer oxygen.
The physician is about to perform carotid sinus massage on a client with supraventricular tachycardia. What equipment is most important for the nurse to have ready?
a. Emesis basin
b. Magnesium sulfate
c. Resuscitation cart
d. Padded tongue blade
The nurse is caring for a client with a complete heart block (third-degree atrioventricular [AV] block). What is the nurse's priority intervention?
a. Perform a cardioversion.
b. Assist with carotid massage.
c. Begin external pacing.
d. Administer adenosine (Adenocard) IV.
A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability
The nurse is caring for a client with a temporary pacemaker. The client's bedside monitor shows a spike followed by a QRS complex. What is the nurse's best action?
a. Remove the pacemaker; it is not needed.
b. Decrease the threshold of the pacemaker.
c. Document the finding in the client's chart.
d. Set the pacemaker to the synchronous mode.
A client with ventricular tachycardia (VT) is unresponsive and has no pulse. The nurse calls for assistance and a defibrillator. What is the nurse's priority intervention while waiting for the defibrillator to arrive?
a. Perform a pericardial thump.
b. Initiate cardiopulmonary resuscitation.
c. Start an 18-gauge IV in the antecubital.
d. Ask the client's family about code status.
A client has an epicardial pacemaker. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiograph (ECG) tracing. How does the nurse interpret this event?
a. Loss of capture
b. Ventricular fibrillation
c. Failure to sense
d. A normal tracing
The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating a client?
a. Make sure the defibrillator is set to the synchronous mode.
b. Deliver a precordial thump to the upper portion of the sternum.
c. Test the equipment by delivering a smaller shock at 100 J.
d. Ensure that all personnel are clear of contact with the client and the bed.
The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately?
a. 2/4 bilateral peripheral edema
b. Heart rate of 56 beats/min
c. Temperature of 96° F (35.5° C)
d. Muffled heart sounds
A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the client's discharge teaching?
a. "Do not submerge your pacemaker, take only showers."
b. "Report pulse rates lower than your pacemaker setting."
c. "If you feel weak, apply pressure over your generator."
d. "Have your pacemaker turned off before having an MRI."
The nurse is providing discharge instructions for a client with an implantable cardioverter-defibrillator (ICD). What statement by the client indicates a good understanding of the instructions?
a. "I should wear a snug-fitting shirt over the ICD."
b. "I will avoid sources of strong electromagnetic fields."
c. "I can't perform activities that increase my heart rate."
d. "Now I can discontinue my antidysrhythmic medication."
A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? (Select all that apply.)
a. Decrease in cardiac output
b. Increase in cardiac output
c. Increase in blood pressure
d. Decrease in blood pressure
e. Increase in urine output
A client with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurse's best response?
a. "Injury to the arteries causes them to spasm, reducing blood flow to the extremities."
b. "Excess fats in your diet are stored in the lining of your arteries, causing them to constrict."
c. "A combination of platelets and fats accumulates, narrowing the artery and reducing blood flow."
d. "Excess sodium causes injury to the arteries, reducing blood flow and eventually causing obstruction."
The nurse is working with clients at a health fair. Which teaching takes priority to reduce the risk of atherosclerosis?
a. Instructing a diabetic client not to smoke or use any tobacco
b. Teaching diet changes to a client with elevated cholesterol levels
c. Suggesting limiting alcohol to an older client with hypolipidemia
d. Encouraging exercise to an obese client who lives a sedentary lifestyle
A client with hyperlipidemia who is being treated with dietary fat restrictions and an exercise program asks the nurse why his serum lipid levels are still elevated. What activity by the nurse is most appropriate?
a. Developing a very low-fat diet that the client will adhere to
b. Explaining familial tendencies in hyperlipidemia
c. Referring the client to a registered dietitian for weight loss
d. Educating the client on antihyperlipidemic medications
A client with atherosclerosis is attempting to stop cigarette smoking with the use of a nicotine patch. Which statement by the client indicates a good understanding of smoking cessation education?
a. "Abruptly discontinuing this patch can cause high blood pressure."
b. "Abruptly discontinuing this patch can cause nausea and vomiting."
c. "Smoking while using this patch increases the risk of respiratory infection."
d. "Smoking while using this patch increases the risk of a heart attack."
A client with hypercholesterolemia and atherosclerosis is prescribed nicotinic acid (Niaspan). Which instruction does the nurse provide the client?
a. "This medication may make you flush."
b. "Take this medication on an empty stomach."
c. "You will not need to change your diet with this medication."
d. "Take this medication when you experience chest pain."
The nurse incorporates dietary teaching into the plan for a client with a low-density lipoprotein (LDL) level of 158 mg/dL. What dietary instruction by the nurse is most appropriate?
a. "You should keep your saturated fat intake below 10% of your total calories."
b. "This result is normal, so continue your current dietary practices."
c. "Your total cholesterol intake should be less than 300 mg/day."
d. "You should restrict protein sources to fish and chicken only."
The nurse is assisting the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client?
a. Cheese omelet, skim milk, whole wheat toast, coffee
b. Skim milk, oatmeal, banana, orange juice, coffee
c. Whole wheat French toast, a side of bacon, coffee
d. Blueberry muffin, orange juice, decaffeinated coffee
The nurse is reviewing the menu selections of a client who has ordered a low-cholesterol diet. What meal items does the nurse question?
a. Vegetarian wrap
b. Cheesesteak sandwich
c. Fruit salad with yogurt
d. Grilled fish sandwich
After reviewing the client's chart upon admission to the unit, the nurse consults the health care provider about a new order for lovastatin (Mevacor). What triggered the nurse's action?
a. Blood glucose of 182 mg/dL
b. History of peptic ulcers
c. History of high cholesterol
d. Elevated liver enzymes
A client with high cholesterol is beginning treatment with simvastatin (Zocor). What priority instruction does the nurse give this client?
a. "Increase your intake of dietary fiber to minimize constipation."
b. "Take this drug on an empty stomach to promote absorption."
c. "Report any muscle tenderness to your health care provider."
d. "You may experience flushing of the skin with this medication."
A client has been diagnosed with Cushing's syndrome. What assessment does the nurse perform to detect vascular complications associated with this illness?
a. Auscultation of heart and lung sounds
b. Assessment of blood pressure
c. Daily weight using the same scale
d. Monitoring of urine output every 24 hours
The nurse is providing care for a client with hypertension. What priority physical assessment does the nurse include in examination of this client?
a. Skin examination for telangiectasia
b. Otoscopic examination of the inner ear
c. Funduscopic examination of the retina
d. Neurologic examination of the cranial nerves
The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions?
a. "I will give my canned soups to the food pantry."
b. "I'm going to miss my evening glass of wine."
c. "I will mostly use salt substitutes for flavoring."
d. "I can have regular coffee only in the morning."
The nurse is assessing a client's understanding of his hypertension therapy. What client statement indicates a need for further teaching?
a. "If I lose weight, I might be able to reduce my blood pressure medication."
b. "If my blood pressure stays under control, I will reduce my risk for a heart attack."
c. "When my blood pressure is normal, I will no longer need to take medication."
d. "When getting out of bed in the morning, I will sit for a few moments then stand."
A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention?
a. Take the client's apical pulse for 1 full minute before drug administration.
b. Place the client in Trendelenburg position to facilitate blood flow to the heart.
c. Educate the client to sit on the side of the bed for a few minutes before rising.
d. Instruct the client to drink 3 L of fluid daily when taking this medication.
The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?
a. Pedal edema is not present in the lower legs.
b. No complaints of sexual dysfunction occur.
c. No indication of renal impairment is present.
d. The blood pressure reading is 148/94 mm Hg.
The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with?
a. Diabetic foot ulceration
b. Peripheral arterial disease
c. Peripheral venous disease
d. Deep vein thrombosis
The nurse notes a venous ulcer on the client's left ankle. What additional assessment finding does the nurse expect in this client?
a. Absence of hair on the left lower extremity
b. Skin surrounding the ulcer mottled but blanchable
c. Brownish discoloration of the lower extremity
d. Cold and gray-blue lower extremity
A client with chronic peripheral arterial disease and claudication tells the nurse that burning pain often awakens him from sleep. What is the nurse's interpretation of this change?
a. The client has inflow disease.
b. The client has outflow disease.
c. The client's disease is worsening.
d. The client's disease is stable.
The nurse is educating a client before a right leg atherectomy. What priority education does the nurse provide?
a. "You may use the bathroom after the procedure."
b. "You will be sedated for 6 hours after the procedure."
c. "You will not need to take a daily aspirin anymore."
d. "You may be on heparin during the procedure."
The nurse is caring for a client with peripheral arterial disease. What priority nursing intervention does the nurse perform to promote vasodilation?
a. Increase the client's exercise regimen daily.
b. Apply a heating pad to the affected limb.
c. Administer an aspirin on a daily basis.
d. Educate the client to abstain from smoking.
The nurse is recovering a client with peripheral arterial disease who has just undergone percutaneous transluminal angioplasty. What complication does the nurse monitor for in the immediate postprocedure period?
c. Hypertensive crisis
d. Chest pain
The nurse is monitoring a client who has returned to the unit after arterial revascularization. The client reports pain in the affected limb that is similar to the pain experienced before the procedure. What is the nurse's best action?
a. Assess the peripheral pulses in the limb.
b. Elevate the affected extremity on pillows.
c. Administer pain medication as prescribed.
d. Place a warm blanket on the operative limb.
A client is recovering after an embolectomy. What clinical manifestations consistent with compartment syndrome does the nurse watch for?
a. Elevated temperature and excessive diaphoresis
b. Loss of sensation and pallor near the surgical site
c. Swelling, pain, and tension of the affected limb
d. Increased pulse and warmth below the surgical site
The nurse is caring for a client who develops compartment syndrome after an embolectomy for peripheral arterial disease. What is the nurse's best action?
a. Perform passive range-of-motion exercise to improve distal blood flow.
b. Prepare the client for return to the operative suite for surgical correction.
c. Medicate the client for pain and place the client in a knee-chest position.
d. Loosen the dressing and elevate the extremity to the level of the heart.
The new graduate nurse is assessing a client with an unrepaired abdominal aortic aneurysm. What assessment technique requires further education by the supervising nurse?
a. Measurement of abdominal girth
b. Observation of abdominal wall movement
c. Auscultation of any area of the abdomen
d. Palpation of the abdominal midline area
A client with a diagnosed abdominal aortic aneurysm (AAA) develops lower back pain radiating to the groin. What is the nurse's interpretation of this information?
a. The aneurysm clotted and is obstructing blood flow.
b. The aneurysm is expanding and is preparing to rupture.
c. The client feels the inflammation of the aneurysm.
d. This is a normal sensation associated with an AAA.
The nurse is preparing a client with an aortic aneurysm for surgery. The nurse notes that the client's systolic blood pressure has increased by 30 mm Hg compared with the reading 1 hour ago. What is the nurse's best action?
a. Measure abdominal girth.
b. Auscultate the abdomen.
c. Increase the IV infusion rate.
d. Reassess the blood pressure.
A nurse is recovering a client who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The client develops coolness of the extremities and reports a bloated feeling in the abdomen. What is the nurse's best action?
a. Measure the abdominal girth and check pulses.
b. Raise the head of the bed to 90 degrees.
c. Assess cardiac output and blood pressure.
d. Auscultate and then palpate the abdomen.
The nurse is providing discharge education to a client after repair of an abdominal aortic aneurysm (AAA). What priority instruction does the nurse include?
a. "No restrictions on driving your car are necessary."
b. "Avoid sleeping on your left side for 6 weeks."
c. "Avoid lifting heavy objects for about 3 months."
d. "You will have a distended abdomen for 2 weeks."
The nurse is caring for a client with Buerger's disease. What client education does the nurse provide to minimize disease progression?
a. "Keep environmental temperatures warm."
b. "Avoid highly stressful activities."
c. "Use a heating pad on your extremities."
d. "Abstain from all forms of tobacco."
The nurse is assessing the extremities of a client with Buerger's disease. What clinical manifestation does the nurse correlate with this disease?
a. Reddened, with diminished distal pulses
b. Cold and pale, with proximal bounding pulses
c. Cyanotic, with decreased deep tendon reflexes
d. Brownish discoloration, with pitting edema
The nurse is providing disease management education to a client with Raynaud's disease. What intervention does the nurse suggest to prevent complications of this disease?
a. "Take vasoconstrictive agents when you have symptoms."
b. "Wear warm clothing when exposed to cool temperatures."
c. "Avoid placing alcohol-based lotion on affected extremities."
d. "Check the strength of pulses in your arms and legs daily."
The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time?
a. 15 seconds
b. 30 seconds
c. 60 seconds
d. 150 seconds
The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action?
a. Administer both heparin and warfarin as prescribed.
b. Turn off the heparin before administering the warfarin.
c. Clarify the warfarin order with the nursing supervisor.
d. Hold the warfarin dose until the heparin is discontinued.
The nurse is discharging home a client at risk for venous thromboembolism (VTE) on low-molecular-weight heparin. What instruction does the nurse provide to this client?
a. "You must have your aPTT checked every 2 weeks."
b. "Massage the injection site after the heparin is injected."
c. "Notify your health care provider if your stools appear tarry."
d. "An IV catheter will be placed to administer your heparin."
The nurse is providing health education to a client with chronic venous stasis ulcers. What priority instruction does the nurse include?
a. "Apply antiembolism stockings before getting out of bed in the morning."
b. "Clean venous ulcers with Betadine before applying a dressing."
c. "Take 1 low-dose aspirin (81 mg) daily to prevent inflammation."
d. "Remove and reapply a new DuoDerm dressing to your ulcers each day."
The nurse is assessing for skin changes in an African-American client admitted with peripheral arterial disease. What does the nurse monitor for?
a. Excess hair growth
b. Pitting edema in the feet
c. Cyanosis of the nail beds
d. Loss of toenails
The nurse assesses a client's legs. Which assessment finding indicates arterial insufficiency?
a. Ankle discoloration and pitting edema
b. Dependent mottling and absence of hair
c. Pain with activity but not while resting
d. Full veins present in dependent extremity
The nurse is reviewing a client's laboratory results. The nurse correlates elevations in which values as risk factors for atherosclerosis? (Select all that apply.)
a. Total cholesterol, 280 mg/dL
b. High-density cholesterol, 50 mg/dL
c. Triglycerides, 200 mg/dL
d. Serum albumin, 4 g/dL
e. Low-density cholesterol, 160 mg/dL
An older adult client is prescribed furosemide (Lasix) for control of hypertension. What client education does the nurse provide? (Select all that apply.)
a. "Confusion can occur when taking this medication."
b. "Drink at least 3 liters of water every day."
c. "Arise slowly from a chair or from your bed."
d. "Persistent coughing is a side effect of this drug."
e. "You should eat foods high in potassium."
The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the health care provider? (Select all that apply.)
a. Laboratory draw for activated partial thromboplastin time (aPTT)
b. Administer vitamin K
c. Laboratory draw for prothrombin time (PT)/international normalized ratio (INR)
d. Administer protamine sulfate
e. Administer enoxaparin (Lovenox)
The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina?
a. Chest discomfort at rest and inability to tolerate mowing the lawn
b. Chest discomfort when mowing the lawn and subsiding with rest
c. Indigestion and a choking sensation when mowing the lawn
d. Jaw pain that radiates to the shoulder after mowing the lawn
The nurse is assessing a client who has a history of stable angina. The client describes a recent increase in the number of attacks and in the intensity of the pain. Which question does the nurse ask to assess the client's change in condition?
a. "How many cigarettes do you smoke daily?"
b. "Do you have pain when you are resting?"
c. "Do you have abdominal pain or nausea?"
d. "How frequently are you having chest pain?"
The community health nurse assesses clients at a health fair. Which statement assists the nurse to identify modifiable risk factors in clients with coronary artery disease?
a. "Would you please state your full name and birth date?"
b. "Have you ever had an exercise tolerance stress test?"
c. "In what activities do you participate on a daily basis?"
d. "Does anyone in your family have a history of heart disease?"
The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease?
a. "Rest is the best medicine at this time. Do not start an exercise program."
b. "You are a man; therefore there is nothing you can do to minimize your risks."
c. "You should talk to your provider about medications to help you quit smoking."
d. "Decreasing the carbohydrates in your diet will help you lose weight."
The emergency department nurse is assessing an 82-year-old client for a potential myocardial infarction. Which clinical manifestation does the nurse monitor for?
a. Pain on inspiration
b. Posterior wall chest pain
c. Disorientation or confusion
d. Numbness and tingling of the arm
Eight hours after presentation to the emergency department with reports of substernal chest pain, a client's laboratory results demonstrate myoglobin levels of 55 ng/mL. What does the nurse do next?
a. Prepare the client for an emergency coronary bypass graft surgery.
b. Administer nitroglycerin to prevent further myocardial cell death.
c. Assess the client to identify another potential cause of the chest pain.
d. Provide client education related to complications of myocardial infarctions.
The nurse evaluates diagnostic results for a client who has chest pain. Which laboratory test is most specific for acute coronary syndromes?
a. Troponin markers
b. Serum lactate dehydrogenase (LDH)
c. Serum myoglobin
d. Creatine kinase (CK)-MB isoenzyme
While evaluating a client's electrocardiogram (ECG) before surgery, the preoperative nurse identifies large, wide Q waves. What is the nurse's best interpretation of this finding?
a. An acute myocardial infarction is occurring.
b. The client had a myocardial infarction in the past.
c. The ventricles are enlarged and failing.
d. The ECG is a common variation of normal sinus rhythm.
The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, "The pain has not gotten any better." What does the nurse do next?
a. Place the client in a semi-Fowler's position.
b. Administer intravenous nitroglycerin.
c. Begin supplemental oxygen at 2 L/min.
d. Notify the health care provider.
The nurse assesses a client who has received thrombolytic therapy after having a myocardial infarction. Which clinical manifestation indicates to the nurse that reperfusion has been successful?
a. ST-segment depression
b. Cessation of diaphoresis
c. Sudden onset of pleuritic chest pain
d. Onset of ventricular dysrhythmias
A client who presented with an acute myocardial infarction is prescribed thrombolytic therapy. The client had a stroke 1 month ago. Which action does the nurse take?
a. Administer the medication as prescribed.
b. Perform a CT scan before administering the medication.
c. Contact the health care provider to discontinue the prescribed therapy.
d. Administer the therapy with a normal saline bolus.
The nurse is administering thrombolytic therapy to a client who had a myocardial infarction. Which intervention does the nurse implement to reduce the risk of complications in this client?
a. Administer prescribed heparin.
b. Apply ice to the injection site.
c. Place the client in Trendelenburg position.
d. Instruct the client to take slow deep breaths.
The nurse is assessing a client who has been prescribed a nonselective beta-blocking agent. Which adverse effect does the nurse monitor for in this client?
b. Postural hypotension
c. Nonproductive cough
The nurse is assisting a client to walk in the hall on the third day after a myocardial infarction. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity?
a. Facial flushing
b. Onset of chest pain
c. Heart rate increase of 10 beats/min at completion of the activity
d. Systolic blood pressure increase of 10 mm Hg at completion of the activity
The nurse is assessing a client who has left ventricular failure secondary to a myocardial infarction. Which clinical manifestation of poor organ perfusion does the nurse monitor for in this client?
c. Urine output of less than 30 mL/hr
d. Heart rate of 55 to 60 beats/min
The nurse is caring for a client who had a myocardial infarction. The client develops increased pulmonary congestion; an increase in heart rate from 80 to 102 beats/min; and cold, clammy skin. Which action does the nurse implement before notifying the health care provider?
a. Administer oxygen.
b. Increase the IV flow rate.
c. Place the client in supine position.
d. Prepare the client for surgery.
The nurse is teaching a client who is prescribed a calcium channel blocking agent after a percutaneous transluminal coronary angioplasty (PTCA). Which instruction does the nurse include in this client's teaching?
a. "Change position slowly."
b. "Avoid crossing your legs."
c. "Weigh yourself daily."
d. "Decrease salt intake."
A client who is post percutaneous transluminal coronary angioplasty (PTCA) reports severe chest pain. Which action does the nurse take first?
a. Administer the prescribed IV morphine.
b. Administer the prescribed sublingual nitroglycerin.
c. Assess the client's vital signs and notify the health care provider.
d. Perform an immediate 12-lead ECG.
The nurse is teaching a client prescribed sublingual nitroglycerin for chest pain. Which statement indicates that the client needs further teaching?
a. "I carry my medicine around in a clear plastic bag so that I can get to it easily if I have chest pain."
b. "Even if I have not used any of the nitroglycerin from one refill, I get another refill every 3 months."
c. "If I still have chest pain after I have taken 3 nitroglycerin tablets, I will go to the hospital."
d. "When my nitroglycerin tablet tingles under my tongue, I know that it is strong enough to work."
The nurse is assessing a client who had percutaneous transluminal coronary angioplasty (PTCA) 1 hour ago. Which complication does the nurse monitor for?
a. Hypertensive crisis
The nurse is assessing a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) and is ordered to receive an IV infusion of abciximab (ReoPro). Which clinical manifestation does the nurse monitor for in this client?
b. Joint pain
c. Pedal edema
d. Excessive thirst
The nurse is assessing a client who has a serum potassium level of 4.5 mEq/L after coronary artery bypass graft (CABG) surgery. Which action does the nurse take?
a. Notify the health care provider.
b. Document the finding.
c. Administer prescribed diuretics.
d. Administer prescribed potassium replacements.
The nurse is assessing a client who is 6 hours postoperative from coronary artery bypass graft surgery. The client's mediastinal tubes are not draining. Which action does the nurse implement at this time?
a. Replace the drainage tubing.
b. Check for kinks in the tubing.
c. Irrigate the tubing with normal saline.
d. Document the finding.
The nurse is caring for an 80-year-old client who has had coronary artery bypass graft surgery. Which assessment does the nurse prioritize for this client?
c. Mental status
The nurse is planning discharge education for a client after coronary artery bypass graft surgery. Which instruction does the nurse include in this client's teaching?
a. "Remember to drink at least 3 liters of fluid daily."
b. "You should abstain from sexual activity for 6 months."
c. "Take your pulse before, midway through, and after exercising."
d. "Stop taking your antihyperlipidemic medication at this time."
The nurse is planning a community health promotion program for cardiovascular disease. Which risk factors of coronary artery disease (CAD) does the nurse include in the education? (Select all that apply.)
a. Cigarette smoking
b. Use of alcohol
The nurse is monitoring the electrocardiogram (ECG) of a client who has a myocardial infarction. Which changes does the nurse expect to see in the ECG tracing? (Select all that apply.)
a. ST-segment depression
b. T-wave inversion
c. Normal Q waves
d. ST-segment elevation
e. T-wave elevation
f. Abnormal Q wave
The nurse administers intravenous dobutamine (Dobutrex) to a client who has heart failure. Which clinical manifestations indicate that the client's status is improving? (Select all that apply.)
a. Decreased heart rate
b. Increased heart rate
c. Increased contractility
d. Decreased contractility
e. Increased respiratory rate
A client is hospitalized after a myocardial infarction. Which hemodynamic parameters does the nurse correlate with cardiogenic shock? (Select all that apply.)
a. Decreased cardiac output
b. Increased cardiac output
c. Increased mean arterial pressure (MAP)
d. Decreased MAP
e. Increased afterload
f. Decreased afterload
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