Labs
The client with chronic heart failure has an echocardiogram which reveals an ejection fraction of 30%. Is this an expected finding?
Yes
Low EF% is often found with chronic HF
The client with a cardiac history is scheduled for an MRI at 0800. What are some questions the nurse would want to ask the client before the scan?
Do you have a pacemaker?
Are you claustrophobic?
Can you lie flat?
HTN
Obesity
DM type 2
Smoking
Alcohol
High cholesterol
The client is walking to the bathroom and states "my chest hurts so bad and I feel like I am short of breath". What is the priority action?
Stop the activity, have the client sit down.
What classification of medications does Nitroglycerin belong to?
Vasodilator
(nitrates)
What causes the release of troponin enzymes?
When the heart is lacking oxygen leading to ischemia, the heart muscle releases this enzyme.
Landmarking - make sure they are in the right spot!
List 3 cues for right sided heart failure
Edema
JVD
Hepatomegaly
Ascites
Weight gain
The client complains of chest pain and shortness of breath and is exhibiting further signs of a heart attack. What is the priority nursing hypothesis?
impaired tissue perfusion
Keep in a cool dry place
Only take when you are experiencing chest pain
Place under your tongue
Take up to 3 doses 5 minutes apart
The client's potassium is 6.9 mg/dL
What is the priority nursing action?
Tele/ECG
The client is scheduled for a cardiac stress test at 0845. What are some nursing considerations?
Consider holding morning cardiac meds
Avoid caffeine
List at least 2 follow-up questions to ask the client after obtaining a high blood pressure reading on admission to the med-surg unit.
What is your baseline?
Are you anxious, stressed, etc.
Do you have a headache, vision changes, other cues, etc.
The client with PAD has diminished pulses to bilateral lower extremities for the past two shifts. Upon your morning assessment, using the doppler there is no pulse found and the extremities are cold and pale. What is the priority action?
SBAR to the provider
The client is receiving furosemide for left sided heart failure. What are 3 nursing interventions?
Daily weights
I&O
Check electrolytes
The client returned from a cardiac catherization and labs were drawn. Labs show an increased BUN/Creatinine. Why would this be and what is the priority nursing action?
Contrast used during cardiac cath can causes AKI.
SBAR the provider with findings
Prepare to administer IVF
The client has returned from a left femoral artery cardiac catherization. What are at least 2 nursing considerations?
Bedrest for 2-6 hours
Frequent neurovascular checks
Assess pressure dressing
HOB only to 45 degrees*
The client has a venous ulcer secondary to PVD. What are some nursing interventions?
Elevate extremities
Wound care
Risk for infection
What is the priority complication with a-fib or a-flutter?
Stroke
The client with congestive heart failure is reporting weight gain and difficulty breathing laying flat. What medication will most likely be increased/prescribed?
Diuretics
What are some labs worth assessing with a client with a new HTN diagnosis?
U/A
Electrolytes
Troponin/cardiac panel
Cholesterol
The ECG reveals sinus tachycardia. What are some next steps?
Assess the client
Causes?
Get full set of vital signs
Is medication needed?
The client with PAD is admitting to the med-surg unit. List 3 nursing priority hypotheses
Impaired perfusion
Acute pain
Risk for falls/Risk for injury
The client has chest pain that does not go away with rest. What are 4 components of care for the nurse to utilize during acute coronary syndrome?
MONA
Oxygen
Nitro
Anticoagulant/antiplatelet
Morphine (pain control if needed)
The client comes in with a blood pressure of 190/118. What medication is most likely to be ordered by the provider?
Nitroglycerin - vasodilator
Beta-Blocker given IV!