Have a Little Heart
A client is in sinus bradycardia with a heart rate of 45 beats/min, complains of dizziness, and has a blood pressure of 82/60 mm Hg. Which of the following should the nurse anticipate will be prescribed? A). Defibrillate the client B). Administer digoxin (Lanoxin) C). Continue to monitor the client D). Prepare the transcutaneous pacing
Ans: D Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Digoxin will further decrease the client’s heart rate. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Continuing to monitor the client delays necessary intervention.
A nurse is preparing for the admission of a client with heart failure who is begin sent directly to the hospital from the physician's office. The nurse would plan on having which of the following medications readily available for use? A) Digoxin (Lanoxin) B) Verapamil (Calan) C) Propranolol (Inderal) D) Diltiazen (Cardizem)
Ans: A Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β-adrenergic blocker) have a negative inotropic effect and would worsen the failing heart.
A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client? A) Bradycardia B) Ventricular dysrhythmias C) Rising diastolic blood pressure D) Falling central venous pressure
Ans: B Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.
A client who had cardiac surgery 24 hours ago has a urine output averaging 20mL/hr 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 and the serum creatinine level is 2.2 mg/dL. Based on these findings, the nurse would anticipate that he client is at risk for which of the following? A) Hypovolemia B) Acute renal failure C) Glomerulonnephritis D) Urinary tract infection
Ans: B The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. 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, urinary tract infection, or glomerulonephritis.
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of which of the following? A) Pneumonia B) Pulmonary edema C) Pulmonary embolism D) Myocardial infarction
Ans: C Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.
A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? A) Atrial fibrillation B) Nutritional anemia C) Peptic ulcer disease D) Recent upper respiratory infection
Ans: C 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
A nurse notes bilateral +2 edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? A) Order daily weights starting on the following morning B) Review the intake and output records for the last 2 days C) Request a sodium restriction of 1g/day from the physician D) Change the time of diuretic administration from morning to evening
Ans: B 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. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.
A nurse is performing CPR on a client who has had a cardiac arrest. An AED is available to treat the client. Which of the following activities will allow the nurse to assess the client's cardiac rhythm? A) Hold the defibrillator paddles firmly against the chest B) Apply adhesive patch electrodes to the chest and move away from the client C) Apply standard electrocardiographic monitoring leads to the client and observe the rhythm D) Connect standard electrocardiographic electrodes to a transtelephonic monitoring device
Ans: B The nurse or rescuer puts two large adhesive patch electrodes on the client’s chest in the usual defibrillator positions. The nurse stops CPR and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if defibrillation is necessary.
A client is having a follow-up physician office visit after vein ligation and stripping. The client describe a sensation of “pins and needles” in the affected leg. Which of the following would be an appropriate action by the nurse based on evaluation of the client's comment? A) Instruct the client to apply warm packs B) Report the complaint to the physician C) Reassure the client that this is only temporary D) Advise the client to take acetaminophen (Tylenol) until it is gone
Ans: B 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. Because complications from this surgery are relatively rare, this symptom should be reported.
A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for which of the following? A) Diarrhea and hypotension B) Fatigue and muscle twitching C) Thrombocytopenia and weight gain D) Anorexia, nausea, and visual disturbances
Ans: D The first signs and symptoms of digoxin toxicity in adults include abdominal pain, nausea, vomiting, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias. Options 1, 2, and 3 are unrelated to digoxin therapy.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds? A) Stridor B) Crackles C) Scattered rhonchi D) Diminished breath sounds
Ans: B Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.
Cardiac magnetic resonance imaging (MRI) is prescribed for a client. The nurse identifies that which of the following is a contraindication for performance of this diagnostic study? A) Client has a pacemaker B) Client is allergic to iodine C) Client has diabetes mellitus D) Client has a biological porcine valve
Ans: A The magnetic fields used for magnetic resonance imaging (MRI) can deactivate the pacemaker. Options 2, 3, and 4 are not contraindications for an MRI.
The client with heart disease is provided instructions regarding a low-fat diet. The nurse determines that the client understands the diet if the client states that a food item to avoid is: A) Apples B Oranges C) Avocado D) Cherries
Ans: C Fruits and vegetables, except avocado, olives, and coconut, contain minimal amounts of fat.
A nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding would indicated the presence of this complication? A) A pulse rate of 60 beats/min B) Flat neck veins C) Muffled or distant heart sounds D) A blood pressure (BP) of 128/82 mm Hg
Ans: C Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory BP greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade.
A nurse is providing instruction regarding high-sodium food items to avoid to a client with a diagnosis of hypertension. The nurse instructs the client to avoid: A) Cantaloupe B) Broccoli C) Mineral water D) Bananas
Ans: C The sodium level can increase by 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, as well as some mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, and demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium. The client would avoid consuming mineral water.
A 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? A) Listening to lung sounds B) Assessing for peripheral and sacral edema C) Assessing for jugular vein distenstion D) Monitoring for organomegaly
Ans: A 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.
A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. The nurse plans to include which of the following items in client teaching about this procedure? A) Avoid cigarettes for 30 minutes before the procedure B) Wear loose clothing with a shirt that buttons in front C) Eat breakfast just before the procedure D) Wear firm, rigid shoes such as workboots
Ans: B 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 wear rubber-soled, supportive shoes, such as athletic training shoes. The client should receive nothing by mouth after bedtime, or for a minimum of 2 hours before the test. 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 is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates a clear understanding of the instructions? A) “I will have to go to the operating room for this procedure.” B) “I probably will feel tired after the test from lying on a hard x-ray table for a few hours.” C) “It will really hurt when the catheter is first put in.” D) “I will receive general anesthesia for the procedure.”
Ans: B It is common for the client to feel fatigued after the cardiac catheterization procedure. Other pre-procedure teaching points include that the procedure is done in a darkened cardiac catheterization room. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.
A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. A nurse caring for the client uses which of the following items as the best means to monitor respiratory status on an ongoing basis? A) Oxygen flowmeter B) Oxygen saturation monitor C) Telemetry cardiac monitor D) Apnea monitor
Ans: B Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if used continuously. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias. An apnea monitor detects apnea episodes, such as when the client has stopped breathing briefly.
A client is being discharged from the hospital after being treated for infective endocarditis. The nurse provides the client with which discharge instructions? A) Take acetaminophen (Tylenol) if the chest pain worsens B) Use a firm bristle toothbrush and floss vigorously to prevent cavities C) Take antibiotics until the chest pain is fully resolved D) Notify all health care providers of the history of infective endocarditis before any invasive procedures
Ans: D The client should alert any health care provider about the history of infective endocarditis before any procedure that involves instrumentation. The provider should place the client on prophylactic antibiotics. Antibiotics should be taken for the full course of therapy. The client should notify the physician if chest pain worsens or if dyspnea or other symptoms occur. The client should use a soft toothbrush and floss carefully to avoid any trauma to the gums, which could provide a portal of entry for bacterial infection.
A nurse is assessing the client's condition after cardioversion. Which of the following observations would be of highest priority to the nurse? A) Status of airway B) Oxygen flow rate C) Level of consciousness D) Blood pressure
Ans: A Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and arrhythmia detection. Airway, however, is always the highest priority.
A nurse is assessing a client with and abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? A) Pulsatile abdominal mass B) Hyperactive bowel sounds in the area C) Systolic bruit over the area of the mass D) Subjective sensation of “heart beating” in the abdomen
Ans: B Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the “heart beating” in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.
A client is brought into the ER with a third degree heart block after experiencing an acute anterior myocardial infarction. Which of the following interventions is the priority on an emergency basis? A) Temporary Pacemaker B) Administer Lidocaine C) Cardioversion D) Administer Atropine
Ans. A) A third degree heart block is a lethal rhythm. It is the complete blockage of the atrial impulses into the ventricles. The block may be at the AV node, Bundle of His resulting in the atrai and ventricles beating independently of each other. The atrial rate is usually normal while the ventricular is slow and below 55 bpm. The causes may be AMI, CAD, surgery, aging, or drug toxicity such as digoxin, procainamide, or verapamil.