Fluid Balance
A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. During the first 4 hr of the shift the client had a total fluid intake of 300 mL. How many mL of fluids can the client have over the next 20 hr?
900mL
A nurse is performing an electrocardiogram on a client who is experiencing chest pain. Which of the following statements should the nurse make?
A. "You may feel a slight tingling while the test is being done."
B. "The test will be complete in 30 to 60 minutes."
C. "I will need to apply electrodes to your chest and extremities."
D. "The radioactivity from the dye lasts only a few hours."
C.
A client has constant crushing chest pain rated at 9 out of 10 that began 30 minutes ago and is increasing in intensity. The nurse should recognize the client is at risk for which disorder?
A. Atherosclerosis
B. Coronary artery disease (CAD)
C. Stable angina
D. Myocardial infarction (MI)
D. Myocardial infarction (MI)
Stable angina is the predictable form of chest pain that occurs when the heart is exerted or is exposed to cold or stress. In this case, the angina is unstable, and therefore the client is at increased risk for MI. Atherosclerosis is a long-term illness that would not cause the increasing pain and intensity described by the client. CAD is the cause of chest pain but is not a disorder that develops as a result of it.
The nurse is monitoring a client who is undergoing an exercise stress test on a treadmill for evaluation of intermittent angina. Which assessment finding requires the most rapid action by the nurse?
A. ST segment elevation on the electrocardiogram (ECG) monitor
B. Blood pressure increase from 134/68 to 150/80 mmHg
C. Pulse change from 80 to 92 beats per minute
D. Client complaint of feeling tired
A. ST segment elevation on the electrocardiogram (ECG) monitor
ECG changes such as ST segment elevation are associated with a myocardial infarction (MI), indicating that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately. Increases in both blood pressure and heart rate are normal responses to aerobic exercise. Tiredness is also normal.
The client diagnosed with a myocardial infarction is six hours post-right femoral percutanous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?
A. The client is keeping the affected extremity straight
B. The pressure dressing to the right femoral area is intact
C. The client is complaining of numbness in the right foot
D. The client's right pedal pulse is +3 and bounding
C. Any neurovascular assessment data that is abnormal requires intervention by the nurse; numbness may indicate decreased blood flow to the right foot
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
A. Intake 2,500 mL, output 500 mL
B. Intake 2,400 mL, output 2,500 mL
C. Intake 1,200 mL, output 700 mL
D. Intake 800 mL, output 2,100 mL
B. Intake 2,400 mL, output 2,500 mL
The nurse is planning to teach a client about coronary angiography. Which information should the nurse include? (Select all that apply.)
A. There will be a flushing sensation while the dye is injected during the procedure.
B. You will not be able to eat or drink for several hours after the procedure.
C. You will need to remain in bed with your leg straight after the procedure.
D. Pulses on your feet will need to be checked frequently after the procedure.
E. Pressure will be applied to the insertion site after the procedure.
A, C, D, E.
A coronary angiogram, obtained through a procedure known as cardiac catheterization, is a radiographic study of the circulation of the coronary arteries. The client will be on bedrest for up to 8 hours after the procedure with his leg straight, and pedal pulses will be checked every 15 minutes following the procedure. There will be a flushing sensation while the dye is injected during the procedure. After the procedure, the client will have pressure applied to the insertion site when the sheath is removed. Food and drink are allowed as tolerated.
The nurse suspects that a client is having a myocardial infarction (MI). Which diagnostic test should the nurse anticipate will be ordered?
A. Troponin
B. Brain natriuretic peptide (BNP)
C. Complete blood count (CBC)
D. Ankle-brachial blood pressure index (ABI)
A. Troponin
When the healthcare provider believes that a client has experienced a myocardial infarction (MI), diagnostic tests will include cardiac markers, including a troponin test, which measures the levels of troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged. Additional tests would include a CPK and CK-MB and an electrocardiogram (ECG). A CBC and BNP will not be useful to confirm the diagnosis of an MI. An ABI tests for peripheral vascular disease that may predict coronary artery disease (CAD), so it is not relevant to the diagnosis of an MI.
The nurse is caring for a client with a history of atherosclerosis. The client has chest pain that occurs with physical exertion or stress and is relieved with sublingual nitroglycerin. Which disorder should the nurse recognize the client is most likely experiencing?
A. Cardiac arrest
B. Acute coronary syndrome
C. Myocardial infarction
D. Stable angina
D. Stable angina
As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug's principle effects are produced by:
A. Antispasmotic effect on the pericardium
B. Causing an increased myocardial oxygen demand
C. Vasodilation
D. Improved conductivity in the myocardium
C. Vasodilation
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
A. High BP and low pulse rate
B. Low BP and low pulse rate
C. High BP and high pulse rate
D. Low BP and high pulse rate
D. Low BP and high pulse rate
Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease?
A) Decrease anxiety
B) Enhance myocardial oxygenation
C) Administer sublingual nitroglycerin
D) Educate the client about his symptoms
B. Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but administration isn't the first priority. Although educating the client and decreasing anxiety are important in care delivery, neither are priorities when a client is compromised.
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?
A. Midepigastric pain and pyrosis
B. Diaphoresis and cool clammy skin
C. Intermittent claudication and palor
D. Jugular vein distention and dependent edema
B. Diaphoresis and cool clammy skin
Diaphoresis is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this in turn, leads to cold, clammy skin
The client diagnosed with known coronary artery disease is experiencing angina while walking to the bathroom. Which action should the nurse implement first?
A. Administer sublingual nitroglycerin
B. Obtain a stat 12 Lead ECG
C. Have the client sit down immediately
D. Assess the client's vital signs
C. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.
A client is scheduled for a cardiac catherization using a radiopaque dye. Which of the following assessments is most critical before the procedure?
A. Intake and output
B. Baseline peripheral pulse rates
C. Height and weight
D. Allergy to iodine or shellfish
D. Allergy to iodine or shellfish
This procedure requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure.
During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?
A. Elevate the head of the bed to high Fowler's.
B. Request NPO status for the client.
C. Check the client's respiratory rate and lung sounds.
D. Measure the client's temperature.
C. Check the client's respiratory rate and lung sounds.
The nurse is teaching a client about coronary artery disease (CAD). Which response by the client indicates the need for further teaching?
A. "Increased levels of HDL cholesterol decrease the risk of atherosclerosis."
B. "It decreases quality of life but does not increase a person's risk of death."
C. "Damage to the linings of my arteries can cause clots and blockage."
D. "It is a leading cause of death for men and women in the United States."
B. "It decreases quality of life but does not increase a person's risk of death."
Coronary artery disease is a leading cause of death for men and women in the United States. A lack of oxygenated blood to the coronary arteries will decrease a client's ability to function and increase their risk of death. High-density lipoproteins attract cholesterol, returning it from peripheral tissues to the liver. Endothelial damage causes the body to send platelets to seal the area and leukocytes to fight inflammation. These protective mechanisms also contribute to the formation of fibrous plaque. Fibrous plaque protrudes into the arterial lumen and invades the muscular media layer of the vessel as well as the inner wall of the intima. This results in a decreased ability of the vessel to dilate.
In regards to the patient in the previous question, after administering the first dose of Nitroglycerin sublingual the patient's blood pressure is now 68/48. The patient is still having chest pain and T-wave inversion on the cardiac monitor. What is your next nursing intervention?*
A. Hold further doses of Nitroglycerin and notify the doctor immediately for further orders.
B. Administer Morphine IV and place the patient in reverse Trendelenburg position.
C. Administer Nitroglycerin and monitor the patient’s blood pressure.
D. All the options are incorrect.
A.
The healthcare provider prescribes Nitroglycerin SL to a patient who was admitted for chest pain and a MI. Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? "I may experience:
A. A headache
B. Increased BP readings
C. A slow Pulse rate
D. Confusion
A. The most common SE of Nitro is a headache. Additional cardio SE are tachycardia, hypotension and dizziness not confusion.
When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to:
A. Help keep him well hydrated
B. Dissolve clots he may have
C. Prevent kidney failure
D. Treat potential cardiac arrhythmias.
B. Dissolve clots he may have
Thrombolytic drugs are administered within the first 6 hours after onset of a MI to lyse clots and reduce the extent of myocardial damage.
Which of the following is the correct order of how blood flows from the heart out to the body and back to the heart again
A. Vena cava, veins, venules, capillaries, arterioles, arteries, aorta
B. Aorta, arteries, arterioles, capillaries, venules, veins, vena cava
C. Capillaries, arteries, veins, arterioles, venules, aorta, vena cava
D. Aorta, vena cava, veins, arteries, venules, arterioles, capillaries
B. Aorta, arteries, arterioles, capillaries, venules, veins, vena cava
A client who has a strong family history of coronary artery disease asks the nurse, "How can I decrease my chances of developing problems with my arteries?" Which response by the nurse is appropriate? (Select all that apply.)
A. "Keeping your blood pressure within normal levels will decrease the risk of injury to your arteries."
B. "A diet high in fruits, vegetables, and unsaturated fatty acids may help protect your arteries."
C. "You can reduce your risk by making some changes in your lifestyle, such as moderate exercise."
D. "As long as your cholesterol is normal, your arteries will remain clear."
E. "There is little you can do except take medication to prevent coronary artery disease."
A, B, C.
The causes of atherosclerosis are not known, but research has shown a connection with modifiable risk factors such as cholesterol, triglycerides, lack of exercise, smoking, obesity, blood pressure, diet, stress, and diabetes. Elevated cholesterol is only one of the factors that can contribute to the development of plaque in the arteries. Excessive pressures within the arterial system can cause injury to the arterial endothelium. Endothelial damage promotes platelet adhesion and aggregation and attracts leukocytes to the area. Risk factors such as age, gender, and heredity cannot be modified. The exact cause is unclear, but it is believed that fruits, vegetables, whole grains, and unsaturated fatty acids have nutrients that help protect the arteries from injury.
What is the first intervention for a client experiencing MI?
A) Administer morphine
B) Administer oxygen
C) Administer sublingual nitroglycerin
D) Obtain an ECG
B. Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they're more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI
2) A client with no history of cardiovascular disease comes into the ambulatory clinic with flulike symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem?
A. "Have you ever had this pain before?"
B. "Can you describe the pain to me?"
C. "Does the pain get worse when you breathe in?"
D."Can you rate the pain on a scale of 1-10, with 10 being the worst?"
C. Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.
In postoperative coronary artery bypass graft the person should be encouraged to:
a. Reduce mobility
b. Drink 3 L of fluid as soon as possible
c. Splint the incision when coughing and moving
d. Close the eyes when coughing
c. Splint the incision when coughing and moving