(Test Bank) HESI Exit Exam Test Bank QUESTIONS AND ANSWERS

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HESI Exit Exam Test Bank QUESTIONS AND ANSWERS 2022 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? It originates from an ectopic focus. If the P wave is firing consistently from the SA node, the P wave will have a consistent shape in a given lead. If the impulse is from an ectopic focus, then the P wave will vary in shape in that lead. The nurse is assessing the client’s electrocardiography (ECG). What does the P wave on the ECG tracing represent? Depolarization of the atria The ECG tracing of a P wave represents electrical changes caused by atrial depolarization. A nurse notes that the PR interval on a client’s electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take? Document the finding in the client’s chart. The PR interval normally ranges from 0.12 t o 0.20 second. This is a normal finding, so the nurse simply documents this. No further action is required . 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? Ventricular and atrial depolarizations are initiated from different sites. Normal rhythm shows one P wave preceding each QRS, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depo larization. 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? Review the client’s daily electrolyte results. Prominent U waves may be the result of hypokalemia. The nurse should review the client’s daily electrolyte results. Although documentation is important, this is not a normal variant. Moving the crash cart closer to the room may or may not be warranted. The client does not need an immediate ECG. The client’s heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take? Document the finding in the chart. Sinus dysrhythmia is noted when the heart rate increases slightly during inspiration and decreases slightly during expiration. Sinus dysrhythmia is a variant of normal sinus rhythm that is frequently observed in healthy children and adults. No other action s are needed. A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? Mid-sternal chest pain Chest pain, possibly angina, indicates that tachycardia may be increasing the client’s myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? Atropine (Atropine) Atropine is a cholinergic antagonist that inhibits parasympathetically -induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate. The other medications are not appropriate. 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? “Minimize or abstain from caffeine.” PACs usually have no hemodynamic consequences. For a client experiencing infrequent bouts of PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. The nurse identifies a client’s rhythm to be a sustained supraventricular tachycardia. What medication does the nurse administer? Diltiazem, a calcium channel blocker, slows depolarization through the conduction system and is commonly used as an agent to terminate a sustained episode of supraventricular tachycardia. 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? “Avoid bearing down or straining while having a bowel movement.” Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition. The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation? Client who is dismissed after coronary artery bypass surgery Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft (CABG) surgery. The other conditions do not place a client at higher risk for atrial fibrillation. 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? Shortness of breath and anxiety The rhythm described is atrial flutter with a rapid ventricular response. Rapid atrial flutter may manifest with palpitations, shortness of breath, and anxiety. Syncope, angina, and evidence of heart failure also may be present. The nurse is caring for a client with atrial fibrillation. What manif estation most alerts the nurse to the possibility of a serious complication from this condition? Speech alterations Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. F atigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance. 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? Warfarin (Coumadin) Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. The other drugs are not appropriate for this complication. 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? Ventricular tachycardia With an acute myocardial infarction (MI), the onset of PVCs may be considered as a warning that could herald the onset of ventricular tachycardia or ventricular fibrillation. A client with myocardial ischemia is having frequent early, wide ventricular complexes seen on the cardiac monitor. Which medication does the nurse administer? Amiodarone (Cordarone) Early, wide ventricular complexes are premature ventricular contractions (PVCs). Amiodarone, an antidysrhythmic, is the treatment of choice for frequent PVCs. The other medications are not appropriate for this condition. The nurse has adm inistered adenosine (Adenocard). What is the expected therapeutic response? A short period of asystole Clients usually respond to this medication with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. A client’s electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurse’s first action? Assess airway, breathing, and level of consciousness. The first action that the nurse should take when ventricular tachycardia is observed is to assess the client’s airway, breathing, and level of consciousness. If the client is unconscious or has experienced respiratory arrest, defibrillation and CPR are begun. 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? Slow the amiodarone infusion rate. IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pac ing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. 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? Document the finding in the chart. This prolonged PR interval indicates a first -degree heart block. First -degree heart block in a stable client requires no intervention. 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? Resuscitation cart Complications of this procedure include brady dysrhythmias , asystole, ventricular fibrillation, and cerebral damage. The resuscitation cart, complete with defibrillator, should be available whenever this procedure is initiated. The other equipment is not needed. The nurse is caring for a client with a complete heart block (third -degree atrioventricular [AV] block). What is the nurse’s priority intervention? Begin external pacing. The nurse would expect the client with complete heart block or third-degree AV block to be paced externally until the client can be scheduled for a permanent pacemaker. 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? Level of consciousness A heart rate of 40 beats/min or less, with widened QRS complexes, could have hemodynamic consequences, and the client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, lighthe adedness, confusion, syncope, and seizure activity. 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? Document the finding in the client’s chart. A spike followed by a QRS complex indicates “capture,” meaning that the pacemaker has successfully depolarized or captured the ventricle. No action other than documentation of this finding is necessary. 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? Initiate cardiopulmonary resuscitation. A client with pulseless VT should be defibrillated immediately. If the defibrillator is not available, the nurse should initiate cardiopulmonary resuscitation (CPR) and then should defibrillate as soon as possible. Basic life support (BLS) is the basis of emergency cardiac care. Providing good quality CPR is vital. The client should have already been assessed for 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? Loss of capture In epicardial pacing, the wires are threaded onto the epi cardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating a client? 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? Muffled heart sounds In the post implantation period, the nurse should be alert for complications of cardiac tamponade, bleeding, and dysrhythmias. Muffled heart sounds are a manifestation of cardiac tamponade. Edema and a lower temperature would not be indicative of a complication of this procedure. Bradycardia might need intervention, but this client’s heart rate is not critically low. A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the client’s discharge teaching? “Report pulse rates lower than your pacemaker setting.” The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. 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? “I will avoid sources of strong electromagnetic fields.” The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. A client is admitted with early -stage heart failure. Which assessment finding does the nurse expect? An increase in heart rate and respiratory rate In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings. A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? Decrease in tissue perfusion In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. St roke volume and oxygen saturation do not increase with a low ejection fraction. The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? Middle -aged woman with aortic stenosis Although most people with heart failure will have failure that progresses from left to right, it is possible to have left -sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left v entricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension. The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? “I have to stop halfway up the stairs to catch my breath.” Clients with left -sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs as fluid moves into the alveoli. Nocturia is often seen with right -sided heart failure. Thirst and blurred vision are not related to heart failure. A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? “Please come into the clinic for an evaluation.” The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible. The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? “My shoes fit really tight lately.” Signs of systemic congestion occur with right -sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left -sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure. The nurse notes that the client’s apical pulse is displaced to the left. What conclusion can be drawn from this assessment? The heart is hypertrophied. The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left. The nurse assesses a client and notes the presence of an S 3 gallop. What is the nurse’s best intervention? Assess for symptoms of left-sided heart failure. The presence of an S 3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted. A client asks the nurse why it is important to be weighed every day if he has right -sided heart failure. What is the nurse’s best response? “Weight is the best indication that you are gaining or losing fluid.” Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse’s best action? Administer loop diuretics as prescribed. The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. Rest is important for clients with heart failure, but this is not the priority. A client with heart failure is experiencing acute shortness of breath. What is the nurse’s priority action? Place the client in a high Fowler’s position. Placing a client in a high Fowler’s position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client’s heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed. A client with heart failure is prescribed enalapril (Vasotec). What is the nurse’s priority teaching for this client? “Avoid using salt substitutes.” Angiotensin -converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life -threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? Instruct the client to ask for assistance when arising from bed. Administration of the first dose of angiotensin -converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect . The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. The client who just started taking isosorbide dinitrate (Imdur) reports a headache. What is the nurse’s best action? Administer PRN acetaminophen. The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? Monitor the client’s blood pressure. Intraven ous nitroglycerin and morphine will decrease the client’s blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client’s glucose levels should not be affected by these medications. The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? “Do not take this medication within 1 hour of taking an antacid.” Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff. A client is taking triamterene -hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? Potassium of 2.9 mEq/L Hypokalemia is a side effect of both thiazide and loop d iuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication. The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client’s activity? Systolic blood pressure change from 136 to 96 mm Hg A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output. The nurse is concerned that an older adult client wit h heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? Confusion Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema. A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? “Weigh yourself daily while wearing the same amount of clothing.” Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse’s priority intervention? Assess respiratory status. Assessment of respiratory and oxygenation status is the pri ority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously. The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client’s stenosis has progressed? Dyspnea on exertion Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client? Narrowed pulse pressure In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assesse d. A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse’s best response? “Blood clots form more easily in artificial replacement valves.” Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education? “I will have my teeth cleaned by the dentist in 2 weeks.” Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics. The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about? History of a systemic infection within the past month The clinical manifestations sugges t infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis. The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use? Standard Precautions The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. A client with pericarditis is admitted to the cardiac unit. What assessment f inding does the nurse expect in this client? Friction rub at the left lower sternal border The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related. The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include? “You should report episodes of dizziness or fainting.” The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcoho l. Cardiac glycosides are contraindicated in obstructive HCM. The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes. Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client’s discharge instru ctions? “Avoid large crowds and people who are sick.” These agents cause immune suppression, leaving the client more vulnerable to infection. A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, “I know a transplant is my last chance, but I don’t want to become a vegetable.” What is the nurse’s best response? “Would you like information about advance directives?” The client is verbalizing a real concern or fear about negative outcomes of the surgery . This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client’s activity level? “Are you able to walk upstairs without fatigue?” Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client’s activity is the same or worse, or whether the client identifies a decrease in activity level. An older adult client with heart failure states, “I don’t know what to do. I don’t want to be a burden to my daughter, but I can’t do it alone. Maybe I should die.” What is the nurse’s best response? “Would you like to talk about this more?” Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open -ended statements allow the client to respond safely and honestly. An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? Echocardiography Echocardiography is considered the best tool for the dia gnosis of heart failure. A chest x -ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure. The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? High Fowler’s, pillows under arms Placing the client in high Fowler’s position, with pillows under the arms, allows for maximum chest expansion. The nurse is instructing a client with heart failure about energy cons ervation. Which is the best instruction? “Gather everything you need for a chore before you begin.” Gathering all supplies needed for a chore at one time decreases the amount of energy needed. A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse’s best action? Administer the Vasotec. The nurse should administer the medication. Generally, the health care provider will maintain the client’s blood pressure between 90 and 110 mm Hg. A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication ? Insert a separate IV access. Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line. The nurse is assessing a client with left -sided heart failure. What conditions does the nurse assess for? Pulmonary cracklesc onfusion, restlessnessS3/S4 summation gallopCough worsens at night Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right -sided failure occurs w ith problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle. The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? Hematocrit (Hct), 32.8% Serum sodium, 130 mEq/L Proteinuria Microalbuminuria The hematocrit is low indicating a dilutional ratio of red blood cells (RBCs) to fluid. The sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. A client with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurse’s best response? “A combination of platelets and fats accumulates, narrowing the artery and reducing blood flow.” Most researchers believe that a combination of platelet and lipid accumulation following intimal injury is responsible for the process of atherosclerosis. The nurse is working with clients at a health fair. Which teaching takes priority to reduce the risk of atherosclerosis? Instructing a diabetic client not to smoke or use any tobacco Atherosclerosis can be caused by mechanical and/or chemical injury. People with diabetes often have premature, severe atherosclerosis from elevated low -density lipoprotein (LDL) levels and intimal injury from hyperglycemia. Cigarette smoking or other tobac co use releases toxins into the bloodstream and causes vasoconstriction, further contributing to intimal injury. 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? Explaining familial tendencies in hyperlipidemia The liver of clients with familial hyperlipidemia makes excessive cholesterol and other fats. If the client is compliant with the treatment regimen and problems persist, a familial problem may exist. The client is already on a low -fat diet and exercise program, so further refining the diet and counseling for weight loss is redundant. A client with atherosclerosis is attempting to stop cigarette smoking with the use of a nicotine patch. Which statement by the client i ndicates a good understanding of smoking cessation education? “Smoking while using this patch increases the risk of a heart attack.” Nicotine constricts blood vessels, increases mean arterial pressure, and increases afterload. Smoking while using a nicotine patch increases afterload to such an extent that the myocardium must work harder, with coronary arteries constricted. This may caus e a myocardial infarction. A client with hypercholesterolemia and atherosclerosis is prescribed nicotinic acid (Niaspan). Which instruction does the nurse provide the client? “This medication may make you flush.” Nicotinic acid causes increased release of prostaglandins, resulting in vasodilation. Clients may experience flushing and a very warm feeling all over. Taking the drug with meals minimizes this side effect. The medication will not take the place of adjusti ng the diet and exercising. Nicotinic acid is not used to treat acute 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? “You should keep your saturated fat intake below 10% of your total calories.” An LDL level of 158 mg/dL is borderline high. American Heart Association (AHA) dietary guidelines advise clients to have a total saturated fat intake of less than 10% of the total caloric intake. A decrease in saturated fat intake is considered more important than decreasing the total cholesterol number because saturated fat is a main determinant of cholesterol synthesis in the body. 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? Skim milk, oatmeal, banana, orange juice, coffee Cholesterol is found in animal -based products such as milk, eggs, and cheese. It is also found in baked goods such as muffins. The cheese omelet, bacon, and muffin are too high in cholesterol. The nurse is reviewing the menu selections of a client who has ordered a low -cholesterol diet. What meal items does the nurse question? Cheesesteak sandwich In collaboration with the dietitian, educate the client about the types of fat content in food. Meats and eggs contain mostly saturated fats, and their intake should be limited. Cholesterol is also found in animal sources, such as meats and eggs. 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? Elevated liver enzymes Treatment with any of the statins for elevated cholesterol and low -density lipoprotein (LDL) levels is contraindicated for clients with active liver disease because these agents can cause increases in liver function. No contraindications to the administration of statins to clients with diabetes mellitus, peptic ulcer disease, or rheumatoid arthritis are known. A client with high cholesterol is beginning treatment with simvastatin (Zocor). What priority instruction does the nurse give this client? “Report any muscle tenderness to your health care provider.” This class of drugs can cause myopathy. Muscle tenderness should be reported to the client’s health care provider. HMG -CoA (3-hydroxy -3-methylglutaryl coenzyme A) reductase inhibitors do not usually cause constipation. It is not recommended that the drug b e taken on an empty stomach. Flushing occurs with niacin but not typically with this class of medications. A client has been diagnosed with Cushing’s syndrome. What assessment does the nurse perform to detect vascular complications associated with this illness? Assessment of blood pressure Dysfunction of the adrenal medulla or the adrenal cortex can cause secondary hypertension. In Cushing’s syndrome, excessive glucocorticoids are excreted from the adrenal cortex. These excessive glucocorticoids cause increased sodium and water retention, which may lead to an increase in blood pressure. No changes in lung sounds are associated. The nurse is providing care for a client with hypertension. What priority physical assessment does the nurse include in examination of this client? Funduscopic examination of the retina The physical examination of a c lient with hypertension should include examination of the retina because the appearance of the retina is a reliable index of the severity of hypertension. Telangiectasia is caused by permanent dilation of small blood vessels and is not associated with hypertension. No changes in ear or cranial nerves secondary to hypertension are noted. 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? “I will give my canned soups to the food pantry.” Canned and processed foods can contain high levels of sodium and should be avoided. Salt substitutes contain potassium and should not be used freely, especially if the client has kidney impairment. The client is advised to refrain from cooking with salt or adding salt to food at the table and is instructed to limit (not eliminate all) alcohol intake. The nurse is assessing a client’s under standing of his hypertension therapy. What client statement indicates a need for further teaching? “When my blood pressure is normal, I will no longer need to take medication.” A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention? Educate the client to sit on the side of the bed for a few minutes before r ising. Angiotensin -converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a few minutes to prevent hypotension -induced falls. The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management? No indication of renal impairment is present. One expected outcome for a client with hypertension is for the client to h ave no evidence of target organ damage, such as renal or heart disease, that can occur with poorly managed hypertension. 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? Peripheral arterial disease Arterial disease is characterized by claudication after walking short distances. Ulcerations caused by peripheral arterial disease are painful and initially are located at the most distal points on the extremity. Diabetic ulcers and venous ulcers are seldom painful and usually tend to occur where pressure is applied. The nurse notes a venous ulcer on the client’s left ankle. What additional assessment finding does the nurse expect in this client? Brownish discoloration of the lower extremity Venous ulcers are characterized by brown pigmentation of the skin of the lower extremity. Mottled skin, the presence of dependent rubor, and cyanosis are features of arterial ulcers. 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? The client’s disease is worsening. Claudication is stage II of chronic peripheral arterial disease. In stage III, clients commonly experience pain while resting that awakens them at night. Pain at rest is a sign that the disease is progressing and perfusion is altered, even with no activity. The nurse is educating a client before a right leg atherectomy. What priority education does the nurse provide? “You may be on heparin during the procedure.” Heparin is often used during this procedure to prevent blood clots. The client will be on bedrest for some time following the procedure so will not be able to get to the bathroom right afterward. The client will not be sedated for 6 hours postprocedure, an d aspirin probably will still be part of the client’s medication regimen. The nurse is caring for a client with peripheral arterial disease. What priority nursing intervention does the nurse perform to promote vasodilation? Educate the client to abstain from smoking. Smoking causes vasoconstriction, and its effects can last up to 1 hour after the cigarette is finished. Increasing activity may lead to collateral circulation but does not cause vasodilation. Use of a heating pad is contraindicated in the client with perip heral artery disease because of the risk of a burn caused by diminished sensation. 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? Bleedin g For this procedure, a catheter is advanced through a cannula inserted through the femoral artery. The nurse must monitor the client for bleeding at the puncture site. 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? Assess the peripheral pulses in the limb. A client is recovering after an embolectomy. What clinical manifestations consistent with compartment syndrome does the nurse watch for? Swelling, pain, and tension of the affected limb Compartment syndrome occurs when tissue pressure within a confined space becomes elevated and blood flow is restricted. This causes increased swelling, tenderness, and tension in the affected limb. 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? Loosen the dressing and elevate the extremity to the level of the heart. When a client develops compartment syndrome, the nurse should remove or loosen the dressing and elevate the extremity to the level of the heart. In addition, the nurse must notify the health care provider immediately. The priority is to relieve pressure by loosening the dressing and positioning the extremity at 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? Palpation of the abdominal midline area Palpation on or near an aneurysm may cause pain and potential rupture. Observation, auscultation, and measurement are appropriate assessments. 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? The aneurysm is expanding and is preparing to rupture. When an aneurysm is expanding or is preparing to rupture, the client may experience severe, sudden back or lower abdominal pain that can radiate to the groin, buttocks, or legs. The other explanations are not related to potential or actual ruptur e of the aneurysm. 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? Measure abdominal girth. A sudden increase in blood pressure or hypertension can cause enlargement or rupture of the aneurysm, which w ould be correlated with an increase in abdominal girth. The other options are not indicated. 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? Measure the abdominal girth and check pulses. Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue color in the flanks, and severe pain. Elevating the head of the bed would place too much pressure on the surgical site. The other two options are not warranted. The nurse is providing discharge education to a client after repair of an abdominal aortic aneurysm (AAA). What priority instruction does the nurse include? “Avoid lifting heavy objects for about 3 months.” Clients who have undergone AAA repair must refrain from placing stress on the graft. They should avoid lifting or pulling heavy objects, and activities such as vacuuming, raking leaves, and playing golf. Clients must be cleared by their surgeon for driving. The other two options are not valid instructions. The nurse is caring for a client with Buerger’s disease. What client education does the nurse provide to minimize disease progression? “Abstain from all forms of tobacco.” The greatest risk factor for the development a nd progression of Buerger’s disease is cigarette smoking. To prevent the progression of Buerger’s disease, complete abstinence from tobacco in all forms is essential. The vasoconstrictive effects of each cigarette may last up to 1 hour after the cigarette is smoked. Teach the client to avoid extreme cold or prolonged exposure to cold to prevent vasoconstriction The nurse is assessing the extremities of a client with Buerger’s disease. What clinical manifestation does the nurse correlate with this disease? Reddened, with diminished distal pulses Clients with Buerger’s disease manifest with reddened or cyanotic extremities in the dependent position and diminished distal pulses caused by occlusions in the smaller vessels. Clients also may have ulcerations or gangrene of the digits secondary to impai red circulation. Pulses are diminished, not bounding. Reflex activity is not usually affected by this disorder. 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? “Wear warm clothing when exposed to cool temperatures.” Education is important for helping the client avoid complications. The client is instructed to wear warm clothing, such as socks and gloves, when exposed to cool temperatures to decrease vasoconstriction. The client may be prescribed vasodi lators to prevent vasoconstriction. 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? 60 seconds Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value. 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? Administer both heparin and warfarin as prescribed. Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the client’s heparin can be safely 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? “Notify your health care provider if your stools appear tarry.” As with any anticoagulation, low -molecular -weight heparin incurs risk of bleeding. Clients should be taught to report to their health care provider the presence of tarry stools, bleeding gums, hematuria, ecchymosis, or petechiae. he nurse is providing health education to a client with chronic venous stasis ulcers. What priority instruction does the nurse include? “Apply antiembolism stockings before getting out of bed in the morning.” Support hose or antiembolism stockings should be applied just before getting out of bed in the morning and should be removed before going to bed at night. Clients are advised that they will probably need to wear these stockings indefinitely. The nurse is assessing for skin changes in an African -American client admitted with peripheral arterial disease. What does the nurse monitor for? Cyanosis of the nail beds Because only severe cyanosis is evident in the skin of dark -skinned clients, cyanosis can be detected by assessing the skin and nail beds for a dull lifeless color. The soles of the feet and the toenails are less pigmented, which can enable detection of cy anosis or duskiness in the lower extremities. Loss of hair on the lower extremities is noted with peripheral artery disease. Pitting edema is associated with venous disease. The nurse assesses a client’s legs. Which assessment finding indicates arterial insufficiency? Dependent mottling and absence of hair Dependent mottling and absence of hair is an indication of arterial insufficiency. Pain may be present with activity and at rest. Edema and ankle discoloration would be indicative of venous insufficiency. 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.) Total cholesterol, 280 mg/dL Triglycerides, 200 mg/dL Low-density cholesterol, 160 mg/dL The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina? Chest discomfort when mowing the lawn and subsiding with rest The client with stable angina reports chest discomfort that occurs with moderate, prolonged exertion. This discomfort is typically relieved with nitroglycerin or rest. The other experiences do not correlate with stable angina. 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? “Do you have pain when you are resting?” An increase in the number of anginal attacks and an increase in the intensity of pain characterize unstable angina. Chest pain or discomfort also occurs at rest. The nurse should assess for this characteristic of unstable angina. The other questions would not be helpful in assessing for unstable angina. 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? “In what activities do you participate on a daily basis?” Modifiable risk factors can be altered or controlled. Cigarette smoking and a sedentary lifestyle are examples of behaviors that are modifiable. Nonmodifiable factors are personal elements that cannot be altered or controlled (e.g., age, gender, family his tory). A stress test would not provide any information about risk factors. 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? “You should talk to your provider about medica tions to help you quit smoking.” Modifiable risk factors can be altered or controlled. Cigarette smoking and a sedentary lifestyle are examples of behaviors that are modifiable. . The nurse needs to encourage the client to stop smoking because this is a proven risk factor for coronary artery disease development. The nurse should also encourage weight loss and moderate exercise. The emergency department nurse is assessing an 82 -year-old client for a potential myocardial infarction. Which clinical manifestation does the nurse monitor for? Disorientation or confusion In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations could also be related to the myocardial infarction. However, the nurse is more concerned about the new o nset of disorientation or confusion caused by decreased perfusion. Eight hours after presentation to the emergency department with reports of substernal chest pain, a client’s laboratory res ults demonstrate myoglobin levels of 55 ng/mL. What does the nurse do next? Assess the client to identify another potential cause of the chest pain. Myoglobin is a heme protein found in skeletal and cardiac muscle. With myocardial injury, myoglobin levels rise within 3 to 6 hours. If myoglobin levels have not risen within that time, the client has not experienced a myocardial infarction. The nurse shou ld assess the client to identify a potential cause for the chest pain, besides an MI. The nurse evaluates diagnostic results for a client who has chest pain. Which laboratory test is most specific for acute coronary syndromes? Troponin markers Although all these laboratory tests are appropriate to confirm or rule out a myocardial infarction, the one most specific for acute coronary syndromes is troponin T. When elevated, it serves to identify the development of unstable angina, subendocardial MI, or MI. 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? The client had a myocardial infarction in the past. A wide and large Q wave develops as a result of myocardial infarction and necrotic ventricular cells that do not conduct electrical impulses. This change is usually permanent. When it appears alone, it indicates a past MI. The other interpretations are not correct. 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? Notify the health care provider. When a client experiences chest discomfort unrelieved by nitroglycerin, the client may be experiencing a myocardial infarction. The provider should be notified and the client prepared for transfer to a unit prepared to provide specialized cardiac care. 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? Onset of ventricular dysrhythmias The nurse monitors for the following indications of clot lysis and artery reperfusion: cessation of chest pain, sudden onset of ventricular dysrhythmias, resolution of ST -segment depression, and a peak of markers of myocardial damage at 12 hours. 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? Contact the health care provider to discontinue the prescribed therapy. Recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy. The nurse should not give the medication under any conditions. The provider must be notified and made aware of the client’s stroke history. None of the other options are appropriate. 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? Administer prescribed heparin. Following clot lysis, large amounts of thrombin are released, increasing the risk of vessel reocclusion. To maintain vessel patency, IV or low -molecular -weight heparin and aspirin are prescribed. The other interventions are not appropriate for this client. 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? Wheezing Nonselective beta blockers can cause bronchoconstrict ion and impair respiratory effort. Clients with pre-existing pulmonary problems should not take nonselective beta -blocking agents. Clients who develop bronchoconstriction should have their therapy changed. The other manifestations are not adverse effects of this medication. The nurse is assisting a client to walk in the hall on th e 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? Onset of chest pain Chest pain on ambulation indicates poor tolerance to activity and is an indication that the heart is not ready for progression. The other manifestations indicate that the client is tolerating 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? Urine output of less than 30 mL/hr The nurse should remain alert for signs of poor organ perfusion that are the result of decreased cardiac output. When the kidneys are not well perfused, urine output drops to less than 30 mL/hr. Other signs include chang es in mental status; cool, clammy extremities with decreased or absent pulses; fatigue; and recurrent chest pain. The other manifestations do not indicate poor organ perfusion. The nurse is c aring 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? Administer oxygen. The nurse recognizes these manifestations as impending cardiogenic shock. Oxygen is needed to prevent further deterioration. The provider is notified immediately so that efforts can be made to reverse this cond ition because it has a mortality rate of 65% to 100%. IV fluids would enhance the respiratory edema. The client should be placed in high Fowler’s position to assist with respirations. 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 teachin g? “Change position slowly.” Calcium channel blocking agents cause systemic vasodilation and postural (orthostatic) hypotension. The client should avoid crossing legs, should weigh daily, and should decrease salt intake, but these are not associated with teaching for a calcium channel blocker. A client who is post percutaneous transluminal coronary angioplasty (PTCA) reports severe chest pain. Which action does the nurse take first? Assess the client’s vital signs and notify the health care provider. After PTCA, a small percentage of clients experience acute restenosis (closure) of the affected coronary artery. Chest pain similar to that experienced before the procedure may indicate acute restenosis. The client will need to return to the catheterization laboratory to have the procedure repeated and may need stent placement to maintain a patent vessel lumen. The nurse may relieve pain with morphine or nitroglycerin after contacting the provider. The nurse is teac hing a client prescribed sublingual nitroglycerin for chest pain. Which statement indicates that the client needs further teaching? “I carry my medicine around in a clear plastic bag so that I can get to it easily if I have chest pain.” The shelf life of nitroglycerin is short. It deteriorates quickly in the presence of light or moisture. A clear plastic bag does not provide sufficient protection to ensure potency of the drug. Nitroglycerin tablets should be replaced every 3 to 5 months. If chest pain continues after taking nitroglycerin, the client should call EMS. Nitroglycerin is given sublingua l. The nurse is assessing a client who had percutaneous transluminal coronary angioplasty (PTCA) 1 hour ago. Which complication does the nurse monitor for? Bleeding In the first few postprocedure hours, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The other problems are not complications in the imme diate post-PTCA period. 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 monit or for in this client? Bleeding Administration of glycoprotein (GP) IIa/IIIb inhibitors is common during the first few hours after PTCA. The nurse should monitor the client closely for bleeding and hypersensitivity reactions, which can include angioedema, urticaria, and even anaphylaxis. The other manifestations are not associated with the administration of GP IIa/IIIb inhibitors. 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? Document the finding. The client who is postoperative fr om a CABG is at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy. Therefore, the potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. This value is at the desired level for this client. The finding requires documentation only. 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? Check for kinks in the tubing. Sudden ces sation of mediastinal drainage could result in cardiac tamponade from accumulation of blood around the heart. If the tubing is kinked, this can be addressed quickly. If the tubing is not kinked, immediate notification of the provider is required. The other actions do not correctly address the problem. 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? Mental status Assessment of mental status is important because older adults are more likely to experience transient neurologic deficits as compared with younger adults. The other assessments are not a priority for this client. The nurse is planning dis charge education for a client after coronary artery bypass graft surgery. Which instruction does the nurse include in this client’s teaching? “Take your pulse before, midway through, and after exercising.” The client is instructed to begin a walking program that gradually lengthens in distance. The client is advised to take his or her pulse before exercising, midway through exercising, and after exercising. The client should stop exercising if the target rate is exceeded or if angina develops. The client should not take in large quantities of fluids or stop taking antihyperlipidemic medications. 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.) Cigarette smoking Hypertension Obesity 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? T-wave inversion ST-segment elevationAbnormal Q wave UWORLD REVIEW • IV Furosemide may cause ototoxicity o Rate should not exceed 4mg/min in doses >120mg • ACE inhibitor o Commonly given post MI to prevent ventricular remodeling (hypertrophy) and progression of heart failure o Can cause hyperkalemia, can lower BP, check K+ & BP • Beta blocker o Given post MI to reduce risk of reinfarction & occurrence of heart failure o S/E – bradycardia – hold med <60/min & notify HCP • Droplet precautions o PPE: surgical mask, private room, fluid contact: nitrile gloves, gown, goggles/shield ▪ Neisseria meningitides ▪ Haemophilus influenza type B ▪ Diphtheria ▪ Mumps ▪ Rubella ▪ Pertussis ▪ Streptococcus group A (strep throat) ▪ Viral Influenza • Airborne precautions o PPE: N95 particle respirator, fluid contact: nitrile gloves, gown, goggles, shield, room: neg air pressure, high eff particulate air filters ▪ Tuberculosis ▪ Varicella (chickenpox) ▪ Rubeola (measles) • CF diet= high cal, high fat, high protein; GF/celiac= BROW; Kidney=low phosphate; FVE (HF, ascites, HTN) = low NA+ • SIADH – water retention, low serum NA+ o TX= Fluid restriction to <1000 mL/day; oral salt tablets; hypertonic saline (3%); vasopressin (conivaptan); strict I&O/daily weights; monitor neuro status • Hyperkalemia and EKG o K+ 6-7 = Prolonged PR, tall peaked T wave o K+ 7-8= Loss of P wave, ST elevation, tall peaked T wave o K+ >8= Widened QRS (sine wave pattern) AV node block, fascicle & BB blocks • 24 hour limit acetaminophen = 4g • Bubbling in water seal = air leak; bubbling in suction control = normal • Iron rich foods – meats, shellfish, eggs, green leafy vegetables • Vit C foods – citrus fruits, potatoes, tomatoes, green vegetables • Rule of nines: • Heartburn during pregnancy tx: upright after meals, small freq meals, keep HOB elevated, drink smaller amounts of fluid when eating, eliminate high fat foods, caffeine/chocolate, spicy foods, carbonated drinks, peppermint • Retinal detachment= curtain appearing in vision • Macular degeneration = loss of central vision • Glaucoma= loss of peripheral vision “tunnel vision” • Cataract= cloudiness, blurry vision • Arab cannot be alone with any other woman, eye contact = no (Arab, Asian, Native American), Native American, Asian silence = respect, Asian/Hispanic touching head = disrespectful • Fractured hip = external rotation, abduction, musc spasm, shortening of extremity • The anatomical location of the phlebostatic axis is the 4th ICS, at the midway point of the AP diameter (½ AP) of the chest wall. The stopcock nearest the transducer is placed here to assure accurate pressure measurements. • Intussusception: intestine telescoping itself; causes intermittent cramping & progressive abd pain, sausage shaped mass, inconsolable crying and currant jelly stool (from blood or mucus); often tx with an air enema • Physiologic anorexia is a normal period of decreased appetite that occurs in toddlers around 18 mo; should be taught to provide mult food options, set a schedule for meals/snacks and avoid tv/games during meal time; do not force to eat • Small bowel obstruction: rapid onset of n/v; colicky ab pain, distention • Large bowel: constipatio n, lack of flatus tx: NPO, NG tube fluids, pain control • Normal troponin <.5 • Spinal immobilization: NSAIDs o N – neuro exam o S – sig traumatic mech of injury o A – alertness o I – intoxication o D- distracting injury o S- Spinal exam • Anticoagulants (heparin/warfarin) do not break down or dissolve clot but prevent further ones or any from getting bigger; warfarin requires an overlap of therapy with heparin for several days until INR is in therapeutic range • Bed to chair transfer o Full weight bear – independent; no assiss; 1 person stand by/observe o Partial – 1 person assist stand and pivot; 2 person assist with full body sling if uncooperative o None - motorized assist device if cooperative & upper body strength; 2 person assist with full body sling if uncooperative/ no strength • Antepartum bleeding: o Normal: intermittent pain w/ contractions, small amt of blood tinged mucus “bloody show” o Placental abruption: sudden -onset vag bleeding, abd pain, hypertonic/tender uterus, tachysystole o Placenta previa: painless vag bleeding, ultrasound w/ placenta covering cervical os o Uterine rupture: sudden -onset vag bleeding, constant abd pain, cessation of uterine contractions, loss of fetal station, fetal deterioration • Early and aggressive fluid resuscitation and IV antibiotic therapy are a priority for clients with systemic inflammatory response syndrome (SIRS) and suspected sepsis. SIRS criteria include temperature >100.4 F (38 C) or <97 F (36 C); tachypnea or pCO 2 <32 mm Hg (4.3 kPa); heart rate >90/min; and white blood cell count >12,000/mm3 (12.0 x 109/L) or <4,000/mm3 (4.0 x 109/L). • Nursing assessment of the client in the last hours to days of life should include the physical changes that indicate where the client is in the dying process. Some signs that the client is nearing death include the following: o Coolness and paleness or mottling of the extremities o A slack, relaxed jaw and open mouth from loss of fascial muscle tone o Difficulty in maintaining body posture or positions o Eyelids half-open o Cheyne -Stokes or uneven respirations with periods of apnea • Mono is viral – antibiotics do not work • The nurse should teach parents of an infant or child with a repaired congenital heart defect to recognize and report signs and symptoms of heart failure to the HCP. These may include rapid breathing rate; rapid heart rate at rest; dyspnea; activity intolerance (especially during feeding in infants); pale, cool extremities; weight gain; reduction in wet diapers; and puffiness around the eyes . • Scabies is spread easily via direct skin -to-skin contact. Due to the lengthy incubation period of scabies, all who have been in contact with the infested child must be treated. This involves a one-time application of a scabicide (typically 1% topical permethrin). The child's bedding and clothing should be placed in plastic bags (for a minimum of 3 days) or washed in hot water and dried on the hottest dryer cycle. • Vaccine at 12 mos - Hib, PCV, MMR, varicella & Hep A – no MMR & Varicella if immunosuppressed CD4 <15% = immunosuppressed • Acute lithium toxicity (>1.5 mEq/L [1.5 mmo l/L]) presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurological symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. The health care provider must be notified at the earliest indication of lithium toxicity • Theophylline relaxes bronchial smooth muscles, improves contractility of the diaphragm, and facilitates mucus transport by the cilia in clients with COPD. However, due to its narrow therapeutic index, theophylline levels are monitored periodically to maintain a target blood level of 10–20 mcg/mL. • Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use. • Torsades de pointes is a polymorphic ventricular tachycardia that may result from a prolonged QT interval. The nurse should question administration of any medications that may prolong the QT interval (eg, antiarrhythmics, macrolide antibiotics). • • The nurse caring for a client receiving a heparin infusion should monitor the aPTT and follow the heparin infusion protocol for titration. A therapeutic level is 1.5–2 times normal, or an aPTT of 46–70 seconds. • A client with cirrhosis may experience pruritus (itching) due to the buildup of bile salts beneath the skin. Comfort measures include encouraging the client to cut nails short and wear long -sleeved cotton shirts and cotton gloves. Baking soda baths, calamine lotion, and wet cloths also help. Cholestyramine increases the excretion of bile salts through the feces, thereby decreasing itching. • A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: o The prodromal phase is the period with warning sign s that precede the seizure (before the aural phase). o The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. o The ictal phase is the period of active seizure activity. o During the postictal phase , the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post -event confusion. • • There are no specific diagnostic tests to identify FES. However, the initial characteristic signs and symptoms include: o Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus (Option 5). o Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia (Option 1). o Petechial rash (eg, pin -sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE (Option 4). o Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction. • The priorities for a client with a suspected cervical spine injury are a patent airway and spinal immobilization. Interventions include applying a rigid hard collar (not soft collar), placing the client on a firm surface (backboard), logrolling if the client needs to be transferred, and preventing movement of the upper extremities until imaging studies are obtained. • Reduce the risk of dumping syndrome o Consume small, frequent meals to reduce the amount of food in the stomach at any one time (Option 5). o Eat slowly in a relaxed environment.