-increase the heparin infusion flow rate by 2mL/hr
-continue to monitor the heparin infusion as prescribed
-request a prothrombin time (PT)
-stop the heparin infusion.
– The aPTT level is above the therapeutic range of 1.5 to 2 times the control value. The nurse should discontinue the heparin infusion immediately and notify the provider to prevent harm to the client.
-“You may no longer be able to feel chest pain.”
-“Your level of activity intolerance will not change”
-“After 6 months, you will no longer need to restrict your sodium intake.”
-“You will be able to stop taking immunosuppressants after 12 months.”
Heart transplant clients usually are no longer able to feel chest pain due to denervation of the heart.
the point of maximal impulse is located at the left 5th intercostal space in the midclavicular line.
-hemoglobin 14 g/dL
-minimal bruising of extremities
-reduced circumference of affected extremity
the nurse should determine that an INR of 2.5 is within the desired therapeutic range and is the best evidence of effective warfarin therapy.
bradydysrhythmia can cause decreased tissue perfusion, which can lead to confusion. therefore, the nurse should monitor the client’s mental status.
-apply the new patch to the same site as the previous patch
-place the patch on an area of skin away from skin folds and joints
-keep the patch on 24hr per day
-replace the patch at the onset of angina
the client should apply the patch to an area of skin that is not prone to movement or wrinkling
-serosanguineous drainage on dressing
-severe pain with coughing
-urine output of 20 mL/hr
-increase in temperature from 36.8 C (98.2 F) to 37.5 C (99.5)
urine output less than 30mL/hr can indicate shock because it reflects decreased blood flow to the kidneys, possible from graft rupture and hemorrhage.
-weight gain of 0.9 kg (2lb) in 24 hr
-increase of 10 mm Hg in systolic blood pressure
-dyspnea with exertion
-dizziness when rising quickly
when using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5-0.9 kg (1-2 lb) in 1 day. this weight gain is an indication of fluid retention resulting from worsening heart failure. the client should report this finding immediately.
-delivery of a precordial thump
-administration of atropine IV
vagal stimulation can help the client’s heart return to a normal sinus rhythm temporarily
-neck vein distention
the greatest risk to this client is graft occlusion or rupture. therefore, monitoring urine output, which reflects blood flow to the kidneys, is the priority assessment.
-“i cant get rid of these hiccups”
-“i feel dizzy when i stand”
-“my incision site stings”
-“i have a headache”
hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can indicate a complication such as lead wire perforation.
-mediastinal drainage 100mL/hr
-blood pressure 160/80 mm Hg
-Temperature 37.1 (98.9)
-Potassium 3.8 mEq/L
the nurse should report an elevated blood pressure following a CABG procedure because increased vascular pressure can cause bleeding at the incision sites.
-limit alcohol intake
-regular exercise program
-decreased magnesium intake
-reduced potassium intake
regular exercise program
clients who have hypertension should limit alcohol intake, a regular exercise program will help reduce blood pressure, low magnesium intake is associated with hypertension, low potassium intake is associated with hypertension, smoking exacerbates hypertension
-“I am still hungry after the bowl of cereal I ate at 7 am”
-“i didn’t take my heart pills this morning because my doctor told me not to”
-“I have had chest pain a couple of times since i saw my doctor in the office last week”
-“i smoked a cigarette this morning to calm my nerves about having this procedure.”
smoking prior to the test can change the outcome and places the client at additional risk, so the test should be rescheduled.
-a client who has hypothyroidism
-a client who has diabetes mellitus
-a client whose daily caloric intake consists of 25% fat
-a client who consumes 2 bottles of beer a day
diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.
-creatine kinase- MB
creatine kinase-MB is the isoenzyme specific to the myocardium and is elevated when that muscle is injured.
a persistent cough is an adverse effect of ACE inhibitors, and the client should discontinue the medication if it occurs.
-explore the client’s family history of peripheral vascular disease
-note the presence or absence of pain at the ulcer site
-inquire about the presence or absence of claudication
-ask if the client has had a recent infection
knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
-administering IV morphine sulfate.
-administering oxygen at 2 L/min via nasal cannula
-helping the client to the bedside commode
-assisting with thrombolytic therapy
-the nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy
-increased abdominal girth
-weak peripheral pulses
-jugular venous neck distention
-weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure
-hemoglobin 14.4 g/dL
-history of peripheral arterial disease
-urine output 200 mL/4hr
-previous allergic reaction to shellfish
the contrast medium used is iodine-based. clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine.
-cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90mg/dL
-cholesterol 185 ml/dL, HDL 50 mg/dL, LDL 120 mg/dL
-cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
-cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
the expected reference range of cholesterol is less that 200 mg/dL, HDL above 40 mg/dL, and LDL less that 100 mg/dL
the greatest risk to this client is injury from an embolus caused by the atrial fibrillation. slurred speech can indicate inadequate circulation to the brain because of an embolus. the nurse should report this finding to the provider immediately.
-shortness of breath
furosemide can cause a substsantial drop in blood pressure, resulting in lightheadedness
-“my arthritis is really bothering me because i havent taken my aspirin in a week.”
-“my blood pressure shouldnt be high because i took my blood pressure medication this morning.”
-“i took my warfarin last night according to my usual schedule.”
-“i will check my blood sugar because i took a reduced dose of insulin this morning.”
clients scheduled for a CABG should not take anticoagulants, such as warfarin, for 5 to 7 days prior to the surgery to prevent excessive bleeding.
-left ventricular failure
-decreased vascular volume
activity intolerance is a finding of left ventricular failure and is associated with dilated cardiomyopathy
valvular disease or damage often occurs as a result of inflammation or infection of the endocardium
-obtain blood samples for laboratory testing
-tell the client to report vision changes
-place the head of the bed at 45 degrees
-initiate an IV
the first action the nurse should take when using the airway, breathing, circulation approach to client care is to place the head of the client’s bed at 45 degrees. this improves respiratory status and promotes venous return to reduce workload on the heart.
-increased WBC count
-blood pressure 140/82 mm/Hg on inspiration and 154/90 mm/Hg on expiration
-sinus rhythm with occasional premature atrial contractions and heart rate 88/min
pulsus paradoxus, when the systolic blood pressure is 10 mm/Hg or higher on expiration than on inspiration, is an indicator of cardiac tamponade.
a. high sodium intake
b. low protein intake
c. high calcium and potassium intake
d. low fat and cholesterol intake
a. low intake of saturated fat
b. high fruit and vegetable intake
c. low energy intake
d. high fluid intake
a. limit intake of high-cholesterol foods
b. become aware of the fat content of foods
c. obtain thorough annual physical examinations
d. develop a heart-healthy lifestyle during childhood
a. trans fat
b. saturated fat
c. polyunsaturated fat
d. monounsaturated fat
c. adenosiine triphosphate
a. low density lipoprotein
b. high density lipoprotein
c. very low density lipoprotein
d. triglyceride lipoprotein
b. 180 mg/dL
d. 250 mg/dL
a. promote weight loss
b. control fluid imbalance
c. increase phosphorus intake
d. decrease saturated fat and cholesterol intakes
a. indigestible dietary fiber
b. dietary fiber supplements
c. soluble dietary fiber
d. insoluble dietary fiber
a.increased fluid intake
b. decreased protein intake
c. sodium restriction
d. potassium restriction
a. a body mass index of 22 or greater
b. a triglyceride level of 150 mg/dl or greater
c. a blood pressure of 110/70 mm Hg or greater
d. a fasting blood sugar of 92 mg/dl or greater
c. stage 1 hypertension
d. stage 2 hypertension
a. soy products
b. milk products
c. grapefruit juice
d. tomato juice
a. soy protein
b. milk protein
c. oat protein
d. bean protein
a. “air should be instilled into the monitoring system.”
b. “the client should be in the prone position”
c. “the transducer should be level with the 2nd intercostal space”
d. “a chest x-ray is needed to verify placement”
a chest x ray is obtained to confirm proper placement of the lines
a. place the client in high fowlers position
b. level transducer to phlebostatic axis
c. zero transducer to room air
d. observe trends in readings
e. compare readings to physical assessment
the level of the transducer should be at the phlebostatic axis (right atrium) to ensure an accurate reading is obtained.
the transducer is zeroed to room air to ensure an accurate reading is obtained. hemodynamic pressure lines should be calibrated to read atmospheric pressure as zero.
the trend of the clients pressure readings assists in providing appropriate medical treatment.
readings are compared to the clients physical assessment findings to evaluate the clients condition and the appropriate treatment provided
a. heart failure
b. cor pulmonale
c. hypovolemic shock
d. pulmonary hypertension
e. peripheral edema
heart failure is associated with left ventricular failure and would be indicated by elevated hemodynamic readings
cor pulmonale is associated with the right side of the heart, and pulmonary problems would be indicated by elevated hemodynamic readings
pulmonary hypertension is associated with high blood pressure in the pulmonary arteries, affects the right side of the heart, and would be indicated by elevated hemodynamic readings.
peripheral edema is associated with left ventricular failure and would be indicated by elevated hemodynamic readings.
a. “moving in bed raises your blood pressure.”
b. “too much activity increases your risk for infection.”
c. “moving in bed increases your risk of a complication due to anesthesia”
d. “too much activity places you at risk for bleeding.”
following angiography, it is important that the client lie still due to the increased risk for bleeding at the insertion site.
a. peripheral saline lock
b. port on the arterial line
c. port on proximal (CVP) lumen of pulmonary artery (PA) catheter
d. port on distal lumen of PA catheter
e. balloon inflation port
IV fluid administration can occur via a lock on a peripheral IV catheter
the proximal (CVP) lumen of a PA catheter is used for hemodynamic monitoring and can also be used for IV fluid administration.
in the disease process underlying heart disease (artherosclerosis), the fatty deposits in blood vessel linings are made up mainly of cholesterol
the problem of CVD could be solved if cholesterol could be removed entirely from the body
hypertension occurs more frequently in Caucasians than in African americans
cholesterol is a dietary essential for adults because people depend entirely on food sources for their supply
lipoproteins are the major transport form of lipids in the blood
one of the initial clinical objectives in treating an acute heart attack is cardiac rest
in chronic congestive heart disease, the heart eventually may fail because its weakened muscle must work at a faster rate to pump the body’s necessary blood supply
the taste for salt is instinctive to ensure a sufficient supply
reduced sodium intake is an effective therapy for congestive heart failure and hypertension
d. nonfat milk
a. lemon juice
b. soy sauce
c. herbs and spices
d. seasoned salt
herbs and spices
a. less that 120 and less than 80
b. 120 to 139 and 80 to 89
c. 140 to 159 and 90 to 99
d. more than 160 and more than 100
c. cured meat
d. canned vegetables
a. a client who has metabolic alkalosis
b. a client who has a serum potassium level of 4.3 mEq/L
c. a client who has an SaO2 of 96%
d. a client who has COPD
e. a client who underwent stent placement in a coronary artery
a client who has an acid-base imbalance such as metabolic alkalosis is at risk for dysrhythmia
a client who has lung disease, such as COPD, is at risk for a dysrhythmia.
a client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia
-Ferrous Sulfate (Feofol) 200 mg PO 0800 and 2000
-Diazepam (Valium) 2 mg PO 0800 and 2000
– Isosorbide (Isordil) 2.5 mg PO 4 times a day AC and HS
-0800: T-99 BP- 142/86 mmHg HR- 88/min and irregular R- 20/min
HISTORY AND PHYSICAL
-bariatric surgery 10 yrs ago
-dyspnea with exertion for 3 yrs
-atrial fibrillation began 3 yrs ago
-client reports taking the following medications for the past 6 wks: iron supplement, multivitamin, antilipemic, and nitroglycerin.
a. respiratory history
b. vital signs
c. medication history
d. medications to be administered
a client who is to undergo cardioversion needs to be on anticoagulant therapy for 4 to 6 weeks prior to the procedure
a. follow up ECG
b. energy settings used
c. IV fluid intake
d. urinary output
e. skin condition under electrodes
the client’s ECG rhythm is documented following the procedure
energy settings used during the procedure are documented
the condition of the client’s skin where electrodes were placed is documentation
b. pacemaker insertion
c. synchronized cardioversion
d. administration of IV lidocaine
a client who has bradycardia is a candidate for a pacemaker to increase his heart rate
a. the cardioverter is being charger to the appropriate setting
b. they should initiate CPR due to pulseless electrical activity
c. they cannot be in contact with equipment connected to the client
d. a time out is being called to verify correct protocols
a safety concern for personnel performing cardioversion is to “stand clear” of the client and equipment connected to the client when a shock is delivered to percent them from also receiving a shock.
a. wear gloves when handling pacemaker leads
b. verify the use of three-pronged grouding plugs
c. minimize client’s shoulder movements
d. keep the lead wires taut when turning the client
e. additional batteries should be kept at the nurses’ station
gloves are worn when handling pacemaker leads
three pronged grounding plugs reduce the risk of accidental electrical discharge by equipment being used
the client’s shoulder movement should be minimized or the client should wear a sling to promote secure anchoring of the lead wires
a. cleanse the client’s skin with soap and water
b. prepare the client for insertion of a permanent pacemaker
c.obtain signed informed consent form for a pacemaker
d. apply transcutaneous pacemaker pads
before applying transcutaneous pacemaker pads, the client’s skin is cleaned with soap and water and dried throroughly
a. cool and clammy foot with capillary refill of 5 seconds
b. observed pacing spike followed by a QRS
c. twitching of intercostal muscle
d. heart rate of 84/min
e. blood pressure of 104/62 mm Hg
a cool, clammy foot may be an indication of a femoral hematoma secondary to insertion of the lead wires and should be reported
twitching of the intercostal muscle may indicate lead wire perforation and stimulation of the diaphragm and should be reported
a. “i will notify the airport screeners about my pacemaker”
b. ” I will call my doctor about hiccups”
c. “i will have to disconnect my garage door opener”
d. “i will take my pulse every morning when I awaken.”
the use of household appliances, such as microwaves and garage door openers, does not affect pacemaker function
a. “this means the pacemaker fires in an asynchronous pattern.”
b. “this means the pacemaker firs only when the heart rate is below a certain rate.”
c. “the pacemaker can automatically adjust to a client’s increased activity level.
d. “the pacemaker activity is triggered by heart muscle activity.”
fixed rate mode is asynchronous, meaning the pacemaker fires without regard for electrical activity in the heart.
a. allow the client to rest, and return in 1 hr.
b. administer IV bolus analgesic, and return in 15 min.
c. document the 200 mL as an appropriate inspired volume.
d. tell the client that he must try to cough if he does not want to get pneumonia
providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness
a. trace of bloody drainage on dressing
b. capillary refill of affected limb of 6 seconds
c. mottled appearance of the limb
d. throbbing pain of affected limb that is decreased following IV bolus analgesic
e. pulse of 2+in the affected limb
capillary refill greater than 2 to 4 seconds is outside the expected reference range and should be reported to the provider
mottled appeariance of the affected extremity is an unexpected finding and should be reported to the provider
a. the client’s demand for oxygen is lowered
b. motion of the heart ceases
c. rewarming of the client takes place
d. the clients metabolic rate is increased
e. blood flow to the heart is stopped
the use of cardiopulmonary bypass reduces the client’s deman for oxygen, which reduces the risk of inadequate oxygenation of vital organs
motion of the heart ceases during cardiopulmonary bypass to allow for placement of the graft near the affected coronary artery
the core body temperature is lowered for the procedure, and rewarming then occurs through heat exchanges on the cardiopulmonary bypass machine
a. retroperitoneal bleeding
b. cardiac tamponade
c. bleeding from the incisional site
d. heart failure
bleeding is occuring from the incision site and then draining under the client. the nurse should assess the incision for hematoma, apply pressure, monitor the client, and notify the provider
a. rubor of the affected leg when elevated
b. 3+ dorsal pedal pulse in left foot
c. thin, peeling toenails of left foot
d. report of intermittent claudication in the affected leg
a client who has peripheral artery disease may report that numbness or burning pain in the extremity ceases with rest (intermittent claudication)
a. angina can be relieved with rest and nitroglycerin
b. the pain of an MI resolves in less than 15 min
c. the type of activity that causes an MI can be identified
d. angina can occur for longer than 30 min
angina can be relieved by rest and nitroglycerin
b. troponin I
c. troponin T
the troponin T level will still be evident 14 to 21 days following an MI
a. “aspirin reduces the formation of blood clots that could cause a heart attack”
b “aspirin relieves the pain due to myocardial ischemia.”
c. aspirin dissolves clots that are forming in your coronary arteries”
d. “aspirin relieves headaches that are caused by other medications.
aspirin decreased platelet aggregation that can cause a myocardial infarction
a. “i should place the tablet under my tongue”
b. ” should have my clotting time checked weekly.”
c. “I will report any ringing in my ears”
d. “i will call my doctor if my pulse rate is less than 60”
the client is advised to notify the provider if bradycardia occurs
a. diet modification
b. relaxation exercises
c. smoking cessation
d. taking omega-3 capsules
according to the airway, breathing, and circulation (ABC) priority-setting framework, adequate oxygenation is the priority. nicotine causes vasoconstriction, elevates blood pressure, and narrows coronary arteries. therefore, smoking cessation should be the first recommended lifestyle change.
a. obtain the client’s weight
b. assist the client into high fowlers position
c. auscultate lungs sounds.
d. check oxygen saturation with pulse oximeter.
using the airway, breaking, and circulation (ABC) priority-setting framework, the first action is to assist the client into high fowlers position. this will decrease venous return to the heart (preload) and help relieve lung congestion
a.”pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink”
b. “each flass contains 8 ounces. there are 30 mL per ounce, so you can have a total of 8 glasses or cups of fluid each day.
c. “this is the same as 2 quarts, or about the same as two pots of coffee.
d. “take sips of water or ice chips so you will not take in too much fluid.”
pouring the amount of fluid consumed into an empty 2L bottle provides a visual guide for the client as to the amount consumed and how to plan daily intake
a. cheddar cheese, 2 oz
b. hot dog
c. canned tuna, 3 oz
d. roast chicken breast, 3 oz
e. baked ham, 3 oz
processed cheese contained 800 mg sodium per 2 oz
a hot dog contains 615 mg sodium
canned tuna contains 350 mg sodium per 3 oz
lean, baked ham contains 1020 mg sodium per 3 oz
a. “i will consume more white rice.”
b. “i will eat more baked potaotes”
c. “i will drink more grape juice.”
d. “i will use more powdered cocoa mixes.”
baked potatoes are a good source of potassium, containing 854 mg
b. persistent cough
c. increased urinary output
d. thick, yellow sputum
tachypnea is an expected finding in a client who has pulmonary edema
a persistent cough with pink, frothy sputum is an expected finding in a client who has pulmonary edema
orthopnea is an expected finding in a client who has pulmonary edema
a. “i will be glad to get back to my exercise toutine right away.”
b. “I will have my prothrombin time checked on a regular basis.”
c. “I will talk to my dentist about no longer needing antibiotics before dental exams.”
d. “I will continue to limit my intake of foods containing potassium.”
anticoagulant therapy with warfarin (coumadin) is necessary for the client following placemtent of a mechanical heart valve; the client’s prothrombin time will be checked on a regular basis.
c. crackles in lung bases
crackles in the lung bases is an expected finding in a client who has pulmonary congestion due to mitral valve insufficiency.
a. surgical repair of an atrial septal defect at age 2
b. measles infection during childhood
c. hypertension for 5 yrs
d. weight gain of 10 lb in the past year
e. diastolic murmur present
a history of congenital malformations is a risk factor for valvular heart disease
hypertension places a client at risk for valvular heart disease.
a murmur indicates turbulent blood flow, which is often due to valvular heart disease.
a. “this will improve blood flow in your mother’s coronary arteries.”
b.” this will permit your mother to resume her activities of daily living.”
c.”this will prolong your mothers life”
d.”this will reverse the effects to the damaged area.”
surgery is indicated for older adult clients when clinical manifestations interfere with activities of daily living.
b. client report of fatigue
d. pleural friction rub
e. peripheral edema
dyspnea is a clinical manifestation of right-sided valvular heart disease
a client’s report of fatigue is a client manifestation of right sided valvular disease
peripheral edema is a clinical manifestation of right sided valvular heart disease
d. friction rub
a friction rub can be heard during auscultation of a client who has pericarditis
a. an older adult who has chronic obstructive pulmonary disease
b. a child who has an upper respiratory streptococcal infection
c. a middle age adult who has lupus erythematosus
d. a younge adult who is at 24 weeks of gestation
a child who has an upper respiratory due to streptococcal bacteria is at highest risk for developing rheumatic endocarditis. approx 50% of clients who have rheumatic fever develop rheumatic endocarditis.
a. platelets 100,000/mm3
b. serum glucose 110 mg/dL
c. serum creatinine 0.7 mg/dL
d.amino alanine transferase (ALT) 30 IU/L
long term NSAID therapy can lower platelets. this finding is outside the expected reference range and should be reported to the provider
a. infective endocarditis.
d. rheumatic endocarditis
splinter hemorrhages in nail beds and a report of fever are findings associated with infective endocarditis
a. arterial blood gases
b. serum albumin
c. liver enzymes
d. throat culture
a. edema around the clients ankles and feet
b. ulceration around the clients medial malleoli
c. scaling eczema of the client’s lower legs with stasis dermatitis
d. pallor on elevation of the clients limbs and rubor when his limbs are dependent
in a clinet who has chronis PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered
a. with the affected limb hanging from the bed
b. with the affected limb elevated on pillows
c. with the head of the bed raised
d. in a side lying, recumbent position
the client will prefer sleeping with the affected extremity in a dependent position because this relieves pain
a. effects may not be apparent for several weeks
b. monitor for the presence of black, tarry stools
c. instruct the client to use an electric razor
d. schedule a weekly PT test
e. advise the client about food sources containing vitamin K
therapeutic benefits may not occur for several weeks when taking plavix
evidence of GI bleedings, such as abdominal pain, coffee-groung emesis, or black, tarry stools should be monitored and reported to the provider
a. “i will remind your provider that you are already receiving heparin.”
b. “laboratory findings indicated that two anticoagulants were needed.’
c.”it takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued.”
d.”only one of these medications is being given to treat your DVT
warfarin depresses synthesis of clotting factors but does not have effect on clotting factors that are present. therefore, it takes 3 to 4 days before the clotting factors that are present decay and the therapeutic effects of warfarin occur.
a. massage both legs firmly with lotion prior to applying the stockings.
b. apply the stockings in the morning upon awakening and before getting out of bed
c. roll the stockings down to the knees if they will not stay up on the thigs.
d. remove the stockings while out of bed for 1 hr, four times a day to allow the legs to rest
applying stockings in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. legs are less edematous at this time.
the pericardial sav is filled with approx 50 mL of serous sanguineous fluid.
20 mL of serous fluid. NOT SANGUINEOUS (bloody)
the heart has 2 main chambers.
the chordae tendineae and papillary muscle are the supporting structures for the heart valves.
epicardium-thin fibrous outter layer
myocardium-muscular middle layer
endocardium-vascular inner layer
a. drinking 8 oz of nonfat milk daily
b. eating popcorn at the movie theater
c. walking 1 mile daily at 12 min/mile pace
d. consuming 36 oz of beer daily
e. getting a masasge once a week
popcorn at a movie theater contains a large quantify of sodium and fat, which increases the risk for hypertension
consuming more than 24 oz of beer per day can contribute to weight gain, which increases the risk for hypertension
a. administer acetaminophin for headache.
b. provide teaching in regard to the importance of not abruptly stopping antihypertensive
c. obtain IV access and prepare to administer an IV antiypertension
d. call social services for a referral for financial assistance in obtainind prescribed medication.
the greatest risk to the client is injury due to a blood pressure of 266/147 mm Hg, which can be life threatening and should be lowered as soon as possible. obtaining IV access will permit administration of an IV hypertensive, which will act more rapidly than by the oral route
d. aortic valve
tricuspid- RA and RV and bicuspid/mitral- LA and LV= S1
Semilunar valves= s2
a. systemic and pulmonic
b. pericardial and effusion
c. pulmonic and systemic
d. pulmonary arteries and veins
Right sided pumping (pulmonic)
SVC, IVC, RA, RV, pulmonary arteries, and lungs
a. pulmonary arteries
b. coronary sinus
c. pulmonary veins
d. coronary arteries
they are perfused during diastolic
b. immediately after lunch
c. immediately before dinner
the client should take furosemide, a diuretic in the morning so that the peak action and duration of the medication occurs during waking hours.
a. coronary arteries
b. pulmonary veins
c. pulmonary arteries
d. coronary sinus
–the hearts venous return system
a. “i should eat a lot of fruits ang vegetables, especially bananas and potaotes.”
b. “i will report any changes in heart rate or rhythym”
c. “i should use a salt substitute that is low in potassium”
d. ” i will continue to take this medication even if i am feeling better.”
potatoes and bananas are high inpotassium, and spironolactone is a potassium-sparing didduretic. consuming these foods can lead to hyperkalemia.
a. takes psyllium hydrophilic muccilloid (metamucil) daily
b. drinks skim milk daily
c. takes metoprolol (lopressor) daily
d. drinks grapefruit juice daily
lopressor can mask the effects of hypoglycemia in clients with diabetes mellitus. this should be reported to the provider
reducing afterload will allow the heart to pump more effectively, which is needed for the client who has cardiogenic shock.
a. maintaining adequate fluid volume with IV infusions
b. administering antibiotic therapy
c. monitoring hemodynamic status
d. administering vasopressor medication
using the safety and risk reduction framework, administration of antibiotics is the priority action by the nurse. eliminating endotoxins and mediators from bacteria will reduce the vasodilation that is occurring
a. methylprednisolone (solu-medrol) IV bolus
b. diphenhydramine (benadryl) sub q
c. epinepherine (adrenaline) IV
d. albuterol (proventil) inhaler
using the airway-breathing-circulation (ABC) priority-setting framework, epinephrine is administered first. it is a rapid-acting medication that promotes effective oxygenation and is used to treat anaphylactic shock.
a. heart rate 60/min
b. seizure activity
c. respiratory rate 42/min
d. increased urine output
e. weak, thready pulse
seizure activity may be present in a client who is in shock
tachypnea is an expected finding in a client who is in shock
a weak, thready pulse is an expected finding in a client who is in shock.
a. administer large volumes of IV fluids
b. assist with insertion of pulmonary artery catheter
c. obtain doppler pulses of the extremtites.
d. gather supplies for insertion of a peripheral IV catheter
a pulmonary artery catheter and pressure-monitoring system are inserted for hemodynamic monitoring of a client.
a. administer plan medication as prescribed.
b. ensure a warm environment
c. administer IV fluids as prescribed
d. initiate a 12-lead ECG
using the ABC priority-setting framework, the greatest risk to the client is inadequate circulatory volume. the priority nursing intervention is to administer IV fluids
a. assess pedal pulses
b. monitor for an increase in pain below the graft site
c. maintain client in high fowlers position
d. administer prescribed antiplatelet agents
e. report an hourly urine output of 60 mL
pulses distal to the graft site should be monitored to detect possible occlusion of the graft
pain below the graft site can be an indication of graft occlusion or rupture
antiplatelet agents and anticoagulants are prescribed to prevent thrombus formation
a. “the wall of an artery becomes thin and flexible.”
b. “it is due to turbulence in bblood flow in the artery”
c. “it is due to abdominal enlargement.”
d.”it is due to hypertension”
hypertension increases pressure within the arterial walls, resulting in rupture
a. increased urine output
b. bounding pedal pulse
c. increased abdominal girth
d. redness of the lower extremtities
abdominal distention is an expected finding with occlusion of a graft of the aorta
b. shortness of breath
c. upper chest pain
e. altered swallowing
cough is a manifestation of a thoracic aortic aneurysm
shortness of breath is a manifestation of a thoracic aortic aneurysm
difficulty swallowing is a manifestation of a thoracic aortic aneurysm
a. pulse rate in upper extremities
b. blood pressure in the left arm
c. description of the pain
d. sound of the apical pulses
if the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. the nurse weighs the patient and measures vital signs. the nurse may measure BP in both arms and compare findings. the nurse assesses apical and radial pulses, noting rate, quality, and rhythm. the nurse also checks peripheral pulses in the lower extremities.
a. by checking peripheral pulses
b. by observing the pt for bleeding
c. by hemodynamic monitoring
d. by checking for cardiac dysrhythmias
peripheral arteriography is used to diagnose occlusive arterial disease in smaller arteries. the nurse observes the pt for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses. hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system.
a. heart failure
b. turbulent blood flow
c. diseased heart valves
d. hypertensive heart disease
auscultation of the heart requres familiarization with normal and banormal heart sounds. an extrea sound just before s1 is an s4 heart sound, or atrial gallop. an s4 sound often is associated with hypertensive heart disease. a sound that follows s1 and s2 is called an s3 heart sound or a ventricular gallop. an s3 heart sound is often an indication of heart failure in an adult. in addition to heart sounds, auscultation may reveal other abnormal sounds, such as murmurs and clicks, caused by turbulent blood flow through diseased heart valves.
automaticity is the ability of specialized electrical cells of the cardiac conduction system to inititiate an electrical impulse. contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse. conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another. excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.
a. 1 inch to the left of the xiphoid process
b. left midclavicular line, 5th intercostal space
d. 2 inches to the left of the lower end of the sternum
the left ventricle is responsible for the apical impulse or the PMI, which is normally palpable in the left midclavicular line of the chest wall at the 5th intercostal space. the right ventricle lies anteriorly, just beneath the sternum. use of inches to identify the location of the PMI is inappropriate based on variations in human anatomy. auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the PMI
a. pulmonary artery wedge pressure
b. pulmonary artery pressure
c. central venous pressure
d. cardiac output
when the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed and the ressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure. central venous pressure is measured in the right atrium. pulmonary artery pressure is measured when the balloon tip is not inflated. cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.
a. sinoatrial (SA) node
b. bundle of His
c. atrioventricular (AV) node
d. purkinje fibers
the SA node is the primary pacemaker of the heart. the AV node coordinates the incoming electrical impulses from the atria and, after a slight delay, relays the impulses to the ventricles. the Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles.
contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while the potassium exits the cell. repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell. diastole is the period of ventricular relaxation resulting in ventricular filling.
a. increased size of left atrium
b. endocardial fibrosis
c. myocardial thinning
d. increase in the number of SA node cells
age-related changes associated with the cardiac system include endocardial fibrosis, increased size of the left atrium, decreased number of SA node cells, and myocardial thickening.
a. reduced stroke volume
b. reduced distensibility of the arteries
c. elevated stroke volume
decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.
a. aortic area
b. erb’s point
c. epigastric area
d. pulmonic area
erb’s point is located at the third IC space to the left of the sternum. the aortic area is located at the second IC space to the right of the sternum. the pulmonic area is at the second IC space to the left of the sternum. the epigastric area is located below the xiphoid process.
b. friction rub
c. opening snap
d. ejection click
in pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. a murmur is created by the turbulent flow of blood. a cause of the turbulence may be a critically narrowed valve. an opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. an ejection clich is caused by very high pressure within the ventricle, displacing a rigid calcified aortic valve.
a. heart rate changes; 78 bpm to 112 bpm.
b. BP changes; 148/80 mm Hg to 166/90 mm Hg
c. dizziness and leg cramping
d. ST-segment changes on the ECG
during the test, the following are monitored: 2 or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temp; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue. the test is terminated when the target heart rate is achieved or if the pt experiences signs of myocardial ischemia. further diagnostic testing, such as cardiac catheterization, may be warranted if the pt develops chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG during the stress test. the other findings would not warrant the testing to be stopped.
a. left sided heart failure (HF)
b. excessive blood loss
the normal CVP is 2 to 6 mm Hg. a CVP greater than 6 mm Hg indicates an elevated right ventricular preload. many problems can cause an elevated CVP, but the most common is hypervolemia (excessive fluid circulating in the body) or right sided HF. in contrast, a low CVP (<2mm Hg) indicates reduced right ventricular preload, which is most often from hypovolemia.
a. “what was your morning blood sugar reading?”
b. “are you having chest pain?”
c. “when was the last time you ate or drank?”
d. “are you allergic to shellfish?
radiopaque contrast agents are used to visualize the coronary arteries. some contrast agents contain iodine, and the pt is assessed before the procedure for the previous reactions to contrast agents or allergies to iodine-containing substances (seafood). if the pt has a suspected or known allergy to the substance, antihistamines or methylprednisolone (solu medrol) may be administered before the procedure. although the other questions are impt to ask the pt, it is most impt to ascertain if the pt has an allergy to shellfish.
a. taking the pts BP with the pt sitting on the edge of the bed with feel dangling
b. obtaining the supine measurements prior to the sitting and standing measurements
c. letting 30 seconds elapse after each position change before measuring BP and HR
d. positioning the pt supine for 10 min prior to taking the initial BP and HR
the following steps are recommended when assessing pts for posturan hypotension: position the pt supine for 10 min before taking the initial BP and HR measurements; reposition the pt to a sitting position with legs in the dependent position, wait 2 min then reassess both BP and HR measurements; if the pt is symptom free or has no significant decreases in systolic or diastolic BP, assist the pt into a standing position, obtain measurements immediately and recheck in 2 min; continue measurements every 2 min for a total of 10 min to rule out postural hypotension. return the pt to supine position if postural hypotension is detected or if the pt becomes symptomatic. document HR and BP measured in each position (e..g., supine, sitting, and standing) and any s/s that accompany the postural changes.
a. position the pt on his/her stomach for the procedure
b. remove the pts transderm nitro patch
c. sedate the pt prior to the procedure
d. remove the pts jewelry
e. offer the pt a headset to listen to music during the procedure
transdermal patches that contain a heat conducting aluminized layer (nicoderm, androderm, transderm nitro, transderm scop, catapres-tts) must be removed before MRA to prevent burning of the skin. a pt who is claustrophobic may been to receive a mild sedative before undergoing an MRA. during an MRA, the pt is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field. pts are instructed to remove any jewelry, watches, or other metal items (ECG leads). an intermittent clanking or thumping that can be annoying is generated by the megnetic coils, so the pt may be offered a headset to listen to music.
a. once the electrodes are applied, change them q72 hr
b. clean the pts chest with alcohol prior to application of electrodes
c. apply baby powder to the pts chest prior to placing the electrodes
d. clip the pts chest hair prior to applying the electrodes
the nurse should complete the following actions when applying cardiac electrodes: clip(do not shave) hair from around the electrode site, if needed; if the pts diaphoretic (sweaty), apply a small amount of benzoin to the skin, avoiding the area under the center of the elctrode; debride the skin surface of dead cells with soap and water and dry well (or as recommended by the manufacturer). change the electrodes q 24 – 48 hrs ( or as recommended by the manufacturer); examine the skin for irritation and apply the electrodes to diff locations.
a. pulmonary edema
b. ventricular hypertrophy
c. heart failure
d. myocardial infarction
a BNP level greater than 100 pg/mL is suggestive of HF. Because this serum lab test can be quickly obtained, BNP levels are useful for prompt diagnosis of HF in settings such as the ED. elevations in BNP can occur from a number of other conditions such as pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy. therefore, the clinician correlates BNP levels with abdnormal physical assessment findings and other diagnostic tests before making a definitive diagnosis of HF.
a. obtain an o2 saturation level
b. assess the pts capillary refill
c. assess pt for pitting edema
d. obtain a 12 lead ECG tracing
clubbing of the fingers and toes indicates chronic hemoglobin desaturation (decreased o2 supply) and is associated with congenital heart disease. the nurse should assess the pts o2 saturation level and intervene as directed. the other assessments are not indicated.
a. supine: BP 140/78 HR 72; sitting: BP 145/78 HR 74; standing: BP 144/78 HR74
b. supine: BP114/82 HR 90 ; sitting: BP 110/76 HR 95 ; standing: BP 108/74 HR 98
c. supine: BP 120/70 HR 70 ; sitting: BP 100/55 HR 90 ; standing: BP 98/52 HR 94
d. supine: BP 130/70 HR 80 ; sitting: BP 128/70 HR 80 ; standing: BP 130/68 HR 82
postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 min of moving from a lying or sitting position to a standing position. the following is an example of BP and HR measurements in a pt with postural hypotension: supine: BP 120/70 HR 70; sitting BP 100/55 HR 90; standing BP 98/52 HR 94. normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure
a. “if any discharge occurs at the puncture site, call 911 immediately.”
b.”you can take a tub bath or shower when you get home.”
c.”do not bend at the waist, strain, or lift heavy objects for the next 24 hrs.”
d. “contact your primary care provider if you develop a temp above 102.”
the nurse should instruct the pt to complete the following: if the artery of the groin was used, for the next 24 hrs, do not bend at the waist, strain, or lift heavy objects; the priary provider should be contacted if any of the following occur: swelling, new bruising or pain from your procedure puncture site, temp of 101 or more. If bleeding occurs, lie down (groin approach) and apply firm pressure to the puncture site for 10 min. notify the primary provider as soon as possible and follow instructions. if there is a large amount of bleeding, call 911. the pt should not drive to the hospital.
b. international normalized ratio (INR)
c. complete blood count (CBC)
d. Partial thromboplastic time (PTT)
the INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from dif labs. the INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. the therapeutic range for INR is 2-3.5, although specific ranges vary based on diagnosis. the other lab values are not used to evaluate the effectiveness of coumadin.
a. BP 108/60 mm Hg, ascites, and crackles
b. disorientation, 20 mL of urine over the last 2 hrs
c. reduced pulse pressure and heart murmur
d. elevated jugular venous distention (JVD) and postural changes in BP
assessment findings associated with reduced cardiac output include reduced pulse pressure, hypotension, tachycardia, reduced uring output, lethargy, or disorientation
c. air embolism
d. catheter-related bloodstream infections (CRBSI)
CRBIs are the most common preventable complication associated with hemodynamic monitoring systems. comprehensive guidelines for the precention of these infections have been published by CDC. complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax, infection, and air embolism. a pneumothorax may occur during the insertion of catheters using a central venous approach (CVP and pulmonary artery catheters:. air emboli can be introduced into the vascular system if the stopcocks attached to the pressure transducers are mishandled during blood drawing, administration of medications, or other procedures that require opening the system to air.
relation to the heart cycle and duration
intensity grades I to VI
quality-harsh, musical, or rough in high, medium, or low pitch
variation with position (sitting, lying, standing)
ostium primum (ASD1): the opening is located at the lower portion of the septum.
ostium seundum (ASD2): the opening is located near the center of the septum.
sinus venosus defect: the opening is located near the junction of the superior vena cava and the right atrium.
s/s of heart failure typically occur at 4-6 wks of age and may include easily tiring and/or color changes and diaphoreis during feeding; lack of thriving; pulmonary infections, tachypnea, or shortness of breath; edema; murmurs; thrill in the chest upon palpation.
congenital heart defects; prosthetic heart valves; central venous catheters; intravenous drug use.
a. steady weight gain since birth
b. softening of the nail beds
c. appropriate mastery of developmental milestones
d. intact rooting reflex
softening of nail beds is the first sign of clubbing due to chronic hypoxia. rounding of the fingernails is followed by shininess and thickness of nail ends.
the normal infant heart rate evgs 120-130 bpm; the toddler’s or preschoolers is 80-105, the school-age child’s is 70-80 bpm, and the adolescent’s heart rate avg 60-68
a. mark the location of the child’s peripheral pulses with an indelible marker
b. mark the child pedal pulses with an indelible marker, then document
c. document the location and quality of the pedal pulses
d. assess the location and quality of the child’s peripheral pulses
the nurse should pay particular attention to assessing the childs peripheral pulses, including pedal pulses. using an indelible pen, the nurse should mark the location of the childs pedal pulses as well as document the location and quality in the childs medical records.
a. his apgar score was an 8
b. i was really nauseous throughout my whole pregnancy
c. i am on a low dose of lithium
d. i had the flu during my last trimester
some medications, like lithium, taken by pregnant women may be linked with the development of congenital heart defects. reports of nausea during pregnancy and an Apgar score of eight would not trigger further questions. febrile illness during the first trimester, not the third, may be linked to an increased risk of congenital heart defects.
a. edema of the lower extremities
b. edema of the face
c. edema in the presacral region
d. edema of the hands
edema of the lower extremities is characteristic of right ventricular heart failure in older children. in infants, peripheral edema occurs first in the face, then the presacral region, and the extremities.
a. appropriate mastery of developmental milestones.
b. bounding pulse
c. preference to resting on the right side
d. pitting periorbital edema
a bounding pulse is characteristic of patent ductus arteriosis or aortic regurgitation. narrow or thready pulses may occur in children with heart failure or severe aortic stenosis. a normal pulse would not be expected with aortic regurgitation.
a. decreased blood pressure
b. a heart murmur
c. cool, clammy, pale extremities
d. accentuated third heart sound
an accentuated third heart sound is suggestive of sudden ventricular distention. decreased blood pressure, cool,clammy, and pale extremities, and a heart murmur are all associated with cardiovascular disorders; however, these findings do not specifically indicate sudden ventricular distention.
a. grade I
b. grade II
c. grade III
d. grade IV
a heart murmur characterized as loud with a precordial thrill is classified as grade IV. grade II is soft and easily heard. grade I is soft and hard to hear. grade III is loud without thrill.
b. 80 to 100/64
c. 94 to 112/56 to 60
d. 100 to 120/50 to 70
the normal adolescent’s BP averages 100 to 120/50 to 70. the normal infant’s BP is about 80/40. the toddler or preschoolers BP averages 80 to 100/64. the normal schoolager’s BP averages 94 to 112/56 to 60.
a. a milk to late ejection click at the apex
b. abdnormal splitting of s2 sounds
c. clicks on the upper left sternal border
d. intensifying of s2 sounds
a mild to late ejection click at the apex is typical of a mitral valve prolapse. abnormal splitting or intensifying of S2 sounds occurs in children with major heart problems, not mitral valve prolapse. clicks on the upper left sternal borner are related to the pulmonary area.
a. the chest tube drainage had been averaging 15-25 mL out per hour and now there is no drainage from the chest tube
b. the childs heart rate has increased from 88 bpm to 126 bpm
c. the childs right atrial filling pressure has decreased
d. the child is resting quietly
e. the childs apical heart rate is strong and easily auscultated
abrupt cessation of chest tube output and an increased heart rate are indicators that the child may have developed cardiac tamponade. the child’s right atrial filling pressure will increase. the child may be anxious and their apical heart rate may be faint and difficult to auscultate.
a. the 4 month old childs apical heart rate is 102 bpm
b. the 12 year olds digoxin level was 0.9 ng/mL from a blood draw this morning
c. the 16 yo child has a heart rate of 54 bpm
d. the 2 yo child has a digoxin level of 2.4 ng/mL from a blood draw this morning
e. the 5 yo child has developed vomiting, diarrhea and is difficult to arouse.
The nurse should not administer digoxin to children with the following issues: the adolescent with an apical pulse under 60 bpm, the child with a digoxin level above 2 ng/mL, and the child who exhibiting signs of digoxin toxicity.
a. the young child has an elevated erythrocyte sedimentation rate
b. the young child has a temp of 101.2
c. the child has painless nodules located on his wrists
d. the child has developed reicarditis with the presence of a new heart murmur
e. the child has developed heart block with a prolonged PR interval
subcutaneous nodules and carditis are considered major criteria used in the diagnosing process of acute rheumatic fecer. the other options are minor criteria.
a. the right groin is soft without edema
b. the childs right foot is cool with a pulse assessed only with the use of a doppler
c. the child has a temp of 102.4
d. the child is complaining of nausea
e. the child has a runny nose
the following information should be reported to the physician following a cardiac catheterization because they are indicative of possible complications: negative changes to the child’s peripheral vascular circulatory status (cool foot with poor pulse), a fever over 100.4, and nausea or vomiting.