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Cardiovascular System

October 21, 2010 Leave a comment Go to comments

Cardiovascular system

  1. A 10-month-old infant with tetralogy of Fallot (TOF) experiences a cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which of the following positions?

    • 1   –   Knee-to-chest
    • 2   –   Fowler’s
    • 3   –   Trendelenburg’s
    • 4   –   Prone

    RATIONALE: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and overriding aorta. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The knee-to-chest position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. During a cyanotic episode, the child with TOF typically assumes this position instinctively. Fowler’s, Trendelenburg’s, and prone positions don’t improve oxygenation.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  2. A 55 year-old male requires a 12-lead electrocardiogram. Identify the area where the nurse will place the V2 lead on the chest wall.
    • -

    RATIONALE: The V2 lead is placed at the fourth intercostal space at the left sternal border.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Comprehension

  3. A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use an intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which of these conditions contraindicates use of the IABP?
    • 1   –   Unstable angina pectoris
    • 2   –   Aortic insufficiency
    • 3   –   Hypertension
    • 4   –   Diabetes mellitus

    RATIONALE: A history of aortic insufficiency contraindicates use of an IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, severe left ventricular dysfunction, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn’t respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren’t contraindications for IABP.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  4. A client comes to the emergency department complaining of visual changes and a severe headache. The nurse measures the client’s blood pressure, which is 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What’s the most common cause of malignant hypertension?
    • 1   –   Pyelonephritis
    • 2   –   Dissecting aortic aneurysm
    • 3   –   Pheochromocytoma
    • 4   –   Untreated hypertension

    RATIONALE: Untreated hypertension is the most common cause of malignant hypertension. Pyelonephritis, dissecting aortic aneurysm, and excessive catecholamine release (an effect of pheochromocytoma) are less common causes. Rarely, malignant hypertension results from eclampsia, ingestion of or exposure to drugs or toxic substances, and food and drug interactions (such as monoamine oxidase inhibitors with aged cheeses).
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  5. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?
    • 1   –   Deficient knowledge related to interventions used to treat acute illness
    • 2   –   Impaired physical mobility related to complete bed rest
    • 3   –   Social isolation related to restricted visiting hours in the intensive care unit
    • 4   –   Anxiety related to the threat of death

    RATIONALE: Anxiety related to the threat of death is an appropriate nursing diagnosis because the client’s anxiety can adversely affect heart rate and rhythm by stimulating the autonomic nervous system. Also, because the client required resuscitation, the threat of death was a real and immediate concern. Unless the nurse deals with anxiety first, the client’s emotional state impedes learning. Client teaching should be limited to clear, concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the knowledge deficit would continue despite attempts at teaching. Impaired physical mobility and social isolation are necessitated by the client’s critical condition; therefore, they aren’t considered problems warranting nursing diagnoses.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

  6. A client comes to the physician’s office for a complete physical examination required for employment. The physician assesses the client’s arms and legs for evidence of peripheral vascular disease. Which of the following is the most commonly used overall indicator of arm and leg circulation?
    • 1   –   Exercise testing
    • 2   –   Ankle-brachial index
    • 3   –   Limb blood pressure
    • 4   –   Allen’s test

    RATIONALE: The ankle-brachial index is the most commonly used overall indicator of arm and leg circulation. Exercise testing reveals the severity of intermittent claudication and suggests how extensively this condition affects the client’s lifestyle. Limb blood pressure is the single best indicator of arm or leg perfusion, but its significance is limited to the limb being examined; limb blood pressures may vary greatly if peripheral vascular disease is present in one limb but not the other. Allen’s test is used to evaluate blood flow in the arm.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  7. A client experiences orthostatic hypotension while receiving furosemide (Lasix) to treat hypertension. How should the nurse intervene?
    • 1   –   Administer I.V. fluids, as ordered.
    • 2   –   Administer a vasodilator, as prescribed.
    • 3   –   Insert an indwelling urinary catheter, as ordered.
    • 4   –   Instruct the client to sit up for several minutes before standing.

    RATIONALE: To minimize the effects of orthostatic hypotension, the nurse should instruct the client to rise slowly to a standing position. Suggesting that the client sit up for several minutes first is typically helpful. Administering I.V. fluids would be inappropriate (unless the client were dehydrated) because it would counteract the effects of furosemide, possibly leading to fluid imbalance. Administering a vasodilator would reduce the client’s blood pressure further and worsen orthostatic hypotension. Inserting an indwelling urinary catheter would aid the monitoring of urine output but wouldn’t minimize the effects of orthostatic hypotension.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  8. A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer:
    • 1   –   an antibiotic.
    • 2   –   an anticoagulant.
    • 3   –   an antihypertensive.
    • 4   –   an anticonvulsant.

    RATIONALE: During PTCA, the client receives an anticoagulant (heparin) as well as calcium agonists, nitrates, or both to reduce coronary artery spasm. An antibiotic isn’t given routinely during PTCA; however, because this procedure is invasive, the client may receive prophylactic antibiotics afterward to reduce the risk of infection. An antihypertensive agent may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn’t indicated because PTCA doesn’t increase the risk of seizures.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  9. A client is admitted for treatment of Prinzmetal’s angina. When developing the care plan, the nurse keeps in mind that this type of angina is triggered by:
    • 1   –   activities that increase myocardial oxygen demand.
    • 2   –   an unpredictable amount of activity.
    • 3   –   coronary artery spasm.
    • 4   –   the same type of activity that caused previous angina episodes.

    RATIONALE: Prinzmetal’s angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; however, anginal pain is increasingly severe.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  10. A client is admitted to an acute care facility with pneumonia. When auscultating heart sounds, the nurse notes a fixed split of the second heart sound (S2-a pathologic split that doesn’t vary with respirations. A fixed S2 split signals which of the following conditions?
    • 1   –   Right bundle-branch block
    • 2   –   Left bundle-branch block
    • 3   –   Atrial septal defect
    • 4   –   Aortic stenosis

    RATIONALE: A fixed split of S2 is the hallmark of atrial septal defect. This split, which is continuous and doesn’t vary with respirations, results from prolonged emptying of the right ventricle. A right bundle-branch block causes a wide S2 split that is louder on inspiration than expiration; this split results from delayed depolarization of the right ventricle and late pulmonic valve closure. Left bundle-branch block, aortic stenosis, and patent ductus arteriosus cause a paradoxical S2 split. Heard only on expiration, a paradoxical S2split results from delayed aortic valve closure.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  11. A client is admitted to the coronary care unit with a suspected diagnosis of acute MI. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the creatine kinase isoenzyme CK-MB, found only in cardiac muscle, can be detected how soon after the onset of chest pain?
    • 1   –   30 minutes to 1 hour
    • 2   –   2 to 3 hours
    • 3   –   4 to 6 hours
    • 4   –   12 to 18 hours

    RATIONALE: Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak in 12 to 18 hours and return to normal in 3 to 4 days.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  12. A client is admitted to the coronary care unit with substernal chest pain that radiates to the jaw. The client subsequently develops hypotension and suffers cardiac arrest. Which of the following calcium preparations is injected into the ventricle during a cardiac arrest?
    • 1   –   Calcium carbonate (BioCal)
    • 2   –   Calcium chloride (Calciject)
    • 3   –   Calcium glubionate (Neo-Calglucon)
    • 4   –   Calcium lactate (Ridactate)

    RATIONALE: Calcium chloride is the only calcium preparation that should be injected into the ventricle during a cardiac arrest, if appropriate.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  13. A client is admitted to the critical care unit after being stabilized in the emergency department. Laboratory results show that the client’s creatine kinase isoenzyme CK-MB level is elevated. Based on this information, the nurse would develop a care plan based on which of the following conditions?
    • 1   –   Generalized tonic-clonic seizure
    • 2   –   Perforated duodenal ulcer
    • 3   –   Kidney stone
    • 4   –   Myocardial infarction

    RATIONALE: Creatine and CK-MB are released into the bloodstream by dying myocardial tissue. The higher the CK-MB level, the greater the damage to the myocardium. Seizures, duodenal ulcers, and kidney stones don’t affect CK-MB levels.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

  14. A client is admitted to the health care facility for treatment of an aneurysm. When planning this client’s care, the nurse formulates interventions with which of the following goals in mind?
    • 1   –   Decreasing blood pressure and increasing mobility
    • 2   –   Increasing blood pressure and reducing mobility
    • 3   –   Stabilizing the heart rate and blood pressure and easing anxiety
    • 4   –   Increasing blood pressure and monitoring fluid intake and output

    RATIONALE: For a client with an aneurysm, nursing interventions focus on stabilizing the heart rate and blood pressure to avoid aneurysm rupture. Easing anxiety is also important because anxiety and increased stimulation may speed the heart rate and boost blood pressure, precipitating aneurysm rupture. Typically, the client with an aneurysm is hypertensive, so the nurse should take measures to lower blood pressure such as administering antihypertensive agents, as prescribed, to prevent aneurysm rupture. To sustain major organ perfusion, a mean arterial pressure of at least 60 mm Hg should be maintained. Although mobility must be assessed individually, most clients need bed rest initially until their condition stabilizes.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  15. A client is recovering from an acute myocardial infarction (MI). During the first week of recovery, the nurse should stay alert for which of the following abnormal heart sounds?
    • 1   –   Opening snap
    • 2   –   Graham Steell’s murmur
    • 3   –   Ejection click
    • 4   –   Pericardial friction rub

    RATIONALE: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week after an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell’s murmur is a high-pitched, blowing murmur with a decrescendo pattern. Heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  16. A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that, for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common, spontaneously resolving symptom?

    • 1   –   Depression
    • 2   –   Ankle edema
    • 3   –   Memory lapses
    • 4   –   Dizziness

    RATIONALE: For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves on its own and doesn’t require medical intervention. Ankle edema rarely follows CABG surgery and may indicate right-sided heart failure; because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic dysfunction, rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, a condition that is abnormal after CABG surgery and should be reported immediately to the physician.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Psychosocial integrity
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

  17. A client is recovering from open-heart surgery for a mitral valve replacement. The recovery is uneventful, and the client actively participates in discharge teaching. If the nurse’s discharge teaching is effective, how would the client respond to a family member’s question about medications?
    • 1   –   “I don’t have any new prescriptions.”
    • 2   –   “I will need to take Coumadin because of the type of surgery I had.”
    • 3   –   “I will need to pick up a prescription for a drug to lower my blood pressure.”
    • 4   –   “I will need to take one aspirin a day.

    RATIONALE: Clients undergoing valve replacement must take Coumadin (an anticoagulant) to prevent any subsequent clot formation. The client will have a new prescription for an anticoagulant, not an antihypertensive, and the client shouldn’t take aspirin because of its anticoagulant effect.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

  18. A client is recovering from surgical repair of a dissecting aortic aneurysm. The nurse should evaluate the client for signs of bleeding or recurring dissection. These signs include:
    • 1   –   hematuria and decreased urine output.
    • 2   –   hypotension and tachycardia.
    • 3   –   increased urine output and bradycardia.
    • 4   –   hypotension and bradycardia.

    RATIONALE: When caring for a client recovering from surgical repair of a dissecting aortic aneurysm, the nurse must monitor for hypotension with reflex tachycardia, decreased urine output, and unequal or absent peripheral pulses - all potential signs of bleeding or recurring dissection. Hematuria, increased urine output, and bradycardia aren’t signs of bleeding from aneurysm repair or recurring dissection.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  19. A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling that is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. When exploring the chief complaint, the nurse should look for other common cardiovascular symptoms, including:

    • 1   –   shortness of breath.
    • 2   –   insomnia.
    • 3   –   irritability.
    • 4   –   lower substernal abdominal pain.

    RATIONALE: Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, dyspnea, palpitations, fainting, fatigue, and peripheral edema. Insomnia rarely indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  20. A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub -; a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position?
    • 1   –   Semi-Fowler’s
    • 2   –   Leaning forward while sitting
    • 3   –   Supine
    • 4   –   Prone

    RATIONALE: When the client leans forward, the heart pulls away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler’s, supine, and prone positions don’t cause this pulling-away action and therefore don’t relieve chest pain associated with pericarditis.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Application

  21. A client who’s 30 weeks’ pregnant has a corrected atrial septal defect and minor functional limitations. Which of the following pregnancy-related physiologic changes places her at greatest risk for more severe cardiac problems?
    • 1   –   Decreased heart rate
    • 2   –   Increased plasma volume
    • 3   –   Decreased cardiac output
    • 4   –   Increased blood pressure

    RATIONALE: Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing the heart rate and boosting cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease by 5 to 10 mm Hg, reaching its lowest point during the second half of the second trimester. During the third trimester, it gradually returns to first-trimester levels.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

  22. A client with angina pectoris must learn how to manage acute angina episodes and reduce risk factors that exacerbate this condition. When developing the client’s care plan, the nurse should include which expected outcome?
    • 1   –   “Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours.”
    • 2   –   “Client will verbalize the intention to avoid exercise.”
    • 3   –   “Client will verbalize the intention to stop smoking.”
    • 4   –   “Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol.”

    RATIONALE: The client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart’s oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn’t subside after three nitroglycerin doses taken 10 to 15 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Analysis

  23. A client with chest pain receives nitroglycerin en route to the hospital. Based on an electrocardiogram obtained on admission, the physician suspects a myocardial infarction (MI) and prescribes I.V. morphine to relieve continuing pain. A primary goal of nursing care for this client is to recognize life-threatening complications of an MI. The major cause of death after an MI is:
    • 1   –   cardiogenic shock.
    • 2   –   cardiac arrhythmia.
    • 3   –   heart failure.
    • 4   –   pulmonary embolism.

    RATIONALE: Cardiac arrhythmias cause roughly 40% to 50% of deaths after MI. Cardiogenic shock accounts for 9% and heart failure for 33% of post-MI deaths. Pulmonary embolism, another potential complication of an MI, is less common.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  24. A client with essential hypertension is started on furosemide (Lasix). The client asks the nurse how a diuretic would help lower the elevated blood pressure. The nurse’s best answer would be:
    • 1   –   “Because Lasix interferes with renin angiotensin conversion, blood pressure is lowered.”
    • 2   –   “Lasix blocks the action of the sympathetic nervous system, which makes blood vessels contract, thus lowering blood pressure.”
    • 3   –   “Lasix dilates small blood vessels, which decreases blood pressure.”
    • 4   –   “Lasix decreases circulating blood volume, thereby reducing the heart’s workload and blood pressure.”

    RATIONALE: Lasix is a loop diuretic that acts to reduce circulating blood volume by increasing urine output. It doesn’t function as stated in the other options.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  25. A client with heart failure must be monitored closely after starting diuretic therapy. What is the most accurate indicator of this client’s status?
    • 2   –   Urine specific gravity
    • 3   –   Vital signs
    • 4   –   Weight

    RATIONALE: Heart failure typically causes fluid overload, which results in weight gain. Therefore, weight is the most accurate indicator of this client’s status. Gain or loss of 1 lb (0.5 kg) is equivalent to 500 ml of fluid. Fluid intake and output is a less accurate indicator than is weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration; although helpful, it isn’t the most accurate indicator because it can be influenced by numerous factors, as can vital signs.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

  26. A client with high blood pressure is receiving an antihypertensive drug. The nurse knows that antihypertensive drugs commonly cause fatigue or dizziness, especially on rising. When developing a client teaching plan to minimize postural hypotension, the nurse should include which of the following instructions?
    • 1   –   “Avoid drinking alcohol and straining at stool, and eat a low-protein snack at night.”
    • 2   –   “Wear elastic stockings, change positions quickly, and hold onto a stationary object when rising.”
    • 3   –   “Flex your calf muscles, avoid alcohol, and change positions slowly.”
    • 4   –   “Rest between demanding activities, eat plenty of fruits and vegetables, and drink 6 to 8 cups of fluid daily.”

    RATIONALE: Measures that minimize postural hypotension include flexing the calf muscles to boost blood return to the heart, avoiding alcohol and straining at stool, eating a high-protein snack at night, wearing elastic stockings, changing positions slowly, and holding onto a stationary object when rising. Although the client should rest between demanding activities and consume plenty of fluids and fiber (contained in fruits and vegetables) to maintain a balanced diet, these measures don’t directly relieve postural hypotension.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  27. A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesias, and a mottled, cyanotic, cold left calf. While the physician determines the appropriate therapy, the nurse should:
    • 1   –   place a heating pad around the affected calf.
    • 2   –   elevate the affected leg as high as possible.
    • 3   –   keep the affected leg level or slightly dependent.
    • 4   –   shave the affected leg in anticipation of surgery.

    RATIONALE: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keep the affected leg level or slightly dependent (to aid circulation), and protect the affected leg from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would compromise tissue perfusion further and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg may cause accidental trauma from cuts or nicks.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  28. A client with venous insufficiency develops varicose veins in both legs. Which of the following statements about varicose veins is accurate?
    • 1   –   Varicose veins are more common in men than in women.
    • 2   –   Primary varicose veins are caused by deep-vein thrombosis and inflammation.
    • 3   –   Sclerotherapy is used to cure varicose veins.
    • 4   –   The severity of discomfort isn’t related to the size of varicosities.

    RATIONALE: Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, deep-vein thrombosis, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is used to treat the signs and symptoms of varicose veins; it doesn’t cure them.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  29. A client, age 59, complains of leg pain brought on by walking several blocks - a symptom that first occurred several weeks ago. The client’s history includes diabetes mellitus and a two-pack-a-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and prescribes pentoxifylline (Trental), 400 mg three times daily with meals. Which of the following instructions for long-term care should the nurse provide?

    • 1   –   “Practice meticulous foot care.”
    • 2   –   “Consider cutting down on your smoking.”
    • 3   –   “Reduce your level of exercise.”
    • 4   –   “See the physician if complications occur.”

    RATIONALE: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe the feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications unless the physician approves them. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. The client must see the physician regularly to evaluate the effectiveness of the therapeutic regimen, not just when complications occur.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  30. A nurse is caring for a client with tachycardia. The nurse is aware that tachycardia can result from which of the following factors?
    • 1   –   Vagal stimulation
    • 2   –   Vomiting, anger, or suctioning
    • 3   –   Fear, pain, or anger
    • 4   –   Stress, pain, or vomiting

    RATIONALE: Increased heart rate (tachycardia) may stem from fear, pain, or anger. Decreased heart rate (bradycardia) can stem from vomiting, suctioning (which causes vagal nerve stimulation), and certain medications. Stress can also increase the heart rate, but vomiting causes bradycardia (decreased heart rate). Bradycardia is also the result of vagal stimulation that occurs, for example, with suctioning and with certain medications.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  31. A nurse is performing a cardiac assessment on a client with hypertension. Identify the area where the nurse should place the stethoscope to best auscultate the pulmonic valve.
    • -

    RATIONALE: The pulmonic valve is usually best heard at the second intercostal space, at the left sternal border.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

  32. A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:
    • 1   –   “Has your child recently been exposed to other children with rheumatic fever?”
    • 2   –   “Has your child had strep throat recently?”
    • 3   –   “Does your child have a congenital heart defect?”
    • 4   –   “Is your child’s Haemophilus influenzae vaccine up-to-date?”

    RATIONALE: Group A streptococcal infection typically precedes rheumatic fever. An inflammatory disease, rheumatic fever affects the heart, joints, and central nervous system. It isn’t infectious and can’t be transmitted from one person to another. Congenital heart defects play no role in the development of rheumatic fever. Haemophilus influenzaevaccine doesn’t prevent streptococcal infection or rheumatic fever.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  33. A white male, age 43, is admitted to an acute care facility with a tentative diagnosis of infective endocarditis. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis?
    • 1   –   Race
    • 2   –   Age
    • 3   –   History of diabetes mellitus
    • 4   –   History of aortic valve replacement

    RATIONALE: A heart valve prosthesis, such as an aortic valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren’t major risk factors for infective endocarditis.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  34. After a motorcycle accident, a 19-year-old is admitted to the hospital. The physician orders an I.V. colloidal solution to be administered while typing and cross-matching are completed. Which of the following fluids would fit the classification to treat hypovolemic shock?
    • 1   –   Lactated Ringer’s solution
    • 2   –   Dextrose and normal saline solution
    • 3   –   Normal saline
    • 4   –   5% albumin

    RATIONALE: Albumin is a plasma protein and expands intravascular volume. The other solutions are crystalloid, rather than colloid, solutions.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

  35. After abdominal surgery, which of the following factors would predispose a client to deep-vein thrombosis?
    • 1   –   The client is 5 5 (1.7 m) tall and weighs 128 lb (58 kg).
    • 2   –   The client has been pregnant four times.
    • 3   –   The client usually walks 3 miles (5 km) per day.
    • 4   –   The client will be immobile after surgery.

    RATIONALE: Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don’t apply to this client. Exercise isn’t a risk factor or preventive measure for deep vein thrombosis.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  36. An intra-aortic balloon pump (IABC) was inserted into a client with cardiogenic shock. Which of the following items would the nurse question if found on the client’s care plan?

    • 1   –   Perform active range of motion (ROM) exercises with all extremities.
    • 2   –   Elevate the head of bed (HOB) to 30 degrees.
    • 3   –   Check femoral, popliteal, and dorsalis pedis pulses.
    • 4   –   Keep affected leg extended.

    RATIONALE: ROM (active or passive) exercises include flexion of the extremities. The HOB should be elevated 30 to 45 degrees and pulses should be checked. The client must keep his affected leg straight or extended to avoid pump malfunction.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  37. An obese, white, male client, age 49, is diagnosed with hypercholesterolemia. The physician prescribes a low-fat, low-cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client’s well-being because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine whether the client has other major risk factors for CAD, the nurse should assess for:

    • 1   –   a history of diabetes mellitus.
    • 2   –   an elevated high-density lipoprotein (HDL) levels.
    • 3   –   a history of ischemic heart disease.
    • 4   –   alcoholism.

    RATIONALE: Diabetes mellitus, smoking, and hypertension are other major risk factors for CAD. Elevated HDL levels aren’t a risk factor for CAD; in fact, increased HDL levels seem to protect against CAD. Ischemic heart disease is another term for CAD, not a risk factor. Alcoholism hasn’t been identified as a major risk factor for CAD.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

  38. At 32 weeks’ gestation, a client is admitted to the hospital with a diagnosis of pregnancy-induced hypertension (PIH). Based on this diagnosis, the nurse expects assessment to reveal which of the following signs?

    • 1   –   Edema
    • 2   –   Fever
    • 3   –   Glycosuria
    • 4   –   Vomiting

    RATIONALE: Classic signs of PIH include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with any number of disorders and is a common symptom of pregnancy.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  39. Documentation notes that aA 75-year-old client has been admitted with peripheral vascular problems. Which of the following nursing diagnoses would the nurse see on this client’s nursing care plan?
    • 1   –   Chronic low self-esteem related to altered body image
    • 2   –   Risk for impaired skin integrity related to compromised circulation
    • 3   –   Imbalanced nutrition: Less than body requirements, related to GI dysfunction
    • 4   –   Decreased cardiac output related to renal insufficiency

    RATIONALE: Compromised circulation to the legs and feet pose a risk for trauma and infection. The other nursing diagnoses wouldn’t be appropriate because documentation doesn’t note that the client’s appearance is altered or that the client exhibits GI or renal symptoms.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  40. During a prenatal visit, a pregnant client with cardiac disease and slight functional limitation reports increased fatigue. To help combat this problem, the nurse should advise her to:
    • 1   –   Eat three large meals a day.
    • 2   –   Exercise 1 hour before each meal.
    • 3   –   Take a vitamin and mineral supplement.
    • 4   –   Divide daily food intake into five or six meals.

    RATIONALE: To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day. This minimizes the energy expenditure associated with consuming three large meals. Exercising before meals would increase fatigue, interfering with the client’s nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on improving the client’s level of energy and decreasing fatigue.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

  41. For a client with cardiomyopathy, the most important nursing diagnosis is:

    • 1   –   Decreased cardiac output related to reduced myocardial contractility.
    • 2   –   Excess fluid volume related to fluid retention and altered compensatory mechanisms.
    • 3   –   Ineffective coping related to fear of debilitating illness.
    • 4   –   Anxiety related to actual threat to health status.

    RATIONALE: Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although options 2, 3, and 4 are important nursing diagnoses, they can be addressed after cardiac output and myocardial contractility have been restored.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  42. On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he has stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?

    • 1   –   Taking daily walks
    • 2   –   Engaging in anaerobic exercise
    • 3   –   Reducing daily fat intake to less than 45% of total calories
    • 4   –   Avoiding foods that increase levels of high-density lipoproteins (HDLs)

    RATIONALE: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat foods that raise HDL levels.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  43. The nurse applies compressions to the lower sternum at what depth when performing cardiopulmonary resuscitation on an adult client?
    • 1   –   r to 1
    • 2   –   1 to 3
    • 3   –   1 to 2
    • 4   –   2 to 4

    RATIONALE: The recommended depth of chest compressions in an adult is 1 to 2. The other options aren’t within the recommended depth according to standards established by the American Heart Association.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Knowledge

  44. The nurse caring for a client with right-sided heart failure realizes this condition occurs in phases. Place the phases of right-sided heart failure in the order in which they occur. (Use all options.)
    • 1   –   Ineffective right ventricular contractility
    • 2   –   Poor right ventricular pumping
    • 3   –   Weight gain, peripheral and organ edema
    • 4   –   Decreased cardiac output to the lungs
    • 5   –   Blood backup into peripheral circulation

    RATIONALE: Right-sided heart failure results from ineffective right ventricular contractile function. Consequently, blood isn’t pumped effectively through the right ventricle to the lungs, causing blood to back up into the right atrium and the peripheral circulation. The client then gains weight and develops peripheral edema and engorgement of the kidneys and other organs.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  45. The nurse is assigned to a client with a cardiac disorder. When taking the client’s temperature, which route should the nurse avoid?

    • 1   –   Rectal
    • 2   –   Oral
    • 3   –   Axillary
    • 4   –   Tympanic

    RATIONALE: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take his temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. Options 2, 3, and 4 are appropriate routes for measuring the temperature of a client with a cardiac disorder.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  46. The nurse is calculating a nitroprusside infusion rate for a 110-lb cardiac client in her care. The physician orders the client to receive nitroprusside 3 mcg/kg/minute. The nitroprusside dosage is 200 mcg/ml. Use the following chart to determine the infusion rate (ml/hr) for the nitroprusside drip.
    • 1   –   5 ml/hr
    • 2   –   10 ml/hr
    • 3   –   45 ml/hr
    • 4   –   4.99 ml/hr

    RATIONALE: First locate the client’s weight on the chart. Next, find the dose prescribed, in the left hand column. Follow the two lines to the point of intersection, to determine the correct infusion rate of 45 ml/hr.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

  47. The nurse is interpreting a rhythm strip. Identify the T wave on this electrocardiogram complex.
    • -

    RATIONALE: The T wave represents repolarization of the ventricles and follows the peaking QRS complex.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Analysis

  48. The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which of these findings significant?
    • 1   –   Croup
    • 2   –   Rheumatic fever
    • 3   –   Severe staphylococcal infection
    • 4   –   Medullary sponge kidney

    RATIONALE: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup - a severe upper airway inflammation and obstruction typically striking children ages 3 months to 3 years - may cause latent complications, such as ear infection and pneumonia. However, it doesn’t affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn’t damage heart structures.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  49. The nurse is preparing to administer digoxin 0.25 mg I.V. The pharmacy has dispensed digoxin in a vial containing 0.125 mg/1ml. Calculate the number of milliliters the nurse will administer to the client.
    • -

    RATIONALE: The nurse should calculate the client’s dose using this method:
    (0.125 mg 9 1ml) = (0.25 mg 9 X)
    0.125X = 0.25
    X = 2 ml
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  50. The physician has ordered the client to receive digoxin twice a day until a therapeutic level is attained. When the nurse takes the client’s apical pulse on the third day, the pulse is 58, and the client complains of nausea. What should the nurse do next?
    • 1   –   Administer the medication and leave a note on the chart for the physician.
    • 2   –   Order a serum digoxin level drawn.
    • 3   –   Administer the medication and medicate the client for nausea.
    • 4   –   Withhold the medication and notify the physician.

    RATIONALE: Withholding the medication and notifying the physician is the first step in treating what very well may be digoxin toxicity. Continuing to administer digoxin may result in heart block, and obtaining a serum level doesn’t treat the problem.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Analysis

  51. The physician orders dopamine hydrochloride (Intropin) for a client in shock to improve the client’s hemodynamic status. When the family asks why the client is taking this medication, the best response by the nurse would be:
    • 1   –   “This drug helps decrease blood pressure, which would decrease the workload of the heart.”
    • 2   –   “This drug helps decrease the circulating blood volume.”
    • 3   –   “This drug decreases the oxygen demand of the heart.”
    • 4   –   “This drug increases cardiac output and stroke volume.”

    RATIONALE: Intropin acts to increase cardiac output and stroke volume, resulting in corrective hypotension and increasing circulating volume and oxygenation. It doesn’t decrease blood pressure, circulating blood volume, or oxygen demand of the heart.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  52. When a client suddenly loses consciousness, which of the following should the nurse do first?
    • 1   –   Call for assistance.
    • 2   –   Assess the client for responsiveness.
    • 3   –   Palpate for a carotid pulse.
    • 4   –   Assess for pupillary response.

    RATIONALE: The nurse should always assess for responsiveness first to prevent injuries to a client who isn’t in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client’s airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is not an appropriate initial assessment in an emergency situation.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

  53. When assessing a client with left-sided heart failure, the nurse expects to note which of the following?
    • 1   –   Ascites
    • 2   –   Jugular vein distention
    • 3   –   Air hunger
    • 4   –   Pitting edema of the legs

    RATIONALE: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  54. When caring for a client with rheumatic fever, the nurse formulates a nursing diagnosis of Activity intolerance related to reduced cardiac reserve and enforced bed rest. Before the nurse can eliminate this nursing diagnosis, the client must meet which outcome measurement criterion?

    • 1   –   “Erythrocyte sedimentation rate returns to normal.”
    • 2   –   “Pulse does not rise above 150 beats/minute with activity.”
    • 3   –   “Temperature remains normal with salicylate administration.”
    • 4   –   “Pericardial friction rub is diminishing in intensity.”

    RATIONALE: Bed rest must continue until the client’s erythrocyte sedimentation rate returns to normal, indicating resolution of rheumatic fever. On the other hand, the resting pulse must be under 100 beats/minute; the client must maintain a normal temperature without salicylates; and pericardial friction rub must disappear completely. If the client needs salicylates to maintain a normal temperature, inflammation is still present and activity may cause serious myocardial damage. Resuming activity before a pericardial friction rub disappears completely may impair cardiac function.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  55. When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are found in the carotid sinus and aorta. Which other area should the nurse mention as the site of arterial baroreceptors?
    • 1   –   Brachial artery
    • 2   –   Radial artery
    • 3   –   Left ventricular wall
    • 4   –   Right ventricular wall

    RATIONALE: Arterial baroreceptors are found in the left ventricular wall as well as in the carotid sinus and aorta. No baroreceptors exist in the brachial artery, radial artery, or right ventricular wall.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  56. Which of the following would be the next step in the conduction pathway of the heart: sinoatrial (SA) node, atrioventricular (AV) node, Bundle of His, and:
    • 1   –   depolarization of the cell membrane.
    • 2   –   contraction of cardiac muscle.
    • 3   –   chordae tendineae.
    • 4   –   Purkinje fibers.

    RATIONALE: The next step of the impulse would be the Purkinje fibers. Depolarization occurs at the beginning of the cardiac cycle. The cardiac muscle contracts after receiving the impulse from the Purkinje fibers. The chordae tendineae aren’t prominent in the cardiac cycle.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

 

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