Deck 3 Module 16 Perfusion Flashcards
The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate?
A) “You will need to have an echocardiogram to determine the reason for the extra sound.”
B) “You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy.”
C) “You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy.”
D) “You have what is known as atrial gallop, and this is cause for concern.”
C) “You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy.”
Rationale: Two other heart sounds may be present in some healthy individuals. The third heart sound (S3) may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can also be present in healthy individuals.
The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client’s potential health problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return
B) Instructing on deep breathing
The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.
An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be prescribed for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids
A) Beta blocker
Rationale: Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.
The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric
C) PR interval 0.30 seconds
Rationale: The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.
The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply.
A) Limit exercise to 15 minutes a day B) Reduce saturated fats in the diet C) Avoid cigarette smoking D) Wear elastic hose E) Limit fluid intake
B) Reduce saturated fats in the diet
C) Avoid cigarette smoking
Rationale: Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.
The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?
A) At the fifth intercostal space
B) At the left nipple
C) At the right nipple
D) At the eighth intercostal space
B) At the left nipple
Rationale: When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.
The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor). What should the nurse teach the client about this medication?
A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids.
B) Change positions slowly.
Rationale: Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.
Which statements are correct regarding the various layers of the heart? Select all that apply.
A) The endocardium covers the entire heart and great vessels.
B) The endocardium is the muscular layer of the heart that contracts during each heartbeat.
C) The outermost layer of the heart is the epicardium.
D) The myocardium consists of myofibril cells.
E) The myocardium has four layers.
C) The outermost layer of the heart is the epicardium.
D) The myocardium consists of myofibril cells.
Rationale: The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.
A client’s stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute (bpm). What is the client’s cardiac output (CO) rounded to the nearest liter?
6 Liters (L)
Rationale: CO = SV × HR
85mL = 0.085 L
CO = 0.085 × 71 = 6.035 = 6 L
Blood pressure is influenced by all except which factor?
A) Pumping action of the heart
B) Peripheral vascular resistance
C) Heart rate
D) Blood volume
C) Heart rate
Rationale: The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.
Which nursing intervention related to perfusion can be performed independently?
A) Administration of drug regimens
B) Insertion of device to measure central venous pressure (CVP)
C) Teaching relaxation techniques
D) Thoracentesis
C) Teaching relaxation techniques
The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.
The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern?
A) Pulse 103 bpm
B) Blood pressure 108/70
C) Hematocrit 24%
D) WBC count 10,340/mm3
C) Hematocrit 24%
Rationale: During pregnancy, red blood cell (RBC) production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.
The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
A) Fatigue B) Lower extremity edema C) Syncope D) Dyspnea E) Angina
A) Fatigue
B) Lower extremity edema
D) Dyspnea
Rationale: Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.
A client states to the nurse, “I know I have high blood pressure, but I don’t want to take medication.” Based on this data, which health problem is the client at risk for developing?
A) Gastritis
B) Diabetes
C) Cardiomyopathy
D) Metabolic syndrome
C) Cardiomyopathy
Rationale: Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with gastritis, diabetes, or metabolic syndrome.
A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client?
A) Increased stroke volume
B) Decreased cardiac output
C) An elongated and dilated aorta
D) Increased blood pressure
B) Decreased cardiac output
Rationale: Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has increased stroke volume, an elongated and dilated aorta, or high blood pressure.
A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating and fatigued with routine care activities. Which nursing diagnosis does the nurse include in the client’s plan of care?
A) Imbalanced Nutrition: Less than Body Requirements
B) Deficient Knowledge
C) Activity Intolerance
D) Self-Care Deficit
C) Activity Intolerance
Rationale: The client is short of breath with ambulation and eating and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. There is not enough information to determine if the client has a knowledge deficit. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.
The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy. Which interventions should the nurse emphasize when planning this client’s care? Select all that apply.
A) Monitor B-type natriuretic peptide (BNP) level.
B) Provide oxygen as prescribed.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
D) Provide information about activity upon discharge.
E) Monitor intake and output.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
E) Monitor intake and output.
Rationale: Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed, and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.
The nurse is providing teaching to a client diagnosed with cardiomyopathy. What statement made by the client indicates the discharge teaching was effective?
A) “I will exercise as much as possible, regardless of feeling weak and short of breath.”
B) “My pants getting tight around the waist means I’m eating too much and should cut back on food.”
C) “I will eat foods containing sodium only if drinking water with them.”
D) “I will see my cardiologist next week to discuss implanting a pacemaker.”
D) “I will see my cardiologist next week to discuss implanting a pacemaker.”
Rationale: Pacemakers are needed in some clients with cardiomyopathy to prevent sudden cardiac death. The client should discuss the need for a pacemaker with his cardiologist. The other client statements indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.
The nurse is caring for a client with hypertrophic cardiomyopathy. Based on this diagnosis, which class of medications does the nurse anticipate being prescribed?
A) Digoxin
B) Vasodilators
C) Nitrates
D) Beta blockers
D) Beta blockers
Beta blockers may be prescribed to relax the heart, stabilize the rhythm, and slow the heart’s pumping action in clients with hypertrophic cardiomyopathy. Digoxin is contraindicated for the client with hypertrophic cardiomyopathy. Vasodilators and nitrates are not used to treat hypertrophic cardiomyopathy.
A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours. Which action by the nurse is correct?
A) Assist the client to ambulate.
B) Document a normal urine output.
C) Notify the healthcare provider.
D) Measure abdominal girth.
C) Notify the healthcare provider.
Rationale: The nurse should notify the healthcare provider, because a urine output of 200 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. The nurse should not assist the client out of bed to ambulate at this time. This is not a normal urine output. Abdominal girth is not an objective measurement of fluid volume; daily weight is more precise.
A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. Which is inappropriate for the nurse to include in the teaching session?
A) Dilated cardiomyopathy
B) Restrictive cardiomyopathy
C) Hypotrophic cardiomyopathy
D) Arrythmogenic right ventricular dysplasia
C) Hypotrophic cardiomyopathy
Rationale: The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right ventricular dysplasia, and unclassified.
The nurse is caring for a client diagnosed with cardiomyopathy. The client experiences tachycardia. Which medication does the nurse anticipate being prescribed?
A) ACE Inhibitor
B) Angiotensin II receptor blocker
C) Beta blocker
D) Cardiac glycoside
C) Beta blocker
Rationale: A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the heart rate. ACE inhibitors and angiotensin II receptor blockers are used to decrease blood pressure in a client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not assist in lowering the heart rate in a client with cardiomyopathy.
A nurse is caring for a client with cardiomyopathy who is experiencing activity intolerance. Which intervention is inappropriate for this nursing diagnosis?
A) Spacing out nursing activities so client fatigue is lessened
B) Assisting with client activities of daily living (ADLs) as necessary
C) Using passive and active range-of-motion (ROM) exercises as tolerated
D) Consulting with a physical therapist on an activity plan
A) Spacing out nursing activities so client fatigue is lessened
Rationale: The client who is experiencing activity intolerance should have nursing interventions implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing ROM exercises, and consulting with physical therapy are all interventions that support this nursing diagnosis. The nurse should cluster nursing activities, not space them out, in order to conserve client energy. This allows the client to rest between periods of nursing care.
A nurse is educating a client with cardiomyopathy about diet choices that are appropriate for the client’s condition. Which statement is inappropriate for the nurse to include in the teaching session?
A) “It is important to monitor your sodium intake.”
B) “Increasing your dietary protein helps with cardiac cell repair.”
C) “Here is a list of high-fat, high-cholesterol foods to avoid.”
D) “I have notified the dietitian regarding your condition in order to provide you with more information.”
B) “Increasing your dietary protein helps with cardiac cell repair.”
Rationale: Diet is an important part of long-term management of heart failure. It also contributes to reducing fluid retention. The nurse should instruct the client with cardiomyopathy to monitor sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting with the dietitian is appropriate with this client.
A 14-year-old child was recently diagnosed with hypertrophic cardiomyopathy. During a follow-up appointment, the mother asks the nurse, “How will this affect my child’s ability to play football in the fall?” How should the nurse respond?
A) “This shouldn’t affect his ability to play football.”
B) “Children with cardiomyopathy should not play football.”
C) “He could participate in flag football but not tackle football.”
D) “This may actually make him a better, stronger football player.”
B) “Children with cardiomyopathy should not play football.”
Rationale: Children with cardiomyopathy should not play competitive sports due to the possibility of collapse or increased heart failure. Depending on the child’s clinical status, low-impact activities may be appropriate, but this should be discussed with the child’s physician.
A 72-year-old client diagnosed with hypertrophic cardiomyopathy (HCM) is speaking to the healthcare team about treatment options. Which treatment option would likely not be recommended for this client, even though it is commonly used to treat younger clients with this condition?
A) Defibrillator implantation
B) Beta-blocker administration
C) Calcium channel blocker administration
D) Physical activity restrictions
A) Defibrillator implantation
Rationale: Treatment guidelines for older clients with HCM are not well established, although they may include the use of beta blockers and/or calcium channel blockers. The client will also likely have restrictions on physical activity. However, the low morbidity and mortality rates among older clients do not support the use of the defibrillator devices frequently implanted in younger clients.
The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. To determine the cause of the defect, which question is appropriate for the nurse to ask the mother?
A) “Did you consume any alcohol before you knew you were pregnant?”
B) “Is there a history of diabetes in your family?”
C) “Was the baby’s father exposed to any toxins in the work environment?”
D) “Do you have a history of hypertension?”
A) “Did you consume any alcohol before you knew you were pregnant?”
Rationale: Most congenital heart defects occur during the first 8 weeks of pregnancy and are a combination of environmental and genetic factors. Fetal exposure to alcohol is one of the greatest factors for the development of these defects. Asking the mother if she consumed alcohol before she was aware that she was pregnant is an appropriate question when determining the cause of the heart defect. A history of hypertension will not cause a fetus to develop a congenital heart defect. The father’s exposure to toxins in the work environment is not known to cause congenital heart defects of children. Maternal diabetes can impair fetal heart development, but a family history of diabetes is not known to cause congenital heart defects.
The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client?
A) Acute Pain
B) Ineffective Breathing Pattern
C) Decreased Cardiac Output
D) Excess Fluid Volume
C) Decreased Cardiac Output
Rationale: Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood flow include Decreased Cardiac Output, Risk for Infection, Caregiver Role Strain, and Activity Intolerance. Acute Pain and Ineffective Breathing Pattern are appropriate nursing diagnoses for a child following cardiac surgery. Excess Fluid Volume is a nursing diagnosis seen in the care of a client with a congenital heart defect that increases pulmonary blood flow.
The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client’s fluid status?
A) Encourage oral intake of fluids when permitted.
B) Limit oral and intravenous intake of fluids.
C) Continue normal saline administration even after oral intake is normal.
D) Convert the intravenous line to a saline lock immediately after surgery.
A) Encourage oral intake of fluids when permitted.
Rationale: The child should be encouraged to begin oral fluids and nutrition when permitted. Although oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and antibiotics should be provided as ordered until the child’s oral intake is normal. Once normal, the line can be converted to a heparin or saline lock.
The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching has been effective?
A) “Our child should be restricted in play and activity for at least 6 months.”
B) “Our child will need to take antibiotics prior to having dental surgery.”
C) “Fluids should be restricted to maximize lung function.”
D) “Our child should not return to normal activities for at least 2 years.”
B) “Our child will need to take antibiotics prior to having dental surgery.”
Rationale: Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for invasive procedures. The child should be encouraged to gradually return to normal activities, including play. The child’s activity should not be restricted for 6 months to 2 years. The child should not restrict fluids.
The nurse is caring for a premature infant diagnosed with patent ductus arteriosus (PDA). Which medication should the nurse anticipate administering to this client?
A) Indomethacin
B) Propranolol
C) Antibiotics
D) Prostaglandin E1
A) Indomethacin
Rationale: Intravenous indomethacin often stimulates the closure of the PDA in premature infants. Prophylactic antibiotics are used in some clients with a congenital heart defect, but this is not common for infants with PDA. Propranolol is used to treat tetralogy of Fallot. Prostaglandin E1 is used with some congenital heart defects to maintain a PDA, not help close the PDA.
B) Intravenous indomethacin often stimulates the closure of the PDA in premature infants. Prophylactic antibiotics are used in some clients with a congenital heart defect, but this is not common for infants with PDA. Propranolol is used to treat tetralogy of Fallot. Prostaglandin E1 is used with some congenital heart defects to maintain a PDA, not help close the PDA.
A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery?
A) Restricting immunizations until after the surgery
B) Preventing exposure to infection
C) Implementing no particular precautions
D) Restricting fluids for a week before the surgery
B) Preventing exposure to infection
Rationale: Preoperative care of a baby having surgery to correct a congenital heart defect should include prevention from infection with good hand washing. There are precautions that the parents should take to ensure the child is in optimal health prior to the surgery. Immunizations should be continued. The parents may be instructed to withhold food and fluids several hours before the surgery. Fluids would not be restricted for a week before surgery.
The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
A) Palpable thrill in the pulmonic area B) Nail clubbing C) Cough D) Apneic periods E) Knee-chest position
A) Palpable thrill in the pulmonic area
B) Nail clubbing
E) Knee-chest position
Rationale: Manifestations of TOF include a palpable thrill in the pulmonic area, clubbing of the fingers due to reduce oxygenation, and the knee-chest position, which the child will perform to decrease the return of systemic venous blood to the heart. A cough and apneic periods are not manifestations of this congenital heart defect.
Which best describes how congenital defects are categorized?
A) By the severity of defect
B) By the pathophysiology and hemodynamics of defect
C) By the location of defect
D) By the infant’s age when the defect was diagnosed
B) By the pathophysiology and hemodynamics of defect
Rationale: Congenital heart defects are categorized by their pathophysiology and hemodynamics. They are not categorized by the severity of the defect, location of the defect, or the infant’s age when the defect is diagnosed.
The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply.
A) Pulmonary artery hypotension
B) Midsystolic murmur at lower right sternal border
C) Mitral valve regurgitation with cleft on mitral valve
D) S1 heart tone may be split due to forceful left ventricular contraction
C) Mitral valve regurgitation with cleft on mitral valve
E) Congestive heart failure
Rationale: ASD occurs when there is an opening in the atrial septum, permitting left-to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal border due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.
The nurse is providing teaching to the parents of a child born with tetralogy of Fallot (TOF). Which statement should the nurse include in her teaching regarding this defect?
A) “Increased pulmonary blood flow causes symptoms with this disease.”
B) “This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta.”
C) “Your child has a decreased amount of red blood cells because of this disease.”
D) “This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta.”
D) “This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta.”
Rationale: TOF consists of four defects—pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. This disease is also characterized by decreased pulmonary blood flow and polycythemia (increased red blood cells due to hypoxia).
The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the client’s family?
A) Norwood procedure
B) Jatene procedure
C) Rastelli procedure
D) Damus-Kaye-Stansel procedure
A) Norwood procedure
Rationale: Hypoplastic left heart syndrome is repaired using the Norwood, Glenn, and Fontan procedures, depending on the child’s age. The Jatene procedure and the Damus-Kaye-Stansel procedure surgically repair the Transposition of Great Arteries (TGA). The Rastelli procedure is used to repair TGA with ventricular septal defect and pulmonary stenosis.
During what period of gestation do congenital heart defects usually develop?
A) First 8 weeks of gestation
B) Second trimester
C) Third trimester
D) Last 4 weeks of gestation
A) First 8 weeks of gestation
Rationale: Most congenital heart defects develop during the first 8 weeks of gestation. They are usually the result of combined genetic and environmental factors.
The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct?
A) A Cesarean section is preferred because you will lose less blood than with a vaginal birth.
B) A Cesarean section is preferred because there is a lower risk of infection than with a vaginal birth.
C) A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis.
D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section.
D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section.
Rationale: Vaginal delivery is preferable to Cesarean section for most clients with congenital heart defects because they will likely lose less blood with vaginal birth. Risk of wound infection and thrombophlebitis are also concerns with Cesarean birth. Dilated aorta, pulmonary hypertension, and aortic stenosis are contraindications for vaginal delivery.
The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for?
A) Deep vein thrombosis
B) Endocarditis
C) Atherosclerosis
D) Shock
B) Endocarditis
Rationale: Common complications of congenital heart defects that develop during adulthood include dysrhythmias, endocarditis, stroke, heart failure, pulmonary hypertension, and heart valve problems. Congenital heart defects do not normally cause deep vein thrombosis, atherosclerosis, or shock.
The nurse is documenting assessment findings on a client with angina. Which term should the nurse use to describe chest pain that occurs at night and is unrelated to activity?
A) Nonanginal pain
B) Prinzmetal angina
C) Unstable angina
D) Stable angina
B) Prinzmetal angina
Rationale: Prinzmetal (variant) angina is unrelated to activity and often occurs at night. Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina occurs with increasing frequency, severity, and duration. The pain is unpredictable. The client has been diagnosed with angina, and, therefore, the chest pain the client is experiencing is likely angina, not non-anginal pain.
The nurse is caring for a client who has had a myocardial infarction. The client states, “I have been smoking for 35 years, what good will quitting do?” Which response is best?
A) “Your risk of continued coronary artery disease will decrease by half when you stop.”
B) “Quitting will enhance the effects of your medications.”
C) “Your medications will not work if you smoke.”
D) “Quitting will ensure you don’t develop any complications.”
A) “Your risk of continued coronary artery disease will decrease by half when you stop.”
Rationale: Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the person has smoked. It will reduce the possibility of lung cancer, decrease complications, and possibly enhance medication effects, but the primary focus for this client is the effect on coronary artery disease.
The nurse is preparing preoperative teaching for a client scheduled for a ventricular assist device (VAD). Which should the nurse include in these instructions?
A) Need to stay on bedrest for a week or more
B) Cardiac pain postoperatively is to be expected
C) Risk for postoperative infection
D) Expect to be ambulating the evening of surgery
C) Risk for postoperative infection
Rationale: Clients with VAD are at considerable risk for infection; strict aseptic technique is used with all invasive catheters and dressing changes. The client may or may not be on bedrest for a week or more after the surgery. Cardiac pain postoperatively is not to be expected and could indicate a myocardial infarction. The client, however, will most likely not be ambulating the evening of the surgery.
The nurse is instructing an older adult client about atorvastatin (Lipitor) to treat elevated cholesterol. Which side effects should the nurse advise the client to report to the healthcare provider? A) Headaches and nausea B) Muscle pain and weakness C) Bruising and excessive bleeding D) Shortness of breath and coughing
B) Muscle pain and weakness
Rationale: Clients taking statins, such as atorvastatin (Lipitor), should promptly report muscle pain, tenderness, or weakness; skin rash, hives, or changes in skin color; and abdominal pain, nausea, or vomiting. Headaches, bruising or bleeding, and shortness of breath or coughing are not common side effects that need to be reported to the physician.
The nurse is providing care to a client who has experienced several episodes of angina. Which agent does the nurse anticipate being ordered to reduce the intensity and frequency of an angina episode?
A) The client will experience relief of chest pain with therapeutic lifestyle changes.
B) The client will experience relief of chest pain with statin therapy.
C) The client will experience relief of chest pain with nitrate therapy.
D) The client will experience relief of chest pain with anticoagulant therapy.
C) The client will experience relief of chest pain with nitrate therapy.
Rationale: A primary goal in the treatment of angina is to reduce the intensity and frequency of angina episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina episode. Therapeutic lifestyle changes are significant if the client is to maintain a healthy heart. Statins are used to decrease cholesterol levels. Anticoagulant therapy is used to prevent additional thrombi from forming post-myocardial infarction.
A client recovering from an acute myocardial infarction is prescribed aspirin. Which teaching points should the nurse include regarding this prescription? Select all that apply.
A) Report any itching after seven days of taking.
B) Check with your healthcare provider before taking herbal remedies.
C) Take at a different time of day than warfarin.
D) Report bleeding or bruising to the healthcare provider.
E) Do not skip any scheduled appointments to have blood drawn for labs.
B) Check with your healthcare provider before taking herbal remedies.
D) Report bleeding or bruising to the healthcare provider
Rationale: Itching is not a common side effect of aspirin therapy. Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can increase the effect of the aspirin. Aspirin and Coumadin are not to be taken concurrently. Bleeding and bruising can occur and should be reported to the healthcare provider. Aspirin inhibits platelet aggregation and clot formation. No lab appointments will be made just for aspirin therapy.
A client with angina is experiencing acute chest pain. The client rates the pain as a 7 out of 10. The client’s vital signs include P 119, R 24, BP 98/63, T 99.1°F, and SpO2 89%. Which actions would the nurse implement at this time? Select all that apply.
A) Administer antianxiety medication as prescribed.
B) Coach in nonpharmacologic pain management techniques.
C) Implement bedrest.
D) Administer morphine sulfate 2 mg intravenous push as prescribed.
E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed.
C) Implement bedrest.
D) Administer morphine sulfate 2 mg intravenous push as prescribed.
E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed.
Rationale: Interventions for the client experiencing acute chest pain include keeping the client on bedrest, administering morphine sulfate as prescribed, and administering oxygen as prescribed. Antianxiety medications are not effective in acute chest pain. Nonpharmacologic pain management techniques are not appropriate for an episode of acute chest pain.
A nurse is teaching a client about the different types of angina. Which client statement indicate the need for follow up teaching?
A) “Stable angina is the most common form of angina.”
B) “Prinzmetal angina is atypical angina that occurs with strenuous exercise.”
C) “Unstable angina occurs with increasing frequency, severity, and duration.”
D) “Clients with unstable angina are at risk for a heart attack.”
B) “Prinzmetal angina is atypical angina that occurs with strenuous exercise.”
Rationale: Angina results from ischemia and can be a one-time event or a chronic condition. There are three types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common form of angina and is relieved with rest and nitrate medications. Unstable angina occurs with increasing frequency, severity, and duration. Clients with unstable angina are at risk for a heart attack, or myocardial infarction. Prinzmetal angina is atypical angina that is unrelated to activity.
The nurse is providing care to a female client who is diagnosed with coronary artery disease. The client states to the nurse, “I don’t know how this happened.” Which response by the nurse is the most appropriate?
A) “Women who take oral contraceptives are more likely to develop this disease.”
B) “Women who have children later in life often develop this disease”
C) “Women with a history of sexually transmitted infections are more likely to develop this disease.”
D) “Women who conceive through the use of in-vitro fertilization are more likely to develop this disease.”
A) “Women who take oral contraceptives are more likely to develop this disease.”
Rationale: Risk factors for coronary artery disease that are unique to women include premature menopause, oral contraceptive use, and hormone replacement therapy (HRT). Having children later in life, a history of sexually transmitted infections, and the use of in-vitro fertilization do not increase the risk of coronary artery disease for women.
The nurse is teaching a client about the associated health risks of cocaine use. Which statement should the nurse use to describe how cocaine can cause myocardial infarction (MI)?
A) Cocaine significantly increases the serum triglyceride level, leading to the development of an atheroma.
B) Cocaine alters the body’s clotting mechanisms, leading to thrombus formation.
C) Cocaine increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction.
D) Cocaine alters electrolyte balance, leading to arrhythmias
C) Cocaine increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction.
Rationale: Acute MI may develop as a result of cocaine intoxication. Cocaine increases sympathetic nervous system activity by both increasing the release of catecholamines from central and peripheral stores and interfering with the reuptake of catecholamines. This increased catecholamine concentration stimulates the heart rate and increases its contractility, increases the automaticity of cardiac tissues and the risk of dysrhythmias, and causes vasoconstriction and hypertension. The other answers do not occur with cocaine intoxication.
A community health nurse is providing education to a group of adults regarding myocardial infarction (MI). When discussing ways to prevent the number of MI-related deaths, which statement by the nurse is inappropriate?
A) “It is important to learn how to perform cardiopulmonary resuscitation (CPR).”
B) “Be sure to take a baby aspirin every day to help prevent an MI.”
C) “Increase your knowledge of the manifestations of MI.”
D) “Seek immediate medical attention when you suspect an MI.”
B) “Be sure to take a baby aspirin every day to help prevent an MI.”
Rationale: When educating clients regarding ways to decrease the number of MI-related deaths, the nurse will stress the importance of prevention. Learning about the manifestations of MI, as well as learning CPR, is appropriate. Clients should be taught to seek immediate medical attention when they suspect an MI. However, instructing all clients to take a baby aspirin every day to help prevent an MI is inappropriate, as not all clients should take this medication.
What is the most common clinical manifestation of coronary artery disease?
A) Chest pain
B) Dyspnea
C) Irritability
D) Tachycardia
A) Chest pain
Rationale: Coronary artery disease is often asymptomatic. When clinical manifestations do occur, the most common indications are angina and myocardial infarction. Angina, acute coronary syndrome, and acute myocardial infarction are all characterized by the presence of chest pain of various intensities. Although dyspnea, irritability, and tachycardia may also be present in some clients, chest pain is the classical manifestation of coronary artery disease.
For a client with coronary artery disease, what can the nurse recommend to the client to help decrease cardiac workload and sympathetic nervous system stimulation?
A) Physical rest
B) Psychological rest
C) Fluid intake
D) Fluid restriction
A) Physical rest
Rationale: For the client with coronary artery disease, physical rest helps decrease cardiac workload and sympathetic nervous system stimulation, promoting comfort. Information and emotional support help decrease anxiety and promote psychological rest. Although fluid overload may increase cardiac workload, the nurse should not restrict fluids unless prescribed by the physician.
The nurse is caring for a 76-year-old client with a history of angina. What atypical age-related warning sign of a myocardial infarction should the nurse need to include in client teaching?
A) Cool, clammy skin
B) Chest pain
C) Tachycardia
D) Abdominal pain
D) Abdominal pain
Rationale: Older adults commonly have atypical symptoms of myocardial infarction, such as difficulty breathing, confusion, fainting, dizziness, abdominal pain, or cough. Cool, clammy skin; chest pain; and tachycardia are all symptoms of myocardial infarction that are more common in younger individuals but less common in older individuals.
The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)?
A) Shortness of breath after activity
B) Two-plus palpable pedal pulses
C) Swelling in one leg with edema
D) Sharp pain in both legs
C) Swelling in one leg with edema
Rationale: Manifestations of DVT include swelling in one leg with pitting edema because the clot is obstructing the venous return from the leg. Shortness of breath that subsides after activity and two-plus palpable pulses are not manifestations of DVT. Pain in the affected extremity is usually dull and aching, not sharp.
The nurse is planning care for a group of clients. Which client should the nurse identify as having the greatest risk for developing deep venous thrombosis (DVT)?
A) The client recovering from laparoscopic gallbladder surgery
B) The client admitted with new-onset type II diabetes mellitus
C) The client admitted with community-acquired pneumonia
D) The client recovering from knee replacement surgery
D) The client recovering from knee replacement surgery
Rationale: Between 40% and 85% of clients recovering from total knee replacement surgery develop a DVT because of the procedure and prolonged immobility after surgery. The client admitted with new-onset type II diabetes mellitus, the client admitted with community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery would be at a lower risk for DVT because prolonged immobility will not occur.
The nurse is caring for a breastfeeding client recovering from a cesarean section. The physician diagnoses her with superficial venous thrombosis. Which intervention should the nurse anticipate carrying out first?
A) Encourage to ambulate freely
B) Aspirin 650 mg every 4 hours
C) Apply warm, moist compresses
D) Provide methylergonovine (Methergine) IM
C) Apply warm, moist compresses
Rationale: The treatment for superficial venous thrombosis involves resting the extremity, administering anti-inflammatory agents, and applying warm, moist compresses over the affected vein. Ambulation would increase the inflammation. Heparin or warfarin is preferred over aspirin for treatment of venous thrombosis, and both are safe for lactating mothers. Methylergonovine is given only for postpartum hemorrhage and would cause vasoconstriction of an already inflamed vessel.
The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client?
A) Infection
B) Fluid volume
C) Peripheral perfusion
D) Sleep pattern
C) Peripheral perfusion
Rationale: Ineffective peripheral tissue perfusion is the priority, because it is related to obstructed venous return, which is the underlying cause of the DVT. Risk for infection would be a priority if complications of infection were present; however, this is not the case. Excess fluid volume and disturbed sleep pattern are incorrect because they are not related to the underlying cause.
The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply. A) Avoid crossing the legs B) Avoid long car trips C) Avoid prolonged standing or sitting D) Take frequent walks E) Take a daily aspirin dose of 650 mg
A) Avoid crossing the legs
C) Avoid prolonged standing or sitting
D) Take frequent walks
Rationale: The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should also be instructed to avoid prolonged standing or sitting, which contributes to venous stasis. The client should also be instructed to take frequent walks to promote venous return. The client does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips. The client should not be instructed to take a daily aspirin, because it will increase anticoagulant activity and could interact with other medication prescribed for the treatment of the DVT.
A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
A) The client will not disturb the intravenous infusion.
B) The client will comply with dietary restrictions.
C) The client will not experience bleeding.
D) The client will keep the right leg elevated on two pillows.
C) The client will not experience bleeding
An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important, but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important, but not as high a priority as an absence of bleeding.
A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?
A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion.
B) Apply oxygen and elevate the head of the bed.
Rationale: Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation. Although reassuring the client and notifying family members are important, they are not a higher priority than promoting oxygenation. Increasing the rate of heparin infusion cannot be done by the nurse without an order from a healthcare provider.
A client being treated for a deep venous thrombosis (DVT) is experiencing pain. Which interventions should the nurse implement? Select all that apply.
A) Apply an egg-crate mattress on the bed.
B) Maintain bedrest as ordered.
C) Apply warm moist heat to the area four times a day.
D) Encourage position changes every 2 hours.
E) Measure calf and thigh diameter daily.
B) Maintain bedrest as ordered.
C) Apply warm moist heat to the area four times a day.
E) Measure calf and thigh diameter daily.
Rationale: Interventions to address pain include applying warm moist heat to the area four times a day, maintaining bedrest as ordered, and measuring calf and thigh diameter daily. Applying an egg-crate mattress on the bed and encouraging position changes every 2 hours would be appropriate for the client experiencing Ineffective Peripheral Tissue Perfusion.
The three pathological factors that are associated with the formation of a thrombus are known as what?
A) Rastelli syndrome
B) Holter triad
C) Vena cava syndrome
D) Virchow’s triad
D) Virchow’s triad
Rationale: Three pathological factors, called Virchow’s triad, are associated with the formation of a thrombus: circulatory stasis, vascular damage, and hypercoagulability. The Rastelli procedure is used to repair some congenital heart defects. A Holter monitor is used record the electrical activity of the heart over 24 to 48 hours. A vena cava filter is used to prevent thrombi from traveling up to the heart from the legs.
What characteristic of veins increases the risk for the development of a thrombus?
A) Low blood flow
B) High pressure
C) Retrograde blood flow
D) Presence of plaque
A) Low blood flow
Rationale: Venous thrombi tend to occur at sites where the vein is normal but blood flow is low. High pressure in the veins does not stimulate the formation of a thrombus. Retrograde blood flow is associated with postthrombotic syndrome, which occurs after a deep vein thrombosis has already developed. Arterial thrombi tend to occur at sites of arterial plaque rupture.
What is the most accurate tool for assessing and diagnosing venous thrombosis?
A) Ascending contrast venography
B) Duplex venous ultrasonography
C) Magnetic resonance imaging
D) Plethysmography
A) Ascending contrast venography
Rationale: All four of these diagnostic tests can be used to help diagnose a venous thrombosis. However, ascending contrast venography is the only invasive test, and it is the most accurate diagnostic tool for venous thrombosis. The other tests are noninvasive and may not be able to directly visualize the clot.
Both a 40-year-old male and a 70-year-old male are placed on anticoagulant therapy after diagnosis of a deep vein thrombosis (DVT). When providing teaching to these clients about their medication, how should the nurse individualize care for each?
A) The younger client will need more frequent monitoring than the older client.
B) The older client will need more frequent monitoring than the younger client.
C) The older client will take a lower dose than the younger client.
D) The younger client will take a lower dose than the older client.
B) The older client will need more frequent monitoring than the younger client.
Rationale: Anticoagulant therapy is commonly used to treat both older and younger adults with DVT. Most drugs are administered in a similar fashion and at comparable doses in older and younger clients, but monitoring may occur more frequently in older adults.
A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply.
A) Tachycardia B) Increased blood glucose level C) Decreased breath sounds D) Confusion E) Thick, tenacious bronchial secretions
A) Tachycardia
C) Decreased breath sounds
D) Confusion
Rationale: Clinical manifestations of DIC include tachycardia, decreased breath sounds, and confusion. Increased blood glucose and thick bronchial secretions are not associated with this health problem.
The nurse is caring for a client who has been admitted to labor and delivery. What should the nurse recognize as risk factors for disseminating intravascular coagulation (DIC)? Select all that apply.
A) Multiparity B) Placental abruption C) Preterm labor D) Fetal death E) Gestational diabetes
B) Placental abruption
D) Fetal death
Rationale: The risk of developing DIC increases in pregnant women who have preeclampsia, fetal death, amniotic fluid embolism, placental abruption, or septic abortion. Multiparity, preterm labor, and gestational diabetes do not cause DIC.
The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which should the nurse identify as a priority intervention for this client?
A) Frequent ambulation
B) Maintenance of skin integrity
C) Preparation for radiograph procedures
D) Restricting fluids
B) Maintenance of skin integrity
Rationale: Impairment of skin integrity can lead to bleeding in DIC. The client with DIC should be placed on bedrest. DIC is not diagnosed with radiograph examination but by serum lab studies. Fluids need to be monitored but will not be restricted
A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen saturation. Which is the priority nursing diagnosis for this client?
A) Acute Pain
B) Impaired Gas Exchange
C) Ineffective Peripheral Tissue Perfusion
D) Anxiety
B) Impaired Gas Exchange
Rationale: The decrease in oxygen saturation is a result of impairment in the client’s gas exchange. Anxiety could contribute to the client’s impaired gas exchange but is not the primary problem to address. Decreased oxygen saturation and anxiety would not be addressed with the diagnoses of Ineffective Peripheral Tissue Perfusion and Acute Pain.
The nurse has identified Ineffective Peripheral Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client?
A) Carefully repositioning the client every 2 hours
B) Administering oxygen
C) Monitoring oxygen saturation
D) Encouraging deep breathing and coughing
A) Carefully repositioning the client every 2 hours
Rationale: The intervention appropriate for the client experiencing ineffective peripheral tissue perfusion is to carefully reposition the client every 2 hours because position changes facilitate circulation and tissue perfusion. The other interventions would be appropriate if the client were experiencing impaired gas exchange.
The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC). Which finding indicates care has been successful for this client?
A) Heart rate 110 beats per minute
B) Oxygen saturation level 86%
C) Urine output 20 mL per hour
D) No evidence of bleeding
D) No evidence of bleeding
Rationale: Care provided to a client with DIC is successful when there is no further bleeding. Heart rate of 110 beats per minute, oxygen saturation of 86%, and urine output of 20 mL per hour would indicate the need for further treatment.
A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment?
A) Aspirin
B) Warfarin (Coumadin)
C) Fresh frozen plasma and platelets
D) Heparin
A) Aspirin
Rationale: When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given first to restore clotting factors and platelets. Aspirin and Coumadin are not indicated in the treatment of DIC. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems.
