Exam 1 Flashcards
Hyperventilation, with a resulting decrease in PaCO2, is an expected compensatory reaction to the acid–base disorder of ____________ acidosis.
metabolic
T/F: Body fluid is located in two fluid compartments: the intracellular space (fluid in the cells) and the extracellular space (fluid outside the cells).
TRUE
T/F: When monitoring a patient’s potassium level, the nurse is aware that tall, tented, “T” waves on an ECG are indicative of hypokalemia.
FALSE: Hypokalemia presents w/ ECG: flattened T waves, prominent U waves, ST depression, prolonged PR interval
The major electrolytes in the extracellular fluid are ____________ and chloride.
sodium
The cardinal feature of metabolic acidosis is a decrease in the serum bicarbonate level.
TRUE
Factors that increase BUN include decreased renal function, GI bleeding, ________________, increased protein intake, fever, and sepsis.
dehydration
T/F: Vital to the regulation of fluid and electrolyte balance, the kidneys normally filter 180 L of plasma every day in the adult and excrete 1 to 2 L of urine.
TRUE
When monitoring daily body weights to assess fluid volume deficit, the nurse understands that a loss of 0.5 kg (1.1 lb) represents a fluid loss of approximately _________ mL.
500
Hyperaldosteronism increases renal ___________________ wasting and can lead to severe potassium depletion.
potassium
T/F: A nurse should assess a patient with hypervolemia for indicators of hypotension, bradypnea, and oliguria.
FALSE: Acute weight loss, ↓ skin turgor, oliguria, concentrated urine, capillary filling time prolonged, low CVP, ↓ BP, flattened neck veins, dizziness, weakness, thirst and confusion, ↑ pulse, muscle cramps, sunken eyes, nausea, increased temperature; cool, clammy, pale skin
T/F: Myocardial dysfunction occurs when irreversibly damaged heart muscle is replaced by adipose tissue.
FALSE
Blood vessels commonly used to bypass occluded coronary arteries include the __________________ veins of the leg.
saphenous
T/F: For a patient to be considered a candidate for a coronary artery bypass graft (CABG), the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if the affected artery is the left main coronary artery).
TRUE
A ___________ provides structural support to a coronary artery following angioplasty to minimize the risk of vessel stenosis.
stent
Angina pectoris is chest pain resulting from myocardial _________ of the heart muscle.
ischemia
Management of an elevated ___________________ level focuses on weight reduction and increased physical activity.
triglyceride
Hypertension also increases the work of the __________________ ventricle, which must pump harder to eject blood into the arteries.
left
T/F: The most common cause of cardiovascular disease in the United States is atherosclerosis, an abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial blood vessel walls.
TRUE
T/F: Clopidogrel (Plavix) is commonly prescribed in addition to aspirin in patients at high risk for MI.
TRUE- blood thinner to prevent MI
T/F: Beta-blockers, such as Lopressor and Toprol, are the standard treatment for angina pectoris.
FALSE
Nitrates
A patient is receiving intravenous fluids (IVF) postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?
fluid volume excess
When evaluating a client’s response to treatment of a fluid imbalance, the most important assessment would be:
trending of daily weights.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
“Increase fluids if your mouth feels dry”
The patient that has fluid overload has been taking a diuretic for the past two days and now experiences changes. Which change indicates that the diuretic is effective?
Weight loss of six pounds
An older woman is admitted to the medical unit with gastrointestinal bleeding (GIB). Clinical manifestations would include:
weight loss
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is:
osmosis
A patient is admitted with congestive heart failure (CHF). What would you expect to find during your admission assessment?
Increased blood pressure and crackles throughout the lungs
Which patient is at risk for experiencing a fluid volume deficient (FVD)? The patient:
who has been vomiting and having diarrhea for 2 days
with continuous nasogastric suction
with an abdominal wound vac at intermittent suction
The nurse obtains a blood pressure reading of 50/30. The patient is awake, alert, and talking calmly with his family. Which action should the nurse take?
Recheck the blood pressure.
What you are seeing in the pt doesn’t match the monitor- double check
A patient has received a new diagnosis of stable angina. The nurse determines the client needs further education when they make the following statement:
“When experiencing angina, cardiac tissue is viable for 60 minutes.”
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
The patient states that the pain “goes away” with one sublingual nitroglycerin tablet.
A nurse enters a client’s room to find the client short of breath, rubbing his left arm and complaining of nausea. Which assessment would be the priority?
Assess for dysrhythmia.
Use an ECG
The nurse is preparing a male patient who experienced a myocardial infarction for discharge. The patient expresses concern about having sex with his wife when he returns home. Which response by the nurse would be most helpful in lessening the patient’s fears?
“It is common for patients to worry about resuming sexual activities. Tell me about your concerns.”
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
The patient states that the pain “goes away” with one sublingual nitroglycerin tablet.
A client comes to the emergency room complaining of chest pain that radiates down the left arm. The nurse prepares to draw a blood specimen to test for:
Cardiac Biomarkers
- Troponin
- CK- MB
- Myoglobin
A client is prescribed medication for angina. The priority long-term goal should be:
increased tolerance for daily activities.
After the nurse has finished teaching a client about the use of sublingual nitroglycerin, which client statement indicates the teaching has been effective?
“I will call 911 if I still have pain after taking my nitroglycerin.”
A patient with angina is instructed to rest when having an episode of chest pain. What is the best explanation for how rest relieves the pain associated with angina?
A balance between myocardial cellular needs and demand is achieved.
While caring for a client recovering from a myocardial infarction and stent placement, the monitor alarm sounds and the nurse notes ventricular fibrillation. What is your priority intervention?
Assess the client’s level of consciousness
Basic life support is “are you okay” can’t shock someone awake/ alert \
A client’s lipid profile reveals an LDL level of 122 mg/dL. This is considered a:
high LDL level.
Explanation:
LDL levels above 100 mg/dL are considered high. The goal is to decrease the LDL level below 100 mg/dL.
To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)?
60 minutes
Explanation:
The 60-minute interval is known as “door-to-balloon time” in which a PTCA can be performed on a client with a diagnosed MI. The 30-minute interval is known as “door-to-needle time” for the administration of thrombolytics after MI. The time frame of 9 days refers to the time until the onset of vasculitis after administration of streptokinase for thrombolysis in a client with an acute MI. The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same client for acute MI.
The nurse is caring for a client with Raynaud’s disease. What is an important instruction for a client who is diagnosed with this disease to prevent an attack?
Avoid situations that contribute to ischemic episodes.
Explanation:
Teaching for clients with Raynaud’s disease and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.
Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?
Morphine sulfate (Morphine) Explanation: Morphine sulfate not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina–type pain, but oral forms (such as isosorbide dinitrate) have a large first-pass effect, and transdermal patch is used for long-term management. Meperidine hydrochloride is a synthetic opioid usually reserved for treatment of postoperative or migraine pain.
The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure?
a serum BUN of 70 mg/dL
Explanation:
These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.
A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client’s response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?
Blood pressure 84/52 mm Hg
Explanation:
Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client’s blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don’t change significantly after nitroglycerin administration.
When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client’s serum electrolytes, anticipating which abnormality?
Hyperkalemia
Explanation:
Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). Hypercalcemia would likely be demonstrated by asystole. Hypomagnesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. Hyponatremia would likely be indicated by weakness, fatigue, and confusion, without a change in T wave formation.
A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding?
“What color is your urine?”
Explanation:
The patient receiving anticoagulation therapy should be monitored for signs and symptoms of bleeding, such as changes in the color of the stool or urine.
A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?
Relieved by rest and nitroglycerin
Explanation:
One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.
A client with a family history of coronary artery disease reports experiencing chest pain and palpitations during and after morning jogs. What would reduce the client’s cardiac risk?
smoking cessation
Explanation:
The first line of defense for clients with CAD is lifestyle changes including smoking cessation, weight loss, stress management, and exercise. Clients with CAD should eat a balanced diet. Clients with CAD should exercise, as tolerated, to maintain a healthy weight. Antioxidant supplements, such as those containing vitamin E, beta carotene, and selenium, are not recommended because clinical trials have failed to confirm beneficial effects from their use.
When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina?
Unstable
Explanation:
Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.
A nurse teaches a client with angina pectoris that he or she needs to take up to three sublingual nitroglycerin tablets at 5-minute intervals and immediately notify the health care provider if chest pain doesn’t subside within 15 minutes. What symptoms may the client experience after taking the nitroglycerin?
Headache, hypotension, dizziness, and flushing.
Explanation:
Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Vasodilators, beta-adrenergic blockers, and calcium channel blockers are three major classes of drugs used to treat angina pectoris. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a beta-adrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic that relieves pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker.
The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse?
ST elevation
Explanation:
The first signs of an acute MI are usually seen in the T wave and the ST segment. The T wave becomes inverted; the ST segment elevates (it is usually flat). An elevated ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e., ST-elevation MI). This client requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.
A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply.
Hyperlipidemia
Obesity
Tobacco use
The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received?
Protamine sulfate
Explanation:
Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin).
A client with known coronary artery disease reports intermittent chest pain, usually on exertion. When teaching the client about nitroglycerin administration, which instruction should the nurse provide?
“Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up.”
Explanation:
Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina. He may repeat the dose every 5 minutes for up to three doses; if this intervention doesn’t bring relief, the client should seek immediate medical attention.
After percutaneous transluminal coronary angioplasty (PTCA), the nurse confirms that a client is experiencing bleeding from the femoral site. What will be the nurse’s initial action?
Apply manual pressure at the site of the insertion of the sheath.
Explanation:
The immediate nursing action would be to apply pressure to the femoral site. Reviewing blood studies will not stop the bleeding. The nurse cannot decrease anticoagulation therapy independently. If the bleeding does not stop, the health care provider needs to be notified.
A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client’s cholesterol profile is as follows: total cholesterol 265 mg/dl, low-density lipoprotein (LDL) 139 mg/dl, and high-density lipoprotein (HDL) 32 mg/dl. The client asks the nurse how to lower his cholesterol. What is the best response by the nurse?
The nurse will ask the dietitian to talk with the client about modifying the diet.
A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication?
Atelectasis
Explanation:
Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.
Which is the most important postoperative assessment parameter for a client recovering from cardiac surgery?
Inadequate tissue perfusion
Explanation:
The nurse must assess the client for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood glucose and mental status, tissue perfusion is the higher priority.
A nurse is caring for a client in the cardiovascular intensive care unit following a coronary artery bypass graft. Which clinical finding requires immediate intervention by the nurse?
Central venous pressure reading of 1
Explanation:
The central venous pressure (CVP) reading of 1 is low (2–6 mm Hg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse’s priority.
In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?
To decrease workload of the heart
Explanation:
Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.
A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse?
“Removing the patch at night prevents drug tolerance while keeping the benefits.”
Explanation:
Tolerance to antianginal effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerin are headaches and contact dermatitis but not the reason for removing the patch at night. It is true that while the client rests, there is less demand on the heart but not the primary reason for removing the patch.
The nurse is administering oral metoprolol. Where are the receptor sites mainly located?
Heart
Explanation:
Metoprolol works at beta 1 -receptor sites. Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.
A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent?
Clopidogrel
Explanation:
Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin. Isosorbide mononitrate is a nitrate used for vasodilation. Metoprolol is a beta blocker used for relaxing blood vessels and slowing heart rate. Diltiazem is a calcium channel blocker used to relax heart muscles and blood vessels.
When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition?
Inadequate fluid volume
Explanation:
Urine output less than 0.5 mL/kg/h may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 0.5 mL/kg/h or more and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric client does not produce urine.
The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication?
160–190 mg/dL
Explanation:
Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.
Which medication is given to clients who are diagnosed with angina but are allergic to aspirin?
Clopidogrel
Explanation:
Clopidogrel or ticlopidine is given to clients who are allergic to aspirin or are given in addition to aspirin to clients who are at high risk for MI. Amlodipine, diltiazem, and felodipine are calcium channel blockers.
Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?
Monitor the site for bleeding or hematoma.
Explanation:
The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma. A nurse does not advise the client to clean the site with disinfectants or refrain from sexual activity for 1 month.
Which is a diagnostic marker for inflammation of vascular endothelium?
C-reactive protein (CRP)
Explanation:
CRP is a marker for inflammation of the vascular endothelium.
The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain?
a lack of oxygen in the heart muscle cells
Explanation:
Angina pectoris refers to chest pain that is brought about by myocardial ischemia. It is the result of cardiac muscle cells being deprived of oxygen due to the progressive symptoms of coronary artery disease. Artery blockage or closure leads to myocardial death. The destroyed part of the heart (death of heart tissue) is a myocardial infarction.
The nurse is assessing a client with suspected post-pericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome?
pericardial friction rub
Explanation:
Post-pericardiotomy syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR. Hypothermia is not a symptom of post-pericardiotomy syndrome.
The nurse is assessing a postoperative patient who had a percutaneous transluminal coronary angioplasty (PTCA). Which possible complications should the nurse monitor for? (Select all that apply.)
Abrupt closure of the artery Arterial dissection Coronary artery vasospasm Explanation: Complications that can occur during a PTCA procedure include coronary artery dissection, perforation, abrupt closure, or vasospasm. Additional complications include acute myocardial infarction, serious dysrhythmias (e.g., ventricular tachycardia), and cardiac arrest. Some of these complications may require emergency surgical treatment. Complications after the procedure may include abrupt closure of the coronary artery and a variety of vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion (Bhatty, Cooke, Shettey, et al., 2011).
The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme?
myocardial necrosis
Explanation:
An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injuries such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.
A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse?
Altered level of consciousness
Explanation:
A client receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding, and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low and indicates the client’s chest pain is subsiding, an expected outcome of this therapy.
The nurse is caring for a client with coronary artery disease. What is the nurse’s priority goal for the client?
enhance myocardial oxygenation
Explanation:
Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn’t the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.
A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern?
hematocrit of 30%
Explanation:
Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding.
The nurse is removing a client’s femoral sheath after cardiac catheterization. What medication will the nurse have available?
atropine sulfate
Explanation:
Removing the sheath after cardiac catheterization may cause a vasovagal response, including bradycardia. The nurse should have atropine sulfate on hand to increase the client’s heart rate if this occurs. Heparin changes clotting of blood; clients should stop taking it before the sheath removal. Protamine sulfate is an antidote to heparin, but the nurse shouldn’t administer it during sheath removal. Adenosine treats tachydysrhythmias.
Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?
Withhold anticoagulant therapy.
Explanation:
The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.
A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client?
Coronary artery disease
Explanation:
The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud’s disease in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.
T/F: A patient with pulmonary edema should be positioned upright, preferably with the legs dangling over the side of the bed, if possible
TRUE
The three major types or classifications of cardiomyopathy, a disease of the myocardium are as follows: dilated, hypertrophic and _______________.
restrictive
T/F: Digitalis (digoxin) is considered the most essential and most frequently prescribed pharmacologic agent for the treatment of heart failure.
FALSE
_____________ causes myocardial dysfunction in heart failure because it deprives heart cells of oxygen and causes cellular damage.
ischemia
T/F: The most common type of heart failure is an alteration in ventricular contraction called diastolic heart failure, which is characterized by a weakened heart muscle.
FALSE
Because HF is a complex and progressive condition, patients are at risk for many complications, including acute decompensated HF, ________________, kidney disease, and life-threatening dysrhythmias.
pulmonary edema
Pulmonary edema can also develop slowly, especially when it is caused by _________________ disorders such as kidney disease and other conditions that cause fluid overload.
noncardiac
Left-sided heart failure refers to failure of the left ventricle, which results in ________________ congestion
pulmonary
T/F: ACE inhibitors are recommended for prevention of HF in patients at risk due to vascular disease and diabetes
TRUE
T/F: Fluid overload and decreased tissue perfusion result when the heart cannot generate cardiac output (CO) sufficient to meet the body’s demands for oxygen and nutrients.
True
The most characteristic manifestation of hypocalcemia and hypomagnesemia is:
Tetany
A nurse is caring for a client diagnosed with hypovolemic hyponatremia. Which IV solution should the nurse anticipate?
0.9% NS
b/c it is also going to replace sodium
A nurse is providing discharge instructions to a client diagnosed with ESRD. The nurse explains that the client is at risk for developing hypernatremia. Which manifestation should the nurse instruct the client to report immediately to a healthcare provider?
Weight gain of 3 lb in 1 day
An elderly clients prescribed furosemide 40mg PO for the treatment of CHF. A nurse teaches the client to observe for signs of potassium imbalance while taking this medication. Which signs should the nurse include?
General muscle weakness, constipation, weak, thready pulse
After receiving change-of-shift report, which patient should the nurse assess first? The patient with:
serum potassium level of 5.2 mEq/L who is complaining of abdominal cramping
serum sodium level of 150 mEq/L who has a dry mouth and is asking for a glass of water
serum magnesium level of 1.1 mg/dL who has tremors and hyperactive deep tendon reflexes
serum phosphorus level of 4.8 mg/dL who has multiple soft tissue calcium-phosphate precipitates
serum magnesium level of 1.1 mg/dL who has tremors and hyperactive deep tendon reflexes
-worry about cardiac effects- torsades
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking Maalox at home for indigestion. Which action should the nurse take first?
Notify the patient’s health care provider
The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient’s discharge teaching to prevent progression of the disease to Acute Decompensated Heart Failure (ADHF)?
Take medications as prescribed.
While working in an outpatient medical clinic, the nurse recognizes a client is experiencing intermittent claudication when the client reports:
“My legs cramp whenever I walk more than a block.”
The nurse is managing care for a client with a DVT (deep vein thrombosis) of the right calf. The client receives heparin intravenously (IV). What is the priority outcome for this client?
The client will not experience bleeding.
What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure?
Hypotension and tachycardia
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes ,
A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C).
A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled.
A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
Acute pulmonary edema caused by heart failure is usually a result of damage to which area of the heart?
Left ventricle.
A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside what should the nurse assess first?
Blood pressure
Why?- sudden difficulty breathing: need to make sure that BP can take a sudden change in position- could become hypotensive
Heart failure patients should have less than ____________ mg of sodium per day.
2,000 mg
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?
Elevate the head ofthe bed to a high-Fowler’s position.
The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip. In anticipation of discharge the healthcare provider (HCP) orders warfarin. Which action should the nurse take?
Administer the warfarin along with the heparin drip as ordered.
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3–) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic alkalosis
Explanation:
A pH over 7.45 with a HCO3– level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3–. The client isn’t experiencing respiratory alkalosis because the PaCO2 is normal. The client isn’t experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.
0.45% NaCl is a __________ solution
hypotonic
Lactated Ringer solution and normal saline (0.9% NaCl) are ________ solutions
isotonic
A 5% NaCl solution is _______?
hypertonic
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider?
Takes high doses of vitamin D
b/c- hypercalcemia can affect many organ systems when calcium levels acutely rise; someone taking Vit. D is also increases absorption of calcium leading to their s/s
Which of the following arterial blood gas results would be consistent with metabolic alkalosis?
Serum bicarbonate of 28 mEq/L
b/c metabolic alkalosis evaluation would reveal a pH >7.45 and a serum bicarb concentration ?26 mEq/L
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
Hypokalemia
b/c it is a potassium wasting diuretic and could drop levels lower than 3.5 mEq/L
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
Instruct the client to breathe into a paper bag.
b/c these findings indicate respiratory alkalosis, so in order to raise the PaCO2 levels (normal range is 38-42mm Hg), it would be best to breathe into bag
Which nerve is implicated in the Chvostek’s sign?
Facial
this sign is associated w/ hypocalcemia
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?
Metabolic acidosis
It is characterized by a low pH (which indicated increased H+ concentration) and a low bicarb concentration.
