Exam 1 : Cardiovascular Chronicity Flashcards
Congestive heart failure
Congestive heart failure is a condition in which your heart can’t pump enough oxygen-rich blood to meet your body’s needs. When your heart doesn’t pump efficiently, blood may back up into your lungs and other tissues.
The severity of congestive heart failure depends on how much pumping capacity your heart has lost. As they age, most people lose some pumping capacity. However, in congestive heart failure, your heart has very little pumping capacity. Congestive heart failure often results from damage caused by a heart attack, high blood pressure, diabetes or other conditions.
Classifications of heart failure
Class I – ordinary activity does not cause concern
Class II – slight limitation of activity
Class III – comfortable at rest. Marked limitation with activity
Class IV – unable to carry on any physical activity without discomfort
Stroke volume
The larger the stroke volume the more it fills the ventricles and therefore it has to work harder, the more the work load of the heart ht emore the oxygen consumpition
True or false
Faster HR the higher the cardiac demands
True
What is the goal of medication therapy in HF?
Goal of medication therapy is to decrease cardiac workload through SV, HR, Preload, after load and contractility
What is cardiac output?
Stroke volume * heart rate
What is Preload?
Preload is the filling pressure of the RV-LV and is influenced by venous return
True or False
In a healthy heart, as you ↑Preload…You will INCREASE SV increasing the force of contraction . . . . . up to a certain point-then further stretching may actually DECREASE contractility
True
What decreases Preload?
Drugs that cause venous dilation (nitrates)- DECREASE preload . (gives fluid more space to disperse)
Diuretics that eliminate excess fluid volume- DECREASE preload
What are some labs you would check when giving a diuretic?
Labs you would check when giving diuretics: creatine, potassium, sodium
CHF exacerbation
CHF exacerbation: give alittle bit of morphine because it lowers anxiety and relieves chest pain and most importantly it’s a peripheral vasodilator…fluid can sit out there for a bit so the heart doesn’t have to deal with it
Low dose nitroglycerin drip: also a vasodilator
Starlings law of the heart
The greater the PRELOAD, the greater quantity of blood that can be ejected during systole due to INCREASED stretch of myocardium.
There is a limit! Greatest force of contraction is when the muscle fibers are stretched 2 ½ times their normal length.
The overstretch of cardiac muscle is like an overstretched rubber band-will DECREASE cardiac contractility and efficiency over time
What is after load?
Force of resistance that the LV must generate to open aortic valve
Influenced by resistance of blood vessels in the body-are the arteries dilated or constricted? –hypothermic constricted, running a temp its dilated
How does after-load correlate with systolic bp
Correlates with systolic blood pressure.. How much pressure is needed to push blood out of the heart into the aorta and into the entire systemic circulation
What medications decrease after-load
Arterial vasodilators (Ca++ channel blockers (CCB), ACE inhibitors) DECREASE afterload
What is contractility?
Ability of heart to change force of inherent contraction strength
Influenced by Ca++ in action potential…therefore Calcium Channel Blockers will do what to contractility?
Negative inotropic meds?
Negative inotropic meds: Calcium channel blockers, beta blockers
What is ejection fraction?
65-70% normal, reflects that with each contraction 65-70% of the blood in the LV is ejected into circulation
As this % goes down it reflects the loss of cardiac contractility and degree of CHF
35% EF is half the normal cardiac output with each contraction
Etiology heart failure
Heart failure is caused by systemic hypertension in 75% of cases.
About one third of clients experiencing myocardial infarction also develop heart failure.
Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart.
Left sided heart failure manifestations
Weakness, fatigue, dizziness, confusion, pulmonary congestion, dyspnea on exertion, orthopnea, paroxysmal nocutnal dypnea, oliguria, renal failrue
Right sided heart failure manifestations
Jugular distention, enlarged liver and spleen, anorexia, nausea, dependent edema (legs and sacrum), distended abdomen, swollen hands and fingers, polyuria at night, weight gain, increased BP
True or false
B NATURETIC PEPTIDE IMPORTANT IN DIAGNOSING HEART FAILURE
True
ONE OF THE BEST WAYS TO DIFFERENTIATE BETWEEN PNEUMONIA AND HEART FAILURE IS B NATURETIC PEPTIDE
ONE OF THE BEST WAYS TO DIFFERENTIATE BETWEEN PNEUMONIA AND HEART FAILURE IS B NATURETIC PEPTIDE
BMP vs BNP
BMP : basic metabolic panel
BNP: brain naturetic peptide
Why would BNP be elevated in heart failure?
BNP would be elevated when the ventricles are being stretched and having to work too hard
Could happen during heart failure, marathon runner in training, genetic makeup can also play in affect,
Normal BNP ranges
Normal range for BNP: 0-100
Elevated BNP: anything above 100
Sympathetic nervous system stimulation: arteries constricts resulting in increased afterload
Sympathetic nervous system stimulation: arteries constricts resulting in increased afterload
Key assessment sin heart failure
Lab assessment: electrolytes, renal panel, ABGs, BNP
Radiographic assessment: chest xray: cardiomegaly (enlarged heart)
Echocardiography: diagnoses valvular function, Ejection fraction
Pulmonary artery catherization: diagnose and manage HF
Impaired gas exchange interventions
Interventions include:
Ventilation assistance – vent or nasal.
Goal O2 sats: ________
Hemodynamic regulation – Swan Ganz
Energy management (conservation), positioning
Diet therapy
Drug therapy
Optimizing cardiac output
Interventions are aimed at optimization of: Stroke volume Preload Afterload Contractility
Why would you give coreg for the a low bp?
the bp went up because the heart didnt have to work as hard
Drugs that reduce after load
ACE inhibitors, ARBs, Nitrates - Human B-type natiuretic peptides for acute HF.
Drugs that enhance contractility
Digitalis
Digitalis toxicity includes anorexia, fatigue, changes in mental status.
Valvular diseases
Mitral stenosis: Stenotic means stiff, possible calcium buildup..too stiff for blood to go through it
Regurgitant valve: blood get regurgitated or sent back up
Mitral valve prolapse: valve is limp and falls through ventricles
Assesment for valvular disease
Sudden onset or slow development of symptoms over many years.
Question client about history of rheumatic fever, infective endocarditis, and IV drug use/abuse.
Common diagnostics include chest x-ray, echocardiogram (TT, TEE), and exercise tolerance test.
Common Nursing Diagnoses related to Valvular Heart Disease
- Decreased Cardiac Output related to altered stroke volume
- Impaired Gas Exchange related to ventilation perfusion imbalance
- Activity Intolerance related to inability of the heart to meet metabolic demands during activity
- Acute Pain related to physiologic injury agent (hypoxia)
Nonsurgical Management for Valvular Heart Disease
Nitrates dilate to allow less resitance and doesn’t make heart work as hard
Surgical Management for Valvular Heart Disease
- Reparative procedures
- Balloon valvuloplasty
- Direct, or open, commissurotomy
- Mitral valve annuloplasty: go in scrape off
- Replacement procedures
(Lifelong anticoagulants r/t mechanical artificial valve.)
Xenograft from other species (pig) do not last as long as artificial (mechanical).
Infective endocarditits
Microbial infection involving the endocardium – most common
Streptococcus viridans or Staphlocococcus aureus
Occurs primarily with IV drug abuse, valvular replacements, systemic infections, or structural cardiac defects
Ports of entry: mouth, skin rash, lesion, abscess, infections, surgery, or invasive procedures including IV line placement
High mortality rate
Manifestations of Endocarditis
- Murmur
- Heart failure – most common complication
- Arterial embolization
- Splenic infarction
- Neurologic changes : TIA, CVA, confusion, dysphagia
- Petechiae (pinpoint red spots)
- Splinter hemorrhages – distal third of nail bed
Interventions for endocarditis
- Antimicrobials – 4-6 weeks, most penicillins or cephalosporins
- Home Care or outpatient therapy for IVs
- Rest, balanced with activity
- Supportive therapy for heart failure
- Anticoagulants if pt has prosthetic valve
- Surgical management to remove or repair infected valve
Pericarditis
Inflammation or alteration of the pericardium
the membranous sac that encloses the heart
Dressler’s syndrome (1-12 wks after MI)
Fever, pericarditis, pleural & pericardial effusions
Postpericardiotomy syndrome
After cardiac surgery
Chronic constrictive pericarditis
Assessment of pericarditis
Substernal precordial pain radiating to left side of the neck, shoulder, or back.
Grating, oppressive pain, aggravated by breathing, coughing, swallowing, position.
Pain worsened by the supine position; relieved when the client sits up and leans forward.
Pericardial friction rub
Elevated WBC and fever
Intervention for pericarditis
Hospitalization for diagnostic evaluation, observation for complications, and symptom relief
Pharmacologic therapy: Nonsteroidal anti-inflammatory drugs, Corticosteroid therapy
Comfortable position, usually sitting
Pericardial drainage
What is cardiac tamponade?
Cardiac tamponade:an extreme emergency
When the space between the parietal and visceral layers of the preicardium fills with fluid
restricts ventricular filling and cardiac output falls.
Symptoms: JVD, paradoxical pulse, ↓CO, muffled heart sounds, circulatory collapse
Pericardiocentesis :draw off fluid, “tap”
Pericardial window : for recurrence of tampanode or pericarditis
Pericardiectomy – removal of the pericardium
Ischemia
Ischemia: oxygen supply insufficient to meet requirements of the myocardium
Infarction
Infarction: necrosis or cell death that occurs when severe ischemia is prolonged and irreversible damage to tissue results
Coronary artery disease
Includes stable angina pectoris and acute coronary syndromes
Angina
Temporary imbalance between the coronary arteries’ ability to supply oxygen and the cardiac muscles’ demand for oxygen.
Chronic Stable Angina (CSA)
Chronic Stable Angina (CSA)
-The ischemia is of limited duration and does not cause permanent myocardial tissue damage.
- Predictable, remains the same over several months.
- Doesn’t go past a 3 on a 0-10, predicatable, same treatment works usually nitro
Metabolic syndrome
Hypertension Low HDL High Triglycerides Elevated blood glucose Large waist size Increased pro-thrombotic state Increased pro-inflammatory state (C-reactive protein
Chest pain diagnostics
- Electrocardiogram (12 lead EKG)
- Stress Test
- Myocardial perfusion imaging
- -Magnetic resonance imaging (-MRI)
- Cardiac Catheterization (Angiogram)
- Cardiac Markers
- Troponin T
- Troponin I
- Myoglobin
- CPK MB
- C-reactive Protein
Chemical stress test
Chemical stress test: dubetamide, persentine
Gold standard for diagnosing chest pain
GOLD STANDARD: ANGIOGRAM ( look and see)
True or false
Dysrhythmias the leading cause of death in clients with MI who die prior to hospitalization
True
Which mind-body therapy intervention would it be most appropriate to implement for a patient reporting pain and anxiety in the hospital setting?
Music therapy
What percentage of Americans age 50 or older are estimated to use some form of complementary and/or alternative medicine?
44%
What health history do you want to know when doing a cardiovascular assessment ?
- Congenital Heart Disease
- Rheumatic Fever
- Heart Murmur
- Hypertension
- High cholesterol
- Diabetes Mellitus
- Confusion: not adequate oxygen perfusion -possibly because of a blockage in the carotid arteries
- Fatigue: Anemia
- Dental Status
Cardiovascualr medications
- Beta Blockers
- ACE Inhibitors
- Angiotensin Receptor Blockers
- Calcium Channel Blockers
- Antidysrhythmic Agents
- Diuretics
Beta blockers
Metoprolol, decreases heart rate, know HR, cardiac rhythm & BP before and after giving med. IV Esmolol can be used in emergency situations (on test)
ACE Inhibitors
Angitoensin converting enzyme, Lisinopril, cough is a side effect of ACE inhibitors, used to treat hypertension
Calcium Channel Blockers
Block calcium during action potentials, slows down impulses and rhythms, Verapamil
Antidysrhythmic Agents:
Digoxin, Amiodarone,
Diuretics
Lasix (furosemide), Bumex,
Look carefully at renal labs such as creatine, BUN and potassium when giving ACE inhibitors and ARBS
True
Ausculating the heart
Auscultation Heart Sounds S1 S2 S3 S4 Murmur: graded 1-6, 1 is the softest, 6 is the loudest, when they occur systolic/diastolic Pericardial Rub Prosthetic Valve : sounds like fingernails rubbing together
S3 and S4 can come and go
What is the hallmark of CHF?
S3 is the hallmark of CHF, when the extra fluid is gone the S3 is gone too
How to distinguish pericardial rub vs pleural rub
if you ask patient to hold breath and it continues its probably pericardial, rubs can come and go, can go after taking chest tubes out
How many sites do you listen to for the heart?
Listen to 4 or 5 sites, one on right and 4 on left going top to bottom of chest
Age related cardiovascular issues
- Calcification in valves
- Pacemaker cells decrease in number
- Conduction time increases
- Left ventricle increases
- Aorta and large vessels thicken and become stiffer
- Baroreceptors less sensitive : Barioreceptors are a lot less sensitive so give them a minte to adjust because their blood doesn’t go by barocrecptors as strong and they wiill feel faint
Classic heart attack symptoms
Nausea, vomiting, pallor, sweating, anxiety
Cardiac diagnostics
- Blood studies (Labs)
- Chest x-ray
- ECG
- Exercise/Stress Testing
- Echocardiogram/TEE
- Nuclear studies
- Magnetic Resonance Imaging
- Cardiac Catheterization
Serum markers of myocardial damage
- Troponin (10 min)
- Creatine kinase
- Myoglobin - muscle
- Serum lipids
- Homocysteine
- C-reactive protein
- Blood coagulation
What causes S1?
S1 is created by the closure of the mitral and tricuspid valves
What causes S2?
S2 is caused by the closing of the aortic and pulmonic valves…S2 is shorter than s1
What is paradoxical splitting?
Abnormal splitting of the S2 is referred to as paradoxical splitting and has a wider split heard on expiration. Paradoxical splitting is heard in patients with severe myocardial depression such as MI, left bundle branch block, aortic stenosis, aortic regurgitation, and righ ventricular pacing
What causes S3 & S4?
S3 is called the ventricular gallop. S4 is called the atrial gallop. An S3 gallop in those under 30 is usually normal however if your over 35 it usually means a decrease in left ventricular compliance. S4 is heard in patients with hypertension, anemia, stenosis, MI, pulmonary emboli
What is a pericardial friction rub?
It originates from the pericardial sac and occurs with movements of the heart during the cardiac cycle. Rubs are usually signs of inflammation, infection or infiltration.
Creatine kinase
Elevations include possible brain, myocardial or skeletal muscle necrosis or injury
CK-MB
Elevations occur with MI injury
Total lipids
Elevations indicate an increased risk of CAD
HIgh HDLs
Elevation protects against CAD
Troponins T & I
Elevations indicate myocardial injury or infarction
Myoglobin
Elevation indicates mI
Cardiac cathertization
The most definitive and invasive test in diagnosing heart disease
Hemodynamic monitoring
An invasive system used to provide info about vascular capacity, blood volume, pump effectiveness and tissue perfusion, It measures pressures in the heart and vessels. PAWP: pulmonary artery wedge pressure 4-12
Normal creatine kinase levels
Female: 30-135
Male: 55-170
Normal CK-MB levels
0
Total lipid levels
400-1000
Normal cholesterol levels
122-200
Normal triglyceride levels
Female: 35-135
Males: 40-160
Normal HDL
Over 55 for female
Over 45 for male
HDL; LDL ratio
3:1
Normal tropinin level
less then 0.03
Normal myoglobin levels
Less than 90 mcg
What is the difference between heart monitors and event monitors
???
What are the three types of heart failure?
- Left sided heart failure
- right sided heart failure
- High output failure
Left sided heart failure
Includes hypertension, CAD, and valvular disease. Decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels indicate left ventricular failure
Left sided heart failure cont.
Left sided heart failure used to be referred to a CHF. It can also be divided into 2 subtypes diastolic or systolic heart failure
Right sided heart failure
May be caused by left ventricular failure, right ventricular MI, or pulmonary hypertension. In this type of heart failure the right ventricle cannot empty completely. Increased volume and pressure develop in the venous system and peripheral edema results.
High output heart failure
Can occur when CO remain above normal. It can be caused by increased metabolic needs or hyperkinetic conditions such as septicemia, high fever, anemia, and hyperthyroidism
Pharmacologic stress echocardiogram
Uses medicine to make the heart work like exercise when the patient cannot tolerate exercise (knee replacements, amputee)
- Persantine
- Adenosine
- Dobutamine
Preload
volume of blood in the ventricles at the end of diastole.
Circulating blood volume, status of AV valves, venous return
Afterload
Resistance/impedance to flow out of the ventricle
Peripheral resistance, Aortic valve status, Blood viscosity
Possible complications of cardiac cauterization
Possible complications:
- myocardial infarction
- stroke
- thromboembolism
- arterial bleeding
- lethal dysrhythmias
- death
What arteries are used for cardiac cauterization
Either femoral or radial arteries are used
What is an angiogram?
Angiogram is just to look and see if the coronary arteries are patent or not, an angioplasty can be done by putting a balloon in and squish it out of the artery
A stent is placed and squished into the plaque and artery and holds the artery open
After someones had stents placed they have to be on an anticoagulant
Hemodynamic monitoring
- Invasive system used in critical care areas to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion
- Systemic intra-arterial monitoring: For direct continuous BP measurement, arterial blood draws.
- Central venous pressure catheter (CVP)
- Pulmonary artery catheter: Reads right atrial and indirect left atrial when balloon is inflated in the “wedge” position in the pulmonary artery
- Low readings – hypovolemia,
- High readings – fluid overload, heart failure
- Can measure cardiac output
B naturetic peptide
Is produced and released by the ventricles when the patient has fluid overload as a result of HF
Left sided heart failure
With left ventricular systolic dysfunction, cardiac output is diminished, leading to impaired tissue perfusion, anaerobic metabolism, and unusual fatigue. Symptoms include: weakness, fatigue, dizziness, acute confusion, pulmonary congestion, breathlessness and oliguria (scant urine)
What is the most common cause of mitral stenosis?
Rheumatic fever
What is acute coronary syndrome?
Its used to describe patients who have either unstable angina or an acute myocardial infarction. In ACS it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus (clot) formation, and vasoconstriction.
The client with unstable angina has received education about the acute coronary syndrome. Which of the following indicates that he understood the teaching?
. “This is a big warning, I must modify my lifestyle or risk having a heart attack in the next year.”
is caring for a group of clients who have sustained myocardial infarction (MI). The nurse observes the client with which type of MI most carefully for the development of left ventricular heart failure?
Anterior wall, Owing to the large size of the anterior wall, the amount of tissue infarction may be large enough to decrease the force of contraction, leading to heart failure.
The nurse is providing a cardiac class for a women’s group. The nurse emphasizes that which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply.
B. Increasing age
C. Family history
D. Abdominal obesity
The nurse is teaching a group of teens about prevention of heart disease. Which point should the nurse emphasize?
Do not smoke or chew tobacco.
Correct: Tobacco exposure, including secondhand smoke, reduces coronary blood flow, causes vasoconstriction and endothelial dysfunction and thickening of the vessel wall, increases carbon monoxide, and decreases oxygen. Because this is highly addicting, beginning smoking in the teen years may lead to decades of exposure.
The nurse is teaching the client that metabolic syndrome can increase the risk for myocardial infarction (MI). Which signs of metabolic syndrome should the nurse include in the discussion? Select all that apply.
B. Hypercholesterolemia
D. Glucose intolerance
E. Client taking losartan (Cozaar)
Correct: Decreased high-density lipoprotein cholesterol (HDL-C) (usually with high low-density lipoprotein cholesterol [LDL-C]), HDL-C less than 40 mg/dL for men or less than 50 mg/dL for women, or taking an anticholesterol drug is a sign of metabolic syndrome.
Correct: Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance) is included in the constellation of metabolic syndrome.
Correct: Blood pressure greater than 130/85 or taking antihypertensive medication indicates metabolic syndrome.
Which of the following atypical symptoms may be present in the female client experiencing myocardial infarction (MI)? Select all that apply.
B. Dyspnea
C. Dizziness
D. Extreme fatigue
To validate that the client has had a myocardial infarction (MI), the nurse assesses for positive findings on which tests?
Myoglobin and troponin
Correct: Myoglobin, troponin, and CK-MB are the cardiac markers used to determine whether MI has occurred.
When caring for a client with acute myocardial infarction, the nurse recognizes that prompt pain management is essential for which reason
B. Pain relief improves the oxygen supply and decreases oxygen demand.
Correct: The focus of pain relief is on reducing myocardial oxygen demand.
When planning care for a client in the emergency department, the nurse recognizes that which interventions are needed in the acute phase? Select all that apply
A. Morphine sulfate
B. Oxygen
C. Nitroglycerin
Correct: Morphine is needed to reduce oxygen demand, preload, pain, and anxiety.
Correct: Administering oxygen will increase available oxygen for the ischemic myocardium.
Correct: Nitroglycerin is used to reduce preload and chest pain.
After thrombolytic therapy, the nurse working in the cardiac catheterization laboratory would be alarmed to notice which sign
B. Facial drooping
Correct: During and after thrombolytic administration, the nurse observes for any indications of bleeding, including changes in neurologic status, which may indicate intracranial bleeding.
The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity should the nurse suggest?
C. Placing a chair in the shower for independent hygiene
Correct: Phase 1 begins with the acute illness and ends with discharge from the hospital. It focuses on promoting rest and allowing clients to improve their ADLs based on their abilities
The nurse is caring for a client 36 hours post coronary artery bypass grafting (CABG), with a diagnosis of activity intolerance related to imbalance of myocardial oxygen supply and demand. Which of these findings causes the nurse to terminate an activity and return the client to bed?
D. Respiratory rate 28
Correct: Tachypnea and tachycardia reflect activity intolerance; activity should be terminated
The nurse in the coronary care unit is caring for a group of clients who have had myocardial infarction. Which client should the nurse see first?
B. Client with third-degree heart block on the monitor
Correct: Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system is involved. Third-degree heart block usually requires pacemaker insertion.
The client in the cardiac care unit has had a large myocardial infarction. How does the nurse recognize onset of left ventricular failure?
B. Crackles in the lung fields
Correct: Manifestations of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields
The client undergoing coronary artery bypass grafting (CABG) asks why the doctor has chosen to use the internal mammary artery for the surgery. Which response by the nurse is correct?
C. “These arteries remain open longer.”
Correct: Mammary arteries have remained patent much longer than other grafts.
The client has just returned from coronary artery bypass graft (CABG) surgery. For which finding should the nurse contact the surgeon?
B. Chest tube drainage 175 mL last hour
Correct: Some bleeding is expected after surgery; however, the nurse should report chest drainage over 150 mL per hour to the surgeon.
The visiting nurse is seeing a client post coronary artery bypass graft. Which nursing action should be performed first?
C. Monitor for dysrhythmias.
Correct: Dysrhythmias are the leading cause of prehospital death. The nurse should monitor the client’s heart rhythm.
During discharge planning after admission for a myocardial infarction, the client says, “I won’t be able to increase my activity level. I live in an apartment, and there is no place to walk.” What is the nurse’s best response
D. “Where might you be able to walk?”
Correct: This response calls for cooperation and participation from the client.
The older adult client, 4 hours post coronary artery bypass graft (CABG), has a blood pressure of 80/50. What action should the nurse take?
C. Assess pulmonary artery wedge pressure (PAWP).
Correct: Decreased preload as exhibited by decreased PAWP could indicate hypovolemia secondary to hemorrhage or vasodilation. Hypotension could cause the graft to collapse.
The nurse is assessing the client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI
D. Substernal chest pressure relieved only by opioids
The client comes to the emergency department with chest discomfort. Which action does the nurse perform first?
B. Obtains the client’s description of the chest discomfort
Correct: A description of the chest discomfort must be obtained before further action can be taken.
Which statement by the client scheduled for a percutaneous transluminal coronary angioplasty indicates a need for further preoperative teaching?
D. “My angina will be gone for good.”
Correct: Reocclusion is possible after the procedure.
24.
After receiving change-of-shift report in the coronary care unit, which client should you assess first?
A. The client with acute coronary syndrome who has a 3-pound weight gain and dyspnea
Correct: Dyspnea and weight gain are symptoms of left ventricular failure and pulmonary edema; the client needs prompt intervention.
An LPN/LVN is scheduled to work on the inpatient “step-down” cardiac unit where you are the team leader. Which of these clients would be best to assign to the LPN/LVN?
C. A 66-year-old who has a prescription for a nitroglycerin (Nitro-Dur) patch and is scheduled for discharge to a group home later today
Correct: The LPN/LVN scope of practice includes administration of medications to stable clients.
1.The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs
B. Mean arterial pressure is 58 mm Hg.
Correct: To maintain tissue perfusion to vital organs, the mean arterial pressure (MAP) must be at least 60 mm Hg.
he nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which of the following actions should be taken by the nurse?
B. Collaborate with the physician to administer a positive inotropic agent.
Correct: A positive inotropic agent will increase the force of contraction (SV), thus increasing cardiac output. Recall that SV × HR = CO.
Which client will be best for the charge nurse to assign to a new graduate RN who has completed 2 months of orientation to the coronary care unit?
B. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes
Correct: The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN.
Which action should the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory?
D. Obtain client vital signs and a resting electrocardiogram (ECG).
Correct: Vital signs and 12-lead ECGs can be assessed by UAP.
An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client will be appropriate for the RN to assign to the LPN/LVN?
B. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index
Correct: The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and in a lower extremity.
All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the physician before the procedure begins?
B. The client develops wheezes and dyspnea after eating crab or lobster.
Correct: The contrast agent injected into the coronary arteries during the arteriogram is iodine based. The client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure.
.A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the physician?
C. Serum troponin I level
Correct: Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications.
The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential?
D. Validate that the client has remained NPO.
Correct: Owing to the risk for aspiration, the client must be NPO before the procedure.
Which assessment finding for a client with left ventricular failure who is receiving pulmonary artery pressure (PAP) monitoring indicates a need for rapid action by the nurse?
A. The waveform shows that the catheter is continuously in the wedge position.
Correct: Because a pulmonary infarction can occur if the catheter is left in the wedged position, the nurse should have the client cough and/or should change the client’s position. If the catheter remains wedged, the physician should be notified immediately.
.A client recovering from a cardiac angiography develops slurred speech. What does the nurse do first?
C. Performs a complete neurologic assessment and notifies the physician
Correct: Based on this assessment, the client most probably is suffering a neurologic bleed. Neurologic changes, such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness, should be reported immediately for prompt intervention.
Which statement about diagnostic cardiovascular testing is true?
B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography.
Correct: Intravascular ultrasoorre
Correct: Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing.
Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial?
B. “I don’t need to change. It hasn’t killed me yet.”
Correct: This statement indicates maladaptive denial.
A client who is to undergo cardiac catheterization should be taught which essential information?
B. Keep your affected leg straight for at least 8 hours.
Correct: The affected leg must remain straight for 6 to 8 hours after the procedure to allow the arterial puncture to heal well and prevent bleeding.
A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history?
D. Slow heart rate
Correct: Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output.
Which client has the highest risk for cardiovascular disease?
A. Man who smokes and whose father died at 49 from myocardial infarction (MI)
Correct: Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death.
Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider?
B. A client with pressure in the mid abdomen and profound diaphoresis
Correct: Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety.
Which statement best reflects correct client education for a client with a blood pressure (BP) of 134/86?
C. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle.
Correct: Although not considered hypertension because the blood pressure is not greater than 140/90, it is consistent with increased risk for heart disease; the client requires further education.
The nurse recognizes that which laboratory findings are consistent with acute coronary syndrome (ACS)? Select all that apply.
A. Troponin 3.2 ng/mL Correct
B. Myoglobin of 234 mcg/L Correct
Correct: Normal troponin should be less than 0.03 ng/mL.
Correct: Normal myoglobin should be less than 90 mcg/L.
Which statement reflects correct cardiac physical assessment technique?
A. Auscultate the aortic valve in the second intercostal space at the right sternal border.
Correct: The aortic valve is auscultated at the second intercostal space at the right sternal border.
The client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction?
D. Troponin of 5.2 ng/mL
Correct: The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL.
The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 2 mm Hg. The nurse anticipates which request by the physician ?
A. Saline infusion
Correct: Normal right atrial pressure is 4 to 10 mm Hg; administering saline will restore normal fluid balance.
The nurse is educating a group of clients about risk factors for cardiovascular disease. Which of these risk factors should be included in the discussion?
B. Elevated C-reactive protein levels Correct
E. Smoking Correct
women about the differences in symptoms of MI in men versus those in women. Which information should be included?
. Women may experience extreme fatigue and dizziness as sole symptoms. Correct
Correct: Women may have atypical symptoms, including absence of chest pain and extreme dizziness and fatigue.
The nurse encourages the client to increase his fluid intake after a cardiac catheterization for which reason?
B. The dye causes an osmotic diuresis.
Correct: The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment.
The nurse is reviewing the medical record of a client admitted with heart failure. Which of the laboratory results warrants a call to the physician for further instructions?
B. Potassium 3.0 mEq/L
Correct: Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations.
The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement reflects the most correct teaching?
D. This test evaluates you for potentially fatal cardiac rhythms.
Electrophysiology studies (EPS) are invasive tests performed to determine whether the client has lethal dysrhythmias.
The nurse is caring for a client with suspected pericarditis. Which signs and symptoms support this? Select all that apply.
B. Chest pain relieved by sitting upright Correct
D. Sudden-onset chest pain relieved by NSAIDs Correct
E. Pain in the chest described as sharp or stabbing Correct
The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8 Pulse: 48 and irregular Respirations: 20 Potassium level: 3.2 mEq/L What action does the nurse take?
D. Hold the digoxin, and obtain a prescription for a potassium supplement.
Correct: Digoxin causes bradycardia; hypokalemia potentiates digitalis. The nurse seeks to correct this situation through collaboration with the provider.
A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription?
B. Serum potassium level of 2.8 mEq/L
Correct: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy.
. In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis
C. B-type natriuretic peptide (BNP) of 760 ng/dL Correct
Correct: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL.
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure
A. Ibuprofen (Motrin)
Correct: Long-term use of NSAIDs, such as ibuprofen (Motrin), causes fluid and sodium retention.
The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication?
B. The risk for hypotension
Correct: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.
The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply
A. Chest discomfort or pain Correct
B. Tachycardia Correct
E. Shortness of breath with exertion Correct
Correct: Decreased tissue perfusion may cause chest pain or discomfort.
Correct: Tachycardia may occur as compensation for or as a result of decreased cardiac output.
Correct: Dyspnea results as pulmonary venous congestion ensues.
The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, pink, frothy sputum, and crackles throughout the lung fields. Which prescription should the nurse carry out first?
C. Furosemide
Correct: The client is displaying typical signs of acute pulmonary edema, secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss.
The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching?
A. “I should avoid grilling hamburgers.”
Correct: Cutting out beef or hamburgers made at home is not necessary; however, fast food hamburgers are to be avoided owing to higher sodium content.
The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply.
B. Sinus bradycardia Correct
C. Fatigue Correct
E. Anorexia Correct
The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality?
B. Carvedilol (Coreg) Correct
Correct: Beta-adrenergic blockers reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; they improve morbidity, mortality, and quality of life.
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen?
B. Client states that she is able to sleep on one pillow.
Correct: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers.
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?
C. The nurse obtains a bedside commode before administering furosemide.
Correct: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.
. Which intervention will best assist the client with acute pulmonary edema in reducing anxiety and dyspnea?
C. Place the client in high Fowler’s position with the legs down.
Correct: High Fowler’s position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.
The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching?
A. “I will call the provider if I have a cough lasting 3 or more days.” Correct
Correct: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified.
. A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective?
D. The client’s weight decreases by 2.5 kg.
Correct: The best indicator of fluid volume loss is daily weight; because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid.
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions?
C. Weight loss of 6 pounds since the last visit
Correct: Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.
The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, “I feel so tired and short of breath.” Which action should the nurse take first?
B. Listen to the client’s posterior breath sounds.
Correct: Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds.
Which of these nursing actions should the nurse delegate to a nursing assistant working on the medical unit?
C. Obtain daily weights for several clients with class IV heart failure.
Correct: Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.
The client who has been admitted for the third time this year for cardiac failure says, “This isn’t worth it anymore. I just want it all to end.” What is the nurse’s best response?
B. Considers further assessment for depression Correct
Correct: This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done.
Which priority problems may be considered for the client with heart failure? Select all that apply.
B. Impaired Physical Mobility related to limited cardiovascular endurance
C. Impaired Gas Exchange related to ventilation-perfusion imbalance
D. Potential for pulmonary edema
E. Risk for Ineffective renal Perfusion related to hypervolemia
Correct: Owing to intra-alveolar edema and poor cardiac output, the client is fatigued and has limited endurance.
Correct: Owing to intra-alveolar edema and poor cardiac output, the client may develop hypoxemia.
Correct: Owing to limited cardiac reserve, the client is at risk for pulmonary edema.
Correct: The client with heart failure has poor cardiac output, reduced blood flow to the kidney, and accumulation of pulmonary and peripheral fluid.
Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance with prescribed home therapy. Which laboratory test confirms the nurse’s suspicions?
D. Digoxin level of 0.2 ng/dL Correct
Correct: A therapeutic digoxin level is 0.8 to 2.0 ng/dL. A level of 0.2 ng/dL indicates that the client has not been taking his digoxin as prescribed.
The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client?
D. Positions the client to alleviate dyspnea Correct
Correct: Positioning the client to alleviate dyspnea will help ease air hunger and anxiety.
The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis?
C. Splinter hemorrhages
Correct: Splinter hemorrhages are indicative of infective endocarditis.
. The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, “This can’t be. I am in great shape. I eat right and exercise.” What is the nurse’s best response?
C. “This may be caused by a genetic trait.” Correct
Correct: Hypertrophic cardiomyopathy is often transmitted as a single-gene autosomal dominant trait.
. After receiving change-of-shift report about these four clients, which client should the nurse assess first?
A. The 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset, frequent premature ventricular complexes Correct
Correct: This client’s premature ventricular complexes may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity should be done and the physician notified about the dysrhythmia.
Which of these clients is best to assign to an LPN/LVN working on the telemetry unit?
B. A client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea
Correct: This client, who needs oxygen only with exertion, is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice.
- When caring for a client who has undergone a partial left ventriculectomy, which of these new-onset clinical manifestations indicates the need for immediate action by the nurse?
C. Muffled heart sounds Correct
Correct: Muffled heart sounds may be a clinical manifestation of bleeding into the pericardial space; the nurse should assess the client for possible decreased cardiac output and should notify the surgeon.
