Circulatory System

126問 • 1年前

問題一覧

Which client statement indicates an understanding of the nurse’s instructions concerning a Holter monitor?

“The monitor will record any abnormal heart rhythms while I go about my usual activities.”

A client with a history of dysrhythmias is to wear a Holter monitor for 24 hours on an outpatient basis. What should the nurse teach the client to do while wearing the monitor?

Keep a written account of activities.

A client with a dysrhythmia is admitted to telemetry for observation. In the morning the client asks for a cup of coffee. What is the nurse’s best response?

“Coffee has caffeine that can affect your heart. It should be avoided.”

A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram. Which explanation should the nurse include when teaching the client about this procedure?

“This is a noninvasive test to check your heart’s response to physical activity.”

A client is admitted with chest pain unrelieved by nitroglyc- erin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client’s physiologic responses?

Inflammation in the myocardium causes a rise in the systemic body temperature.

What must the nurse do to determine a client’s pulse pressure?

Subtract the diastolic from the systolic reading.

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.8° C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care pro- vider about the client’s temperature?

A fever increases the cardiac output.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?

Constriction of the peripheral vessels increases the force of flow.

During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client’s rectum. What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client’s bowel movements?

Slowing of the heart

A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What physiologic changes should the nurse conclude are the result of this disease process? Select all that apply.

Stasis ulcer, Brown discoloration

A nurse is caring for a client with chronic occlusive arterial disease. What precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions?

Trauma from mechanical, chemical, or thermal sources

A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?

Pulmonary embolism

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider?

Systolic blood pressure drops from 130 to 90 mm Hg.

After abdominal surgery a client suddenly reports numbness in the right leg and a “funny feeling” in the toes. What should the nurse do first?

Instruct the client to remain in bed and notify the health care provider.

After a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure, but there is no evidence of bleeding. What should the nurse identify as the most likely cause of the change in blood pressure?

Reallocation of the blood supply

A nurse inspects a two-day-old intravenous site and identi- fies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?

Discontinue the infusion.

While convalescing from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply.

Pain in the calf, Redness in the affected area, Localized warmth in the lower extremity

A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do?

Notify the health care provider.

A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include?

Put the stockings on before getting out of bed in the morning.

A health care provider orders thigh-high antiembolism stockings for a client with varicose veins. The client’s thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?

Ask the health care provider if an elastic bandage can be used in place of the stockings.

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension?

Sit on the edge of the bed for 5 minutes before standing.

A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client’s medications?

ACE inhibitors

What client response indicates to the nurse that a vasodilator medication is effective?

Blood pressure changes from 154/90 to 126/72

What should the nurse assess to determine if a client is experiencing the therapeutic effect of valsartan (Diovan)?

Blood pressure

What information should the nurse include when teaching a client with heart disease about cholesterol?

Decreases when unsaturated fats are substituted for satu- rated fats

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)?

“Increase your intake of fiber and fluid.”

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction?

Whole milk with oatmeal

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instruc- tions when the client identifies the following foods. Select all that apply.

Chicken broth, Enriched whole milk, Red meats, such as beef, Liver and other glandular organ meats

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? Select all that apply

Avoid prolonged exposure to the sun., Schedule regular ophthalmic examinations., Contact your health care provider if skin becomes gray-bronze.

Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider?

Difficulty breathing

What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?

Heart muscle ischemia

What instructions about the use of nitroglycerin should the nurse provide to a client with angina?

“Before physical activity place 1 tablet under the tongue, and repeat the dose in 5 minutes if pain occurs.”

Which nursing action is most important when caring for a client after a cardiac catheterization?

Check a pulse distal to the insertion site.

For which common complication of myocardial infarction should the nurse monitor clients in the coronary care unit?

Dysrhythmia

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitor- ing the pulmonary artery pressure?

Left ventricular functioning

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to con- clude that the anticoagulant therapy is effective?

An APPT twice the usual value

What specifically should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel (Plavix)?

Epistaxis

A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?

INR

What should the nurse teach a client to expect when prepar- ing for discharge after surgery for a coronary artery bypass graft?

Some edema in the leg used for the donor graft is expected with activity

A client with left ventricular heart failure is taking digoxin (Lanoxin) 0.25 mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? Select all that apply.

Diuresis, Decreased edema, Decreased pulse rate

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (Bumex) and digoxin (Lanoxin). What does the nurse determine is the cause of the depletion?

Diuretic therapy

A client is in cardiogenic shock. What explanation of car- diogenic shock should the nurse include when responding to a family member’s questions about the condition?

A failure of the circulatory pump

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

Syncope

A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority?

Ventricular fibrillation

While a pacemaker catheter is being inserted, the client’s heart rate drops to 38 beats/min. What medication should the nurse expect the health care provider to prescribe?

Atropine sulfate (Atropine)

A client with a bundle branch block is on a cardiac monitor. What ECG change should the nurse identify on the client’s cardiac monitor?

Widening of QRS complexes to a minimum of 0.12 second

In addition to atrial fibrillation, what ventricular rhythm exhibited by a client does the nurse determine may be con- verted to a sinus rhythm by cardioversion?

Tachycardia with a pulse

What nursing action should be included in the plan of care for a client who had a permanent fixed (asynchronous) pacemaker inserted?

Teach the client to keep daily accurate records of the pulse.

What assessment of the pulse should the nurse identify when a client’s on-demand pacemaker is functioning effectively?

At least at the demand rate

When a client develops ventricular fibrillation in a coronary care unit, what is the responsibility of the first person reach- ing the client?

Initiate defibrillation.

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes ventricu- lar irritability on the screen. What medication should the nurse prepare to administer?

Amiodarone (Cordarone)

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse pre- pares for cardioversion. What nursing action is essential to avoid the potential danger of inducing ventricular fibrilla- tion during cardioversion?

Synchronizer switch is in the “on” position

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?

How long the client was anoxic

A client is found unconscious and unresponsive. What should the nurse do first?

Initiate a code.

A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?

2 to 2 1/2 inches

A nurse is performing external cardiac compression. How should the nurse exert downward vertical pressure?

Interlocking the fingers with the heel of one hand on the sternum and the heel of the other on top of it

A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent?

Right ventricular heart failure

A client with a history of type 2 diabetes is admitted to the hospital with chest pain and scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the proce- dure and for 48 hours after the procedure?

Metformin

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention would the nurse anticipate will be prescribed?

Prepare for transcutaneous pacing.

Thenurseinamedicalunitiscaringforaclientwith heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the pri- mary health care provider and prepares to imple- ment which priority interventions? Select all that apply.

Administering oxygen, Inserting a Foley catheter, Administering furosemide, Administering morphine sulfate intravenously

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client’s breath sounds?

Crackles

A client with myocardial infarction is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock?

Ventricular dysrhythmias

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action would the nurse take?

Monitor for any rhythm change.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action?

Check the client’s status

The nurse is watching the cardiac monitor and notices that a client’s rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the cli- ent is experiencing which dysrhythmia?

Ventricular tachycardia

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Which factor is highest priority with regard to this dysrhythmia?

It can develop into ventricular fibrillation at any time.

A client is having frequent premature ventricular contractions. The nurse would place priority on assessment of which information?

Blood pressure and oxygen saturation

The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. Which associated findings would the nurse anticipate in the assessment? Select all that apply.

Syncope, Dizziness, Palpitations

A client’s cardiac rhythm suddenly changes on the monitor. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How would the nurse interpret the rhythm?

Atrial fibrillation

The nurse is assisting to defibrillate a client in ventricular fibrillation. Which intervention is a priority after placing the pads on the client’s chest and before discharging the device?

Confirm the cardiac rhythm.

A client’s ventricular fibrillation is about to be defibrillated. Which energy level (in joules, J) would the nurse set on the monophasic defibrillator machine for the first delivery?

360 J

The nurse is evaluating a client’s response to cardioversion. Which assessment would be the priority?

Airway patency

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter- defibrillator. Which assessment is the nursing priority?

Activation status and settings of the device

A client’s electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR in- terval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse interpret this rhythm?

Sinus tachycardia

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How would the nurse interpret the client’s neurovascular status?

The neurovascular status is expected because of increased blood flow through the leg.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The cli- ent’s blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/ dL (159 mcmol/L), measured this morning. Which nursing action is the priority?

Call the primary health care provider.

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching?

“My spouse told me that since I have this problem, we are going to stop walking in the mall every morning.”

A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent?

Right ventricular heart failure

A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?

Elevate the legs.

What clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply

Edema, Dyspnea

What change in pressure does the nurse conclude is responsible for the lower extremity pitting edema of a client with right ventricular heart failure?

Increase in plasma hydrostatic pressure

The family of a client with right ventricular heart failure expresses concern about the client’s increasing abdominal girth. What physiologic change should the nurse consider when explaining the client’s condition?

Increased pressure within the circulatory system

What dietary choices should the nurse instruct the client taking spironolactone (Aldactone) to avoid? Select all that apply.

Potatoes, Cantaloupe

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?

Endocarditis

What effect of anxiety makes it particularly important for the nurse to allay the anxiety of a client with heart failure?

Increases the cardiac workload

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema?

Place the client in the orthopneic position.

A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction. What statement by the client indicates to the nurse that there is a need for further teaching?

“I am not good at remembering to take medications.”

Two hours after a cardiac catheterization that was accessed via the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first?

Check the client’s pedal pulses

A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What response should the nurse consider the priority when assessing this client?

Hematoma formation

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests is ordered. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?

Troponin T

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first?

Assess the client’s heart and lung sounds.

A client has contrast medium injected into the brachial artery so that a cerebral angiogram can be performed. What nursing assessment is most essential immediately after the procedure?

Symmetry of the radial pulses

A nurse is leading a discussion in a senior citizen center about the risk factors for developing coronary heart disease (CHD) for women versus men. What should the nurse respond when asked to identify the most significant risk factor?

Diabetes

A nurse is teaching a group of clients about risk factors for heart disease. Which factors increase a client’s risk for a myocardial infarction? Select all that apply

Obesity, Hypertension

What is the most important nursing action when measuring a client’s pulmonary capillary wedge pressure (PCWP)?

Deflate the balloon as soon as the PCWP is measured.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

The RR intervals are relatively consistent., One P wave precedes each QRS complex.

What is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease?

Lower extremity color

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply.

Tachycardia, Increased CVP, Jugular vein distention

A client with upper gastrointestinal (GI) bleeding develops mild anemia. What should the nurse expect to be prescribed for this client?

Iron salts

100

An emergency department nurse is admitting a client after an automobile collision. The health care provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit?

Apical heart rate of 142 beats/min

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS