The nurse performs a rapid assessment on a client who states, "I feel really sick and my heart is beating so fast." What signs and symptoms would indicate
... [Show More] to the nurse that the client's cardiac output is inadequate?
Select All That Apply
1. CVP 5 mm Hg.
2. Moist skin.
3. Urinary output 150 mL over 4 hours.
4. Weak radial pulses.
5. BP 90/50, HR 200, RR 22.
6. Mild chest discomfort.
2, 4, 5, 6
Rationale
2, 4, 5, & 6. Correct: When cardiac output is inadequate, the vital organs are not being perfused properly. Skin will be cool and clammy (moist) because the skin is not being perfused. Radial pulses will be weak and thready, because less blood is pumping through the arteries. Less volume means less pressure, so BP is low. The heart rate is too fast, so blood does not have time to get in the ventricles before it is contracting again which decreases cardiac output. Less blood is being pumped to the body. Chest pain means oxygenated blood is not reaching the heart muscle.
1. Incorrect: Normal CVP is 2-6 mmHg, so this is a normal finding.
3. Incorrect: Normal urinary output (UOP) should be at least 30 mL per hour. This client's UOP was 150 mL over 4 hours (50 mL per hour). So no concern here.
The nurse is caring for a client post cardiac catheterization that was performed via the right femoral artery. What assessment finding in the right lower extremity would be of concern to the nurse?
Choose One
1. Right pedal pulse 2+/4+.
2. Capillary refill 2 seconds.
3. Erythema.
4. Slight oozing of blood.
4
Rationale
4. Correct: The number 1 complication is bleeding. So slight oozing of blood is a problem. Assume the Worse! This is bleeding and you must do something.
1. Incorrect: 2+/4+ is a normal pulse amplitude. We worry about 1+.
2. Incorrect: This is a normal capillary refill. Remember, we want color to return within 2 seconds.
3. Incorrect: Erythema is redness of the skin or mucous membranes, caused by an increased blood flow in superficial capillaries. We are worried about decreased blood flow which would be evidenced by pallor.
A client reports dizziness and weakness while walking down the hall. The nurse notes the client's cardiac rhythm displayed on the telemetry monitor. What actions should the nurse take?
2, 3
Rationale
2. & 3. Correct: The client is dizzy and weak. This client is at risk for falling, so think safety and get the client back in bed. Use a wheelchair to accomplish this. Then obtain the client's BP. It may be low, indicating poor tissue perfusion to the vital organs. One cause of premature ventricular contractions (PVCs) includes heart failure, so assess the lungs for adventitious sounds.
1. Incorrect: This client is dizzy and weak. Having the client ambulate back to the bed is a safety risk. The client could fall or the condition could deteriorate while ambulating.
4. Incorrect: Cardioversion is not indicated with an underlying rhythm that is normal (NSR) with PVCs. Oxygen may decrease the PVCs. If not, medication can be administered to decrease the rate of the PVCs.
5. Incorrect: Oxygen may abate the PVCs; however, it should be initiated at 2 liters/NC rather than at 100% per nonrebreather mask. Start with the least amount of oxygen that could relieve symptoms.
The nurse has informed a client diagnosed with heart failure about the treatment plan, including prescriptions for an ACE inhibitor and a 2 gm sodium diet. Which statement by the client would indicate to the nurse that the client understands the treatment plan?
Select All That Apply
1. "I plan to elevate the head of my bed on concrete blocks so I can sleep better."
2. Instead of using salt, I should use a salt substitute to season my food."
3. "It is important that I weigh myself weekly to monitor for weight gain."
4. "I need to eat foods high in potassium while taking an ACE inhibitor."
5. "A low sodium diet will help decrease swelling in my legs."
1, 5
Rationale
1., & 5. Correct: Lying flat when a client has heart failure will cause excess fluid, which has pooled in the extremities while up, to move into the thorax and back up into the lungs. This is why the client can breathe better when the head of the bed is elevated. A low sodium diet decreases fluid retention which decreases preload, the amount of fluid entering the right side of the heart. So, yes, a low sodium diet can help decrease dependent edema.
2. Incorrect: Salt substitutes are high in potassium and can be dangerous when taking an ACE inhibitor. ACE inhibitors block aldosterone, which causes the body to lose sodium and water and retain potassium.
3. Incorrect: The client should weigh self daily, not weekly, and report a weight gain of more than 2-3 pounds (1-2 kg).
4. Incorrect: This client needs to eat food low in potassium since ACE inhibitors cause the retention of potassium.
The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. What information should the nurse include?
Select All That Apply
1. Deoxygenated blood enters the heart through the pulmonary vein.
2. Blood flows from the right atrium through the mitral valve to the right ventricle.
3. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated.
4. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle.
5. The right ventricle pumps the blood out through the aorta to the body.
3, 4
Rationale
3., & 4. Correct: These are true statements. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle.
1. Incorrect: Deoxygenated blood comes from the body to the heart via the superior and inferior vena cava.
2. Incorrect: Blood flows from the right atrium through the tricuspid valve to the right ventricle.
5. Incorrect: The left ventricle pumps the blood out through the aorta to the body.
The nurse is providing teaching to a group of clients newly diagnosed with chronic stable angina. What points should the nurse include?
Select All That Apply
1. Wait 1/2-1 hour after eating to exercise.
2. Attend classes such as guided imagery to reduce stress.
3. Temperature extremes can precipitate an angina attack.
4. Gradually increase weightlifting training to improve cardiac output.
5. Eat a low fat, low fiber diet to lose weight.
6. Medications prescribed to prevent angina work by increasing the workload of the heart.
2, 3
Rationale
2., & 3. Correct: We want to teach clients who have angina to do whatever they can to decrease the workload of the heart. Stress can increase the workload on the heart, so learning ways to decrease or deal with stess is a positive step. This can be done through guided imagery or music therapy. Temperature extremes can precipitate an attack, so the client should dress warmly in cold weather and be cautious out in extremely hot weather.
1. Incorrect: The client should wait at least 2 hours after eating to exercise. During this time, more blood is going to the digestive system. We don't want the heart to have to compete with the gut.
4. Incorrect: Weightlifting will increase the workload of the heart. We don't want to increase the workload of the heart in a client with a cardiac issue.
5. Incorrect: Losing weight is often beneficial for the cardiac client, so we advise them to decrease calorie consumption and maintain a low fat, high fiber diet.
6. Incorrect: We want to decrease the workload of the heart, not increase it. Medications prescribed to prevent angina work to decrease the workload of the heart.
A 70 year old female client reports an occasional choking sensation over the past 12 hours. What additional symptoms reported by the client would indicate to the nurse that the client may be having a myocardial infarction?
Select All That Apply
1. Unusual fatigue.
2. Indigestion.
3. Aching jaw.
4. Feeling faint
5. Pain between the shoulder blades.
6. Left arm paresthesia.
1, 2, 3, 4, 5
Rationale
1., 2., 3., 4., & 5. Correct: Look at the hints - elderly, female, choking sensation. Women often present with GI signs and symptoms, epigastric complaints, or pain between the shoulders, aching jaw, or choking sensation. The triad of symptoms: feeling of fullness in the abdomen, unusual fatigue, and an inability to "catch one's breath". Remember that the elderly may just faint or only have SOB.
6. Incorrect: Left arm paresthesia sounds more like a stroke rather than an MI.
The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which finding best indicates that bumetanide is having a therapeutic effect?
Choose One
1. Apical pulse 108/irregular.
2. Foamy sputum.
3. Urine output 175 mL for one hour.
4. Respiratory rate 28/min
Su
3
Rationale
3. Correct: Bumetanide is a diuretic that can be given IVP or continuous IV to provide rapid fluid removal. We know the medication is working because we have a good hourly urinary output.
1. Incorrect: The heart rate is still too fast and irregular. As excess fluid is removed, the heart rate should come down to a regular rate.
2. Incorrect: Pulmonary edema will cause the client to have a productive cough with pink, frothy (foamy) sputum. The presence of foamy sputum does not indicate that the medication has been effective.
4. Incorrect: The respiratory rate is too fast, so the pulmonary edema has not resolved. As fluid is pulled off the body, the respiratory rate should decrease.
The nurse is assessing a client one hour post coronary artery bypass graft surgery (CABG). Based on the assessment data, what action should the nurse take?
Client increasingly more difficult to arouse. Skin cool/damp. Distended neck veins. Lungs clear bilaterally. Heart sounds distant. CVP 8 mm Hg. BP 90/60.
Choose One
1. Administer stat dose of clopidogrel.
2. Notify cath lab to prepare for angioplasty.
3. Set up for a central catheter line.
4. Prepare for immediate pericardiocentesis.
4
Rationale
4. Correct:The assessment findings point to cardiac tamponade, which is an emergency situation. Did you pick up on the classic s/s of this? Here we see the decreasing level of consciousness and evidence of poor perfusion from decreased cardiac output, distended neck veins from the backward pressure, muffled lung sounds from the fluid collection around the heart, increasing CVP, and the narrowing pulse pressure as the heart is being compressed. Treatment involves a pericardiocentesis to remove blood that has formed around the heart. The primary healthcare provider will insert a needle into the pericardial space to remove the fluid.
1. Incorrect: Clopidogrel is an anti-platelet medication that will not correct cardiac tamponade.
2. Incorrect: If the client were re-occluding, then the client would go to the cath lab or back to surgery. This is not the problem indicated by the signs/symptoms.
3. Incorrect: A central line is not going to correct cardiac tamponade. Immediate removal of the fluid compressing the heart is needed.
The nurse is educating a client newly diagnosed with chronic stable angina about Nitroglycerin SL. What points should the nurse include?
Select All That Apply
1. Nitroglycerin increased blood flow to the heart.
2. Take one nitroglycerin every five minutes until pain stops.
3. Sit or lie down when taking nitroglycerin.
4. The most common side effect is a headache.
5. Keep nitroglycerin in a clear, plastic bottle.
1, 3, 4
Rationale
1, 3, & 4. Correct: Nitroglycerin dilates the coronary arteries to allow more oxygen to get to the heart muscle. Because nitroglycerin also dilates all arteries and veins, the client's BP will drop. So they could faint. To prevent this, they should sit or lie down when taking the nitro. The most common side effect is that the client will get a headache. It is not life threatening, but advise the client that this will occur.
2. Incorrect: One Nitroglycerin can be taken SL every five minutes up to three doses. If pain is not relieved, the EMS should be activated. The client may be having an MI rather than angina.
5. Incorrect: Nitroglycerin should be stored in a dark, glass bottle so that it does not lose its potency. [Show Less]