A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
Selected Answer:... [Show More] d. Disorientation and confusion
In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.
Ms. Richards, a 39-year-old female, is seen in the Emergency Department for dizziness, dyspnea, and heart palpitations. Vital Signs: BP 92/58, HR 225/min, RR 24/min; SPO2 90% on Room Air. Ms. Richards' rhythm on the telemetry monitor and subsequent 12-lead ECG show Supraventricular Tachycardia (SVT). Which of these is an intervention a nurse may implement to decrease Ms. Richards’ heart rate?
Selected Answer: My Answer Carotid Massage (Right Answer Valsalva)
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
Selected Answer: Speech Alterations
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, “Why will I need to take anticoagulants for the rest of my life?” How should the nurse respond?
Selected Answer: “Blood clots form more easily in artificial replacement valves.”
Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.
Your newly admitted patient has a history of Atrial Fibrillation and is on warfarin at home. On your skin assessment, you note more than 12 large bruises and petechiae in addition when she brushes her teeth you note bleeding gums. Which of the following is most important to check before following the order “continue home medications at current dosages”?
Selected Answer: Check for a PT/INR result
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
Selected Answer: A 36-year-old woman with aortic stenosis
Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
Selected Answer: Heart rate of 120 beats/min
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.
Mr. Jones was admitted for left-side heart failure. Mr. Jones is in Sinus Tachycardia with frequent Premature Atrial Contractions (PACs). He complains of weakness, fatigue, and SOB. VS: Afebrile, RR: 24/minute, HR: 135 BPM, BP 145/90, SPO2 on room air is 88%. Other assessment findings: disoriented to time and place, lips are cyanotic, posterior bibasilar crackles, wheezes, and S3 are auscultated. The patient is coughing blood tinged sputum. Identify medications which might be ordered to help improve cardiac contractility (inotropy) and control heart rate (chronotropy).
Selected Answer: Lanoxin (Digoxin) and Beta Blocker
A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?
Selected Answer: Friction rub at the left lower sternal border
The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.
Which of the following is NOT a common sign of cardiac tamponade?
Selected Answer: Hypertension
The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? (Select all that apply.)
Selected Answers: Unusual fatigue, Syncope, Dyspnea
Which of the following patient statements indicates the patient requires further education after pacemaker placement?
Selected Answer: I cannot prepare my food by myself anymore as it is not safe to be
around my fridge, blender, microwave, or toaster
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met?
Selected Answer: Distal pulse on affected extremity 2+/4+
Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
Selected Answer: Allergies to iodine-based agents
Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.
Mr. Jones, 73-year-old male, is admitted to the DOU with left sided heart failure. Telemetry monitoring shows Mr. Jones is in Sinus Tachycardia with frequent Premature Atrial Contractions (PACs). He complains of weakness, fatigue, and SOB. VS: Afebrile, RR: 24/minute, HR: 135 BPM, BP 145/90, SPO2 on room air is 88%. Other assessment findings: disoriented to time and place, lips are cyanotic, posterior bibasilar crackles, wheezes, and S3 are auscultated. The patient is coughing blood tinged sputum. Select all that apply. (2 correct answers)
Selected Answers: Decreased Cardiac Output related to Sinus Tachycardia and PACs,&
Impaired Gas Exchange related to left sided heart failure
(Incorrect: Impaired Mobility)
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
Selected Answer:Pulse decreased from 100 beats/min to 80 beats/min
Beta blockers block the stimulation of beta 1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta 2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client’s health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
Selected Answer:Notify the health care provider before scheduling the MRI.
The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.
Mr. Jones was admitted for left-sided heart failure. Mr. Jones is in Sinus Tachycardia with frequent Premature Atrial Contractions (PACs). He complains of weakness, fatigue, and SOB. VS: Afebrile, RR: 24/minute, HR: 135 BPM, BP 145/90, SPO2 on room air is 88%. Other assessment findings: disoriented to time and place, lips are cyanotic, posterior bibasilar crackles, wheezes, and S3 are auscultated. The patient is coughing blood tinged sputum. Identify the Nursing Intervention the RN should do first.
Selected Answer:Start O2 at 2 L/min
Mr. Jones was admitted for left-sided heart failure. Assessment findings: disoriented to time and place, lips are cyanotic, posterior bibasilar crackles, wheezes, and S3 are auscultated. The patient is coughing blood tinged sputum. Which medication orders do you anticipate to decrease preload?
Selected Answer:Diuretics and morphine
Tina, 36 year old female, presents with occasional palpitations and dizziness. On cardiac assessment you notice a systolic murmur. Her vital signs reveal : BP 116/80, HR 76, O2 Saturation 98%, RR 20, Temperature 98.6F. EKG reveals NSR with occasional PAC’s. The physician orders a 2-D echocardiography. Which valve is most likely to cause Tina’s condition?
Selected Answer:Mitral Valve(1st choice: Instructor agreed to change to Aortic Valve)
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
Selected Answer:Assess the color and temperature of the left leg.
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client’s problem.
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?
Selected Answer:Initiation of an external pacemaker
The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction. [Show Less]