The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure. Which S/S would the nurse expect to find when assessing this client? a. apical pulse rate of 110 and 4+ piting edema of feet b. thick white sputum and crackles that clear with cough c. the client sleeping with no pillow and eupnea d. radial pulse rate of 90 and capillary refill time
A. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the hear to pump effectively" is written. Which short term goal would be best for the client? The client will: a. be able to ambulate in the hall by date of discharge b. have an audible S1 and S2 with no S3 heard by end of shift c. turn, cough, and deep breathe every two hours d. have a pulse oximeter reading of 98% by day two of care
B. Audible S1 and S2 sounds are normal for a heart with adequat output. An audible S3 sound might indicate left ventricular failure that could be life threatening.
The nurse is developing a discharge teaching plan for the client diagnosed with CHF. Which intervention should be included in the plan? Select all that apply a. Notify HCP of a weight gain of more than 1 pound in a week b. teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. c. Instruct client to remove the salt shaker from the table d. Encourage client to monitor urine output for change in color to become dark e. Discuss the importance of taking the loop diuretic furosemide at bedtime.
B. the client should not take digoxin if radial pulse is less than 60 C. The client should be on a low-sodium diet to prevent water retention
The nurse enters the room of the client diagnosed with CHF. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? a. sponge the client's forehead b. obtain a pulse oximetry reading c. take the client's vital signs d. assist the client to a sitting position
D. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.
The nurse is assessing the client diagnosed with CHF. Which S/S would indicate that the medical treatment has been effective? a. the client's peripheral pitting edema has gone from 3+ to 4+ b. the client is able to take the radial pulse accurately c. the client is able to perform ADLs without dyspnea d. the client has minimal jugular vein distention
C. Being able to perform ADLs without shortness of breath (dypnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.
The nurse is assessing the client diagnosed with CHF. Which lab data would indicate that the client is in severe CHF? a. an elevated B type natriuretic peptide (BNP) b. an elevated creatine kinase (CK-MB) c. a positive D dimer d. a postive ventilation perfusion (V/Q) scan
A. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF.
The HCP has ordered an angiotensin-converting enzyme inhibitor for the client diagnosed with CHF. Which discharge instructions should the nurse include? a. instruct the client to take a cough suppressant if a cough develops b. teach the client how to prevent orthostatic hypotension c. encourge the client to eat bananas to increase potassium level d. explain the importance of taking medication with food
B. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored.
The nurse on the telemetry unit has just received the A.M. shift report. Which client should the nurse assess first? a. The client diagnosed with MI who has an audible S3 heart sound b. The client diagnosed with CHF who has 4+ sacral pitting edema c. The client diagnosed with pneumonia who has a pulse oximeter reading of 94% d. The client with chronic renal failure who has an elevated creatinine level
A. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation.
The nurse and an unlicensed nursing assistant are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse delegate to the unlicensed nursing assistant? a. assist the client to go down to the smoking area for a cigarette b. transport the client to the ICU via a stretcher c. provide the client going home discharge teaching instructions d. help position the client who is having a portable xray done
D. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgement.
The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? a. the client diagnosed with CHF who is being discharged in the morning b. The client who is having frequent incontinent liquid bowel movements and vomiting. c. The client with an apical pulse rate of 116, a respiratory rate of 26, and blood pressure of 90/62 d. The client who is complaining of chest pain with inspiration and a nonproductive cough
C. This client is exhibiting S/S of shock, which makes this client the most unstable. An experienced nurse should care for this client.
The client diagnosed with CHF is complaining of leg cramps at night. Which nursing interventions should be implemented? a. check the client for peripheral edema and make sure the client takes a diuretic early in the day b. Monitor the client's potassium level and assess the client's intake of bananas and orange juice c. Determine if the client has gained weight and instruct the client to keep the legs elevated d. Instruct the cleint to ambulate frequently and perform calf-muscle stretching exercises daily
B. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medicaiton. Bananas and orange juice are foods that are high in potassium.
The nurse has written an outcome goal of "demonstrates tolerance for increased activity" for a client diagnosed with CHF. Which intervention should the nurse implement to assist the client to acheive this outcome? a. measure I and O b. Provide a 2g sodium diet c. weigh client daily d. plan for frequent rest periods
D. Scheduling activities and rest periods allows the client to participate in his or her own care and addreses the desired outcome.
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a MI? a. Creatine phosphokinase (CPK-MB) b. lactate dehydrogenase (LDH) c. Troponin d. White blood cells
C. Troponin is the enzyme that elevates within 1 to 2 hours
Along with persistent, crushing chest pain, which S/S would make the nurse suspect that the client is experiencing a MI? a. mid-epigastric pain and pyrosis b. diaphoresis and cool clammy skin c. intermittent claudication and pallor d. jugular vein distention and dependent edema
B. Sweating is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.
The client diagnosed with rule out MI is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? a. administer sublingual nitroglycerin b. obtain a STAT electrocardiogram c. have the client sit down immediately d. assess the client's vital signs
C. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.
The nurse is caring for a client diagnosed with a MI who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply a. administer morphine intramuscularly b. administer an aspirin orally c. apply oxygen via a nasal cannula d. place the client in a supine position e. administer nitroglycerin subcutaneously
B. Aspirin is an antiplatelet medicaiton and should be administered orally. C. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.
The client is diagnosed with a MI. Which referral would be most appropriate for the client? a. social worker b. physical therapy c. cardiac rehabiliation d. occupational therapist
C. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation, which includes progressive exercise, diet teaching, and classes on modifying risk factors.
The client is one day postoperative coronary artery bypass surgery. The client complains of chest pains. Which intervention should the nurse implement first? a. medicate the client with intravenous morphine b. assess the client's chest dressing and vital signs c. encourage the client to turn from side to side d. Check the client's telemetry monitor
B. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.
The client diagnosed with a MI is six hours post-right femoral percutaneous transluminal angioplasty, also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? a. the client is keeping the affected extremity straight b. the pressure dressing to the right femoral area is intact c. the client is complaining of numbness in the right foot d. the client's right pedal pulse is 3+ and bounding
C. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood suppy to the right foot.
The ICU nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses a S3 heart sound. Which intervention should the nurse implement? a. notify the HCP immediately b. Elevate the head of the client's bed c. document this as a normal and expected finding d. administer morphine intravenously
A. An S3 indicates left ventricular failure and should be reported to the health-care provider. It is potentially life-threatening complication of a myocardial infarction.
The nurse is administering a calcium channel blocker to the client diagnosed with a MI. Which assessment data would cause the nurse to question administering this medication? a. the client's apical pulse is 64 b. the client's calcium level is elevated c. the client's telemetry shows occasional PVCs d. the client's BP is 90/62
D. The client's blood pressure is low and a calcium channel blocker would cause the blood pressure to bottom out.
The client diagnosed with a MI is on bed rest. The unlicensed nursing assistant is encouraging the client to move the legs. Which action should the nurse implement? a. instruct the assistant to stope encouraging leg movements b. report this behavior to the charge nurse ASAP c. praise the nursing assistant for encouraging the client to move legs d. take no action concerning the nursing assistant's behavior
C. The nurse should praise and encourage assistants to participate in the client's care. Clients on bed rest are at risk for DVT, and moving the legs will help prevent that.
The client diagnosed with a MI asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? a. your heart is damaged and needs about four to six weeks to heal b. there is necrotic myocardial tissue that puts you at risk for dysrhythmias c. your doctor has ordered bed rest. therefore you must stay in bed d. just because you chest doesn't hurt anymore doesn't mean that you are out of danger
A. The heart tissue is dead, stress or activity may cause heart failure, and it does take about 6 weeks for scar tissue to form.
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? a. the client's BP is 110/70 and pulse is 90 b. the client groin dressing is dry and intact c. the client refuses to keep the leg straight d. the client denies any numbness and tingling
C. If the client bends the leg, it could cause the insertions site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.
The male client is diagnosed with CAD and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? a. I should keep the tablets in the dark colored bottle they came in b. If the tablets do not burn under my tongue, they are not effective c. I should keep the bottle with me in my pocket at all times d. If my chest pain is not gone with one tablet, I will go to the ER.
D. The client should take one tablet every five minutes and, if no relief occurs after the third tablet, have someone drive him to the ED or call 911.
The client with CAD asks the nurse, "Why do I get chest pain?" Which statement would be the most response by the nurse? a. Chest pain is caused by decreased oxygen to the heart muscle b. There is ischemia to the myocardium as a result of hypoxemia c. The heart muscle is unable to pump effectively to perfuse the body d. Chest pain occurs whtn the lungs cannot adequately oxygenate the blood
A. This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? a. Perform passive range of motion exercises b. Assess the client's neurovascular status c. Keep the client in high-Fowler's position d. Assess the gag reflex prior to feeding the client
B. The nurse must make sure that blood is circulating to the right leg so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor.
The nurse is preparing to administer a beta blocker to the client diagnosed with CAD. Which assessment data would cause the nurse to question administering the medication? a. the client has a BP of 110/70 b. the client has an apical pulse of 56 c. the client is complaining of a headache d. th client's potassium level is 4.5 mEq/L
B. A beta-blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.
Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with CAD? a. assess the client's radial pulse b. assess the client's serum potassium level c. assess the client's glucometer reading d. assess the client's oximeter reading
B. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication.
Which client teaching should the nurse implement for the client with CAD? Select all that apply a. encourage a low fat, low cholesterol diet b. instruct the client to walk 30 minutes a day c. decrease the salt intake to 2g a day d. refer to counselor for stress reduction techniques e. increase fiber in the diet
A. A low fat, low cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. B. Walking will help increase collateral circulation. D. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. E. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.