ch 51 Flashcards
(30 cards)
During assessment, the nurse notes a cardiac murmur that occurs between S1 and S2. The nurse documents this murmur as being
- diastolic.
- holosystolic.
- systolic.
- pansystolic.
3
The nurse is planning teaching for a client that focuses on Healthy People 2020 objectives for cardiovascular health. Which modifiable risk factors should the nurse include in this teaching?
Standard Text: Select all that apply.
- Age
- Gender
- Obesity
- Smoking
- Hypertension
Correct Answer: 3, 4, 5
The client has experienced a myocardial infarction with damage to the inferior portion of the heart. Due to this history, the nurse monitors the client for the development of rhythm disturbances that are most directly based upon which factor?
- The resultant change in blood sugar
- Electrolyte disturbances from tissue damage
- The automaticity of cardiac cells
- Decreased blood flow to the liver
3
The client has experienced a myocardial infarction with damage to the inferior portion of the heart. Due to this history, the nurse monitors the client for the development of rhythm disturbances that are most directly based upon which factor?
- The resultant change in blood sugar
- Electrolyte disturbances from tissue damage
- The automaticity of cardiac cells
- Decreased blood flow to the liver
3
A client has a heart rate of 170 beats per minute. For what will the nurse assess next in this client?
- Increased cardiac output
- Increased preload
- Decreased afterload
- Decreased cardiac output
4
The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value should the nurse review first while assessing this complaint?
- Blood urea nitrogen
- Hemoglobin and hematocrit
- Blood sugar
- Serum potassium
2
The nurse assessing a 1-day-old infant discovers the heart rate is 140 and irregular. What action should the nurse take?
- Immediately contact the infant’s physician.
- Prepare to resuscitate the infant.
- Note this normal finding in the infant’s medical record.
- Stimulate the infant gently.
3
The 50-year-old who is postmenopausal asks the nurse about the use of estrogen replacement therapy to protect the heart. How should the nurse respond?
- “This therapy is well proven to protect the heart in postmenopausal women.”
- “Estrogen replacement therapy is helpful to reduce the sleep disturbances and hot flashes associated with menopause, but does not protect the heart.”
- “Estrogen replacement therapy has been proven to have no effect on any postmenopausal symptoms and is not protective of the heart.”
- “The use of estrogen replacement therapy is complex and requires a thoughtful review of the balance between possible benefits and possible risks.”
4
The post–myocardial infarction client asks the nurse about return to exercise. What information should the nurse give this client?
- It is better to exercise when it is cold.
- Environmental temperatures have little impact on cardiac function.
- Avoid exercise when the weather is hot or cold.
- Hot temperatures increase peripheral blood vessel contraction.
3
What dietary teaching should the nurse provide to the client who has homocysteine elevation?
- Reduce salt intake.
- Take a B-complex vitamin supplement daily.
- Increase fluid intake to 2,000 mL per day.
- Avoid alcohol intake.
2
The client has a history of recurrent transient ischemic attack (TIA). Based upon this history the nurse should be most concerned about the client’s potential to develop
- renal failure.
- gangrene.
- myocardial infarction.
- stroke.
4
The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this condition?
- Ruddy skin color over legs
- Bounding pedal pulses
- Hot spots on the feet and legs
- Decreased hair on the legs
4
The client is admitted with a possible deep vein thrombosis. Nursing interventions should be designed to prevent which complication?
- Myocardial infarction
- Renal failure
- Pulmonary embolism
- Pneumonia
3
The nurse is collecting equipment to assess a client’s ankle/brachial index (ABI). What equipment should be taken to the client’s bedside?
- Blood pressure cuff and a Doppler ultrasound device
- None, as no special equipment is needed
- Stethoscope and penlight
- Reflex hammer and tuning fork
1
The nurse notes a widely bizarre pattern on the client’s cardiac monitor. What is the nurse’s priority action?
- Call a code blue.
- Check the client’s pulse.
- Immediately defibrillate the client.
- Check the rhythm in a different lead.
2
The nurse is reviewing the laboratory results of a client who is being observed for possible myocardial infarction. Which laboratory result would be most important for the nurse to discuss with the physician?
- Increased hemoglobin
- Decreased creatine kinase
- Increased troponin
- High normal potassium
3
A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement should the nurse choose for this client?
- Ineffective Tissue Perfusion
- Decreased Cardiac Output
- Activity Intolerance
- Risk for Injury
1
A client is on strict bed rest following hip surgery. What nursing intervention would support vascular health?
- Place pillows under the unaffected knee for support.
- Position the bed to flex the knees at least 20 degrees.
- Have the client alternately flex and extend the feet several times a day.
- Keep the client in a prone position for at least 20 minutes twice a day.
3
The nurse finds a client pulseless and breathless. The client’s skin is pale and cool, but not cyanotic. Because of this finding, what should the nurse suspect?
- Respiratory arrest occurred prior to cardiac arrest.
- Cardiac arrest occurred prior to respiratory arrest.
- The client cannot be resuscitated.
- Arrest was caused by airway obstruction.
2
A client has a long history of hypertension and has developed heart failure. The nurse should anticipate giving medications for which purpose?
- To increase preload
- To decrease afterload
- To decrease contractility
- To decrease cardiac output
2
The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices?
Standard Text: Click and drag the options below to move them up or down.
- Place in the dorsal recumbent or semi-Fowler’s position.
- Place a sleeve under each leg with the opening at the knee.
- Wrap the sleeve securely around the leg, securing the Velcro tabs.
- Turn on the control unit and adjust the alarms and pressures as needed.
- Connect the sleeves to the control unit and adjust the pressure as needed
Correct Answer: 1, 2, 3, 5, 4
The nurse is planning morning care for a client who has sequential compression devices in place. How should the nurse instruct the UAP who will be giving the bath?
- “Come get me when it is time to remove the devices, because that must be done by a nurse.”
- “You may remove the devices, but standards require that only a nurse put them back on the client.”
- “You may leave the devices off until the client’s legs air dry.”
- “Put the devices on as quickly as possible after the bath.”
4
The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this child’s blood pressure?
- Yes, blood pressure is measured for all children over the age of 3 years.
- No, blood pressure measurements are not required until age 13.
- Only if the child complains of headache or has an elevated pulse rate.
- Yes, but the measurement must be taken in the child’s thigh.
1
A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration in cardiovascular functioning? Standard Text: Select all that apply. 1. Chronic fatigue 2. Lower-extremity edema 3. Pallor 4. Shortness of breath 5. Hypotension
Answer: 1, 3, 4, 5
