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0

The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply.
1. Presence of cardiac pain
2. Medications taken before hospitalization
3. Presence of jugular vein distention
4. Heart sounds and apical rate
5. Presence of diaphoresis
6. History of difficulty breathing

1. Presence of cardiac pain
3. Presence of jugular vein distention
4. Heart sounds and apical rate
5. Presence of diaphoresis

1

The nurse is assessing a client whose condition is being stabilized after experiencing an acute coronary syndrome (myocardial infarction). What finding on the nursing assessment would indicate inadequate renal perfusion?
1. Decreasing serum blood urea nitrogen (BUN) level
2. Urine specific gravity of less than 1.010
3. Urine output of less than 30 mL/hr
4. Low urine osmolality and creatinine clearance

3. Urine output of less than 30 mL/hr

A sustained low cardiac output decreases renal perfusion and results in oliguria and impaired renal function. Oliguria is marked by output of less than 30 mL/hr. Increased BUN, changes in specific gravity (osmolarity), and creatinine clearance will be affected in the client develops renal failure

2

During the night, a client with a diagnosis of acute coronary syndrome (myocardial infarction) if found to be restless and diaphoretic. What is the best nursing action?
1. Check his temperature and determine his serum blood glucose level.
2. Turn the alarms low and promote sleep by decreasing the number of interruptions.
3. Check the monitor to determine his cardiac rhythm and evaluate vital signs.
4. Call the physician to obtain an order for sedation.

3. Check the monitor to determine his cardiac rhythm and evaluate vital signs.

Restlessness and diaphoresis may indicate decreased cardiac output, frequently originating from a dysrhythmia. Checking temp and blood glucose is not a priority.

3

The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure? Select all that apply.
1. Verify consent form has been signed.
2. Explain procedure to patient.
3. Provide clear liquid, no caffeine diet.
4. Evaluate peripheral pulses.
5. Obtain a 12 lead EKG.
6. Obtain history for shellfish allergy.

1. Verify consent form has been signed.
4. Evaluate peripheral pulses.
6. Obtain history for shellfish allergy.

Contrast dye is injected into the coronary arteries, which allows visualization of the coronary arteries and provides information on patency. Informed consent is required before any invasive procedure but the physician would explain the procedure to the patient. It is important to check for iodine sensitivity or shellfish allergy because the procedure involves injecting contrast medium. Evaluating peripheral pulses is a nursing measure following the cardiac catheterization.

4

The nurse is caring for a client who is recovering from a myocardial infarction. The nurse is assisting the client to ambulate around his room. The client begins to complain of shortness of breath and "just a little chest pain." What would be the first nursing action?
1. Assist the client back to bed and begin oxygen.
2. Check the cardiac monitor and obtain a rhythm sample.
3. Administer morphine subcutaneously now.
4. Further assess the characteristics of the chest pain.

1. Assist the client back to bed and begin oxygen.

The cardinal rule when clients experience chest pain is put them to rest and start oxygen. The other options may be appropriate, but only after stopping all client activity and beginning the oxygen.

5

The nurse is caring for a client who underwent cardiac catheterization 2 hours ago. What is an important nursing measure at this time?
1. Measure urinary output hourly and maintain continuous cardiac monitoring.
2. Encourage client to perform slow passive exercise of the affected side to promote circulation.
3. Assess the catheter insertion site and determine distal circulation status.
4. Evaluate apical pulse and determine presence of pulse deficit.

3. Assess the catheter insertion site and determine distal circulation status.

Assessment of the catheter site for any evidence of bleeding and evaluation of distal circulation are critical in the first few hours after cardiac catheterization. Pressure should be maintained at the site initially. Checking urinary output, monitoring vital signs, and maintaining cardiac monitoring are correct, but are not the priority, which would be monitoring for complications, i.e., bleeding from the catheter insertion site.

6

The nurse is performing an assessment of a client who experienced an acute coronary syndrome (myocardial infarction (MI) of the left ventricle 3 days ago. The nurse is concerned about the development of complications. What area of the physical assessment would the nurse focus on?
1. The lower extremities and the jugular vein for the presence of systemic venous congestion.
2. The area on the chest where the point of maximum impulse (PMI) is heard most clearly.
3. The level of dependent edema and fluid intake over the past 24 hours.
4. The presence of dyspnea and auscultation of crackles in the lungs.

4. The presence of dyspnea and auscultation of crackles in the lungs.

The client had a left acute coronary syndrome or left ventricular MI. One of the most common complications is left-side heart failure, resulting in heart failure. This would be first manifested as pulmonary congestion and difficulty. Right-side heart failure with venous symptoms would also occur soon after the development of left-side heart failure. The PMI is the point at which the apical pulse can be heard most clearly.

7

A client is admitted to rule out an acute coronary syndrome or myocardial infarction. He has an IV in place, is attached to a cardiac monitor, and is in a semi-Fowler's position. He suddenly complains of severe subsubsternal chest pain. The priority nursing action would be to:
1. Order stat cardiac enzymes, particularly creatinine phosphokinase-MB (CPK-MB)
2. Determine what medications he received last
3. Begin oxygen via nasal cannula to 5 to 6 L/min
4. Call the doctor and advise him of the status of the client

3. Begin oxygen via nasal cannula to 5 to 6 L/min

It is important to decrease the workload of the heart; this can be done by keeping the client in bed and starting oxygen.
Before calling dr: start oxygen, give pain medication, pattern monitored, vital signs evaluated.

8

A client comes into the ER via an ambulance and is complaining of severe chest pain. Which nursing assessment data would suggest the pain is caused by an acute coronary syndrome or myocardial infarction (MI)?
1. Pain increases when the client inhales deeply.
2. Client reports the pain has gotten progressively more severe over past hour.
3. Pain is immediately relieved with sublingual nitroglycerin.
4. Pain is relieved by administering oxygen at 3 L via nasal cannula.

2. Client reports the pain has gotten progressively more severe over past hour.

Chest pain that lasts for 20 minutes or more is characteristic of acute unstable angina or acute coronary syndrome. Pain occurring when the arms are raised or the client moves is more often associated with pericarditis or thoracic muscle. Nitroglycerin usually relieves the pain in chronic stable angina.

10

The nurse is assessing a client who has been admitted for evaluation of chronic stable angina. What assessment information would correlate with this diagnosis?
1. Chest pain arouses the client around midnight to 3 AM
2. Pain is relieved with one sublingual nitroglycerin tablet
3. Pain has been occurring more frequently over the past several weeks
4. Pain is primarily midsternal, radiating toward the left arm

2. Pain is relieved with one sublingual nitroglycerin tablet

The pain from chronic stable angina is relieved most often by rest or sublingual nitroglycerin. Pain that arouses the client at night or pain that occurs at rest is more typical of unstable angina. The location of chest pain does not assist to differentiate chronic angina from unstable angina.

11

You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action?
1. Blood pressure of 152/88 mm Hg
2. Heart rate of 134 beats/min
3. Oxygen saturation of 91%
4. Chest pain level of 3 (on a scale of 10)

4. Chest pain level of 3 (on a scale of 10)

Rationale:
Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing.

12

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? (Select all that apply.)
1. Attaching cardiac monitor leads
2. Giving heparin 5000 units IV push
3. Administering morphine sulfate 4 mg IV
4. Obtaining a 12-lead electrocardiogram (ECG)
5. Asking the client about pertinent medical history
6. Having the client chew and swallow aspirin 162 mg

1. Attaching cardiac monitor leads
4. Obtaining a 12-lead electrocardiogram (ECG)
6. Having the client chew and swallow aspirin 162 mg

Rationale:
Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced ED LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice.

13

You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the health care provider about a change in the drug therapy?
1. Client reports frequent urination.
2. Client's blood pressure is 138/86 mm Hg.
3. Client coughs often during the visit.
4. Client says, "I get dizzy sometimes."

3. Client coughs often during the visit.

ationale:
A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme (ACE) inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy.

14

You are the charge nurse for the coronary care step-down unit. Which client is best to assign to a "float" RN who has come for the day from the general medical-surgical unit?
1. Client requiring discharge teaching about coronary artery stenting before going home today
2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure
3. Client who just transferred in from the radiology department after a coronary angioplasty
4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure

Rationale:
An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have ACS and with collaborative treatments such as coronary angioplasty and coronary artery stenting.

15

At 9:00 PM, you admit a 63-year-old with a diagnosis of acute MI. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase [Activase]) for the client?
1. The client was treated with alteplase about 8 months ago.
2. The client takes famotidine (Pepcid) for esophageal reflux.
3. The client has ST-segment elevations on the 12-lead ECG.
4. The client has had continuous chest pain since 8:00 AM.

4. The client has had continuous chest pain since 8:00 AM.

Rationale:
Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use.

16

You are working with an experienced UAP and an LPN/LVN on the telemetry unit. A client who had an acute MI 3 days ago has a nursing diagnosis of Activity Intolerance related to fatigue and chest pain. Which nursing activity included in the care plan is best delegated to the LPN/LVN?
1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities
2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation
3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand
4. Explaining the rationale for alternating rest periods with exercise to the client and family

1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities

Rationale:
Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice.

17

You are working in the ED caring for a client who was just admitted with left anterior chest pain, possible ACS. Which action will you take first?
1. Insert an IV catheter.
2. Auscultate heart sounds.
3. Administer sublingual nitroglycerin.
4. Draw blood for troponin I measurement.

3. Administer sublingual nitroglycerin.

Rationale:
The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority.

18

An 80-year-old client on the coronary step-down unit tells you that he does not want to take the ordered docusate (Colace) because he does not have any problems with constipation. Which action is most appropriate?
1. Document the medication on the client's chart as "refused."
2. Mix the medication with food and administer it to the client.
3. Explain that his decreased activity level may cause constipation.
4. Reinforce that the docusate has been prescribed for a good reason.

3. Explain that his decreased activity level may cause constipation.

Rationale:
The best option in this situation is to educate the client about the purpose of the docusate (to counteract the negative effects of immobility and narcotic use on peristalsis). Charting the medication as “refused” or telling the client that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as client education. It is unethical to administer a medication to a client who is unwilling to take it, unless someone else has health care power of attorney and has authorized use of the medication.

19

You have given morphine sulfate 4 mg IV to a client who has an acute MI. When you evaluate the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action?
1. Blood pressure decrease from 114/65 to 106/58 mm Hg
2. Respiratory rate drop from 18 to 12 breaths/min
3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min
4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

Rationale:
The goal in pain management for the client with an acute MI is to completely eliminate the pain. Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time.

20

You are caring for a hospitalized client with heart failure who is receiving captopril (Capoten) and spironolactone (Aldactone). Which laboratory value will be most important to monitor?
1. Sodium level
2. Blood urea nitrogen level
3. Potassium level
4. Alkaline phosphatase level

3. Potassium level

Rationale:
Hyperkalemia is a common adverse effect of both ACE inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening.

21

The health care provider telephones you with new prescriptions for a client with unstable angina who is already taking clopidogrel (Plavix). Which medication is most important to clarify further with the health care provider?
1. Aspirin (Ecotrin) 162 mg daily
2. Omeprazole (Prilosec) 20 mg daily
3. Metoprolol (Lopressor) 50 mg daily
4. Nitroglycerin patch (Nitrodur) 0.4 mg/hour

2. Omeprazole (Prilosec) 20 mg daily

Rationale:
Since proton pump inhibitors such as omeprazole affect the metabolism of clopidogrel and decrease its effectiveness, the health care provider may want to discontinue the omeprazole in this client with unstable angina. The other medications should also be verified, but current national guidelines for clients with unstable angina indicate that providers should consider avoiding proton pump inhibitors in those who require clopidogrel.

22

At 10:00 AM, a hospitalized client receives a new order for transesophageal echocardiography (TEE) as soon as possible. Which action will you take first?
1. Put the client on "nothing by mouth" (NPO) status.
2. Teach the client about the procedure.
3. Insert an IV catheter in the client's forearm.
4. Attach the client to a cardiac monitor.

1. Put the client on "nothing by mouth" (NPO) status.

Rationale:
Because TEE is performed after the throat is numbed using a topical anesthetic and possibly after IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the TEE but do not need to be implemented immediately.

23

You assess a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern?
1. Blood pressure is 144/78 mm Hg
2. Pedal pulses are palpable at +1
3. Left groin has a 3-cm bruised area
4. Apical pulse is 122 beats/min and regular

4. Apical pulse is 122 beats/min and regular

Rationale:
The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern.

24

You are working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to an experienced UAP?
1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated
2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing
3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography
4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated

Rationale:
Measurement of ankle and brachial blood pressures for ankle-brachial index calculation is within the UAP's scope of practice. Calculating the ankle-brachial index and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN.

25

While working on the cardiac step-down unit, you are serving as preceptor to a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate?
1. 19-year-old with rheumatic fever who needs discharge teaching before going home with a roommate today
2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV
3. 50-year-old with newly diagnosed stable angina who has many questions about medications and nursing care
4. 75-year-old who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV

Rationale:
The new RN's education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and client care. The other clients require more complex assessment or client teaching by an RN with experience in caring for clients with these diagnoses.

26

A client with a diagnosis of acute coronary syndrome is on a cardiac monitor. The nurse interprets the monitor rhythm to be ventricular tachycardia at a rate of 150 beats/min. The client is awake and coherent, and oxygen is being administered at a rate of 6 L/min via a nasal cannula. What is the first nursing action?
1. Immediately defibrillate.
2. Administer lidocaine (Xylocaine) IV push.
3. Initiate tranvenous pacing.
4 Administer adenosine IV push.

2. Administer lidocaine (Xylocaine) IV push.

The treatment of choice is lidocaine IV push to attempt to the dysrhythmia before it progresses to ventricular fibrillation. Amiodarone (Codarone), procainamide, sotalol are other medications used for treatment ventricular tachycardia. Adenosine is given for supraventricular tachycardia. Transvenous pacing is initiated for symptomatic bradycardia or asystole. Defibrillation will be necessary if the client loses consciousness.

27

The nurse is caring for a client with right-side heart failure. What nursing assessment information correlates with an increase in venous pressure?
1. Jugular vein distention with client sitting at a 45-degree angle
2. Crackling sounds over the lower lobes with client in an upright position
3. Bradycardia, restlessness, and an increase in respiratory rate
4. Decreased pulsations at the point of maximum impulse

1. Jugular vein distention with client sitting at a 45-degree angle

Jugular vein distention with the client in a sitting position, or with a 45-degree head elevation, is indicative in the central venous pressure. Many clients experience jugular vein distention when in a supine position, and this is not indicative of an increase in central venous pressure. Adventitious breath sounds, bradycardia, restlessness and tachypnea are not directly associated with increase JVD but may occur if the client develops right-sided heart failure.

28

In discharge planning for the client with heart failure, the nurse discusses the importance of adequate rest. What information is most important?
1. A warm quiet room is necessary.
2. Bed rest promotes venous return.
3. A hospital bed is necessary.
4. Adequate rest decreases cardiac workload.

4. Adequate rest decreases cardiac workload.

29

The nurse is taking the history of a client with heart failure caused by chronic hypertension. The nurse identifies what data as supportive f the clients medical diagnosis?
1. Dyspnea after walking about half a block
2. Weight loss of 15 pounds over 3 months
3. Lower extremity edema in the evenings
4. Dizziness and fainting when rising too quickly.

1. Dyspnea after walking about half a block

Dyspnea on exertion is a classic sign of left ventricular problems, regardless of the precipitating cause.

30

A client is admitted with mitral valve disease and left ventricular dysfunction. What is the most reliable test to determine cardiac status?
1. Electrocardiogram
2. Stress test
3. Cardiac angiogram
4. Echocardiogram

4. Echocardiogram
An echocardiogram provides information regarding blood flow through the mitral valve and LV performance. An angiogram is done to determine coronary artery blood flow. A stress test is done to evaluate exercise tolerance. An ECG is done to evaluate cardiac conduction.

31

A client develops tachycardia, severe dyspnea, diaphoresis, crackles, and a profuse, frothy pink sputum. The nurse would place the client in which position?
1. Sims
2. Semi-Fowler's
3. Trendelenburg's
4. Fowler's position with legs lowered

4. Fowler's position with legs lowered

The symptoms indicate pulmonary edema. To decrease venous return, the nurse should elevate the patient's head and lower the legs, letting blood pool in the peripheral areas.

32

Which pathophysiologic finding most strongly suggests left-side heart failure?
1. A decrease in pulse rate
2. An increase in central venous pressure
3. A rise in pulmonary artery diastolic pressure
4. A decline in the mean pulmonary artery pressure

3. A rise in pulmonary artery diastolic pressure
A rise in pulmonary artery diastolic pressure strongly suggests left-side heart failure. An increase in central venous pressure would indicate right-side heart failure. The pulse rate would increase in heart failure. The mean pulmonary artery pressure would increase in heart failure.

33

Which assessment finding would mot likely indicate that the client is developing right-side heart failure? Select all that apply.
1. Orthopnea
2. Peripheral edema
3. Increased urine output
4. Pink-tinged sputum
5. Abnormal heart sounds
6. Distended jugular veins

2. Peripheral edema
6. Distended jugular veins

In right-side heart failure, systemic backup of blood causes JVD and peripheral edema.

34

What would be the most important for the nurse to document as an indication of the progress of a client with heart failure?
1. Telemetry recordings
2. Accurate intake record
3. Length of afternoon nap
4. Record of daily weight loss

4. Record of daily weight loss

Weight loss is used to evaluate the success of diuretic therapy in the client with CHF.

35

An older client is admitted with heart failure. What observation by the nurse indicates the client's condition is getting worse?
1. Increasing irritability and confusion
2. Blood pressure of 160/98 mmHg and pulse 110 BPM
3. Arterial blood gases showing a significant decrease in the pH and PCO2
4. Urinary output of 60 mL/hr and crackles heard at the base bilaterally

1. Increasing irritability and confusion

Increasing irritation and confusion are early indications of hypoxia.

36

You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol?
1. Creatine kinase MB level
2. Troponin I level
3. Myoglobin level
4. C-reactive protein level

2. Troponin I level

Rationale:
Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction.

37

While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/60 to 138/85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.)
1. Referral to community programs that assist in smoking cessation
2. Teaching about the impact of family history on cardiovascular risk
3. Education about the need for a change in antihypertensive therapy
4. Assistance in reducing the stress associated with her cardiovascular risk
5. Discussion of the risks associated with having a sedentary lifestyle

1. Referral to community programs that assist in smoking cessation
2. Teaching about the impact of family history on cardiovascular risk

Rationale:
The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client.

38

You are monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention?
1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest
2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min
3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions
4. Client who recently started taking atenolol (Tenormin) and has a first-degree heart block, with a rate of 58 beats/min

3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions

Rationale:
Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of MI.

39

Ventricular fibrillation is identified in an unresponsive 50-year-old client who has just arrived in the ED. Which action will you take first?
1. Defibrillate at 200 J.
2. Start cardiopulmonary resuscitation (CPR).
3. Administer epinephrine (Adrenalin) 1 mg IV.
4. Intubate and manually ventilate.

1. Defibrillate at 200 J.

Rationale:
Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client's rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available.

40

Two weeks ago, a 63-year-old client with heart failure received a new prescription for carvedilol (Coreg) 3.125 mg orally. When evaluating the client in the cardiology clinic, you obtain the following data. Which finding is of most concern?
1. Reports of increased fatigue and activity intolerance
2. Weight increase of 0.5 kg over a 1-week period
3. Sinus bradycardia at a rate of 48 beats/min
4. Traces of edema noted over both ankles

3. Sinus bradycardia at a rate of 48 beats/min

Rationale:
Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, the slow heart rate does require further follow-up, because bradycardia may progress to more serious dysrhythmias such as heart block.

41

You have just received a change-of-shift report about the following clients on the coronary step-down unit. Which one will you assess first?
1. 26-year-old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today
2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change
3. 56-year-old who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure
4. 77-year-old who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6° F (38.1° C)

2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change

Rationale:
The client's symptoms indicate acute hypoxia, so immediate further assessments (such as assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other clients also should be assessed soon, because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic client.

42

As the charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and UAPs, you have developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to delegate to an LPN/LVN team member?
1. Weighing all residents with heart failure each morning
2. Listening to lung sounds and checking for edema weekly
3. Reviewing all heart failure medications with residents every month
4. Updating activity plans for residents with heart failure every quarter

2. Listening to lung sounds and checking for edema weekly

Rationale:
LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice.

43

During a home visit to an 88-year-old client who is taking digoxin (Lanoxin) 0.25 mg daily to treat heart failure and atrial fibrillation, you obtain this assessment information. Which finding is most important to communicate to the health care provider?
1. Apical pulse of 68 beats/min and irregularly irregular
2. Digoxin taken with meals
3. Vision that is becoming "fuzzy"
4. Lung crackles that clear after coughing

3. Vision that is becoming "fuzzy"

Rationale:
The client's visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregularly irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure.

44

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next?
1. Lower the client's left foot below heart level.
2. Administer oxygen at 4 L/min to the client.
3. Notify the client's physician about the change in status.
4. Reassure the client that embolization is common in endocarditis.

3. Notify the client's physician about the change in status.

Rationale:
The client's history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the physician should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the client that embolization is a common complication of endocarditis will not reassure a client who is experiencing acute pain.

45

You are preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse?
1. Famotidine (Pepcid) 20 mg IV
2. Furosemide (Lasix) 40 mg IV
3. Digoxin (Lanoxin) 0.25 mg PO
4. Warfarin (Coumadin) 2.5 mg PO

4. Warfarin (Coumadin) 2.5 mg PO

Rationale:
Anticoagulant medications are high-alert medications and require special safeguards, such as double-checking of medications by two nurses before administration. Although the other medications require the usual medication safety procedures, double-checking is not needed.

46

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor?
1. Serum potassium
2. B-type natriuretic peptide
3. Blood urea nitrogen
4. Hematocrit

2. B-type natriuretic peptide

Rationale:
Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored, but do not indicate whether the client has heart failure.

47

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?
1. Sinus bradycardia
2. Sick sinus syndrome
3. Normal sinus rhythm
4. First-degree heart block

3. Normal sinus rhythm

Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

48

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, and the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions

3. Ventricular tachycardia

Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The rhythm is regular.

49

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?
1. Regular insulin
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)

4. Metformin (Glucophage)

Rationale:
Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.

50

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?
1. Sinus bradycardia
2. Sick sinus syndrome
3. Normal sinus rhythm
4. First-degree heart block

3. Normal sinus rhythm

Rationale:
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

51

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
1. Sensation of palpitations
2. Causative factors, such as caffeine
3. Precipitating factors, such as infection
4. Blood pressure and oxygen saturation

4. Blood pressure and oxygen saturation

Rationale:
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.

52

The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse?
1. Blood pressure
2. Status of airway
3. Oxygen flow rate
4. Level of consciousness

2. Status of airway

Rationale:
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.