A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor and concludes that these complexes are a sign of what?
- Atrial fibrillation
- Cardiac irritability
- Impending heart block
- Ventricular tachycardia
B. Cardiac irritability
A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?
- Atrial fibrillation
- Sinus tachycardia
- Ventricular fibrillation
- First-degree atrioventricular block
B. Sinus tachycardia
The nurse concludes that the gradual occlusion of the internal or common carotid arteries, manifested by transient ischemic attacks, may occur because of what reason?
- Acquired valvular heart disease
- Atherosclerosis of the vascular system
- Emboli associated with atrial fibrillation
- Developmental defects of the arterial wall
B. Atherosclerosis of the vascular system
A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take?
- Continue to monitor the client
- Notify the health care provider
- Ensure that a defibrillator is close by
- Administer lidocaine intravenously as per protocol
A. Continue to monitor the client
What client response must the nurse monitor to determine the effectiveness of amiodarone?
- Absence of ischemic chest pain
- Decrease in cardiac dysrhythmias
- Improvement in fasting lipid profile
- Maintenance of blood pressure control
B. Decrease in cardiac dysrhythmias
A nurse in the cardiovascular clinic reviews a client's ECG. What should the nurse do?
- Recommend the Valsalva maneuver.
- Document that the rhythm is normal.
- Prepare to defibrillate the client at 200 joules.
- Advise the client to reduce the intake of caffeine.
B. Document that the rhythm is normal.
A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority?
- Elective cardioversion
- Immediate defibrillation
- An intramuscular (IM) injection of digoxin
- An intravenous (IV) line for emergency medications
B. Immediate defibrillation
The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in Vitamin K and that should be avoided. What should the nurse include on the list? Select all that apply.
- Chicken breast
- Sweet potatoes
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain does what?
- Causes mild perspiration
- Occurs after moderate exercise
- Continues after rest and nitroglycerin
- Precipitates discomfort in the arms and jaw
C. Continues after rest and nitroglycerin
What are the clinical manifestations of myocardial infarction in women? Select all that apply.
- Unusual fatigue
- Sleep disturbances
- Tightness of the chest
C. Unusual fatigue
D. Sleep disturbances
A client experiences angina and is admitted to the telemetry unit for observation. Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain. Which instruction should the nurse include when teaching the client about the correct use of sublingual nitroglycerine?
- Plan to take the tablet between meals.
- Take the tablet with a full glass of juice.
- Dissolve the tablet in water before swallowing it.
- Hold the tablet under the tongue until it is dissolved.
D. Hold the tablet under the tongue until it is dissolved.
The health care provider prescribes isosorbide dinitrate (Isordil) 10 mg as needed three times a day and a nitroglycerin transdermal disk once a day for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. What is the nurse's best response?
- “The isosorbide dinitrate prevents the blood from clotting.”
- “The isosorbide dinitrate suppresses irritability in the ventricles.”
- “The isosorbide dinitrate allows more oxygen to get to heart tissue.”
- “The isosorbide dinitrate increases the force of contraction of the heart.”
C. “The isosorbide dinitrate allows more oxygen to get to heart tissue.”
A nurse is preparing to teach a client to apply a nitroglycerin patch (Nitro-Dur) as prophylaxis for angina. Which instruction should the nurse include in the teaching plan?
- Apply the patch on a distal extremity
- Remove a previous patch before applying the next one
- Massage the area gently after applying the patch to the skin
- Apply a warm compress to the site before attaching the patch
B. Remove a previous patch before applying the next one
A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective?
- Pain subsides as a result of arteriole and venous dilation
- Pulse rate increases because the cardiac output has been stimulated
- Sublingual area tingles because sensory nerves are being triggered
- Capacity for activity improves as a response to increased collateral circulation
A. Pain subsides as a result of arteriole and venous dilation
A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). What does the nurse explain to the client about TIAs?
- TIAs are temporary episodes of neurological dysfunction
- TIAs are intermittent attacks caused by multiple small clots
- TIAs are ischemic attacks that result in progressive neurological deterioration
- TIAs are exacerbations of neurological dysfunction alternating with remissions
A. TIAs are temporary episodes of neurological dysfunction
Family members of a client who had a brain attack (CVA) ask why the client cries easily and without provocation. The nurse explains what about the client?
- The client is making an attempt to get attention
- The client has selective memory from the past, especially the sad events
- The client has little control over this behavior
- The client feels guilty about the demands being made on the family
C. The client has little control over this behavior
A client is admitted to the hospital with weakness in the right extremities and speech that is slightly slurred. A diagnosis of brain attack (CVA) is suspected. During the first 24 hours after symptom onset, what is the priority nursing intervention?
- Assess the temperature
- Evaluate motor status
- Monitor blood pressure
- Obtain a urinalysis
B. Evaluate motor status
The nurse is caring for a client two days after the client had a brain attack (CVA). What should the nurse do to prevent the development of plantar flexion?
- Place a pillow under the thighs
- Elevate the knee gatch of the bed
- Encourage active range of motion
- Maintain the feet at right angles to the legs
D. Maintain the feet at right angles to the legs
A nurse begins planning for the discharge of a client who had a brain attack (CVA) with residual hemiparesis and hemianopsia. What information should the nurse include in the discharge teaching plan for this client?
- Necessity for bed rest at home
- Use of oxygen therapy at home
- Significance of a safe environment
- Need for decreased protein in the diet
C. Significance of a safe environment
A client is admitted with a brain attack (CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?
- Keeping the client's head turned to the right
- Approaching the client from the left side
- Teaching the client to use head movements to scan the left field of vision
- Arranging the furniture in the client's room so that the door is in the right visual field
C. Teaching the client to use head movements to scan the left field of vision
A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA). The client is right-handed. Which task will be most difficult for this client?
- Eating meals
- Writing letters
- Combing the hair
- Dressing every morning
D. Dressing every morning
To prevent excessive bruising when administering subcutaneous heparin, what should the nurse do?
- Administer the injection via the Z-track technique
- Inject the drug into the vastus lateralus muscle in the thigh
- Avoid massaging the injection site after the injection
- Use 2 mL of sterile normal saline to dilute the heparin
C. Avoid massaging the injection site after the injection
What should the nurse expect the health care provider to prescribe if a client exhibits clinical indicators of warfarin (Coumadin) overdose?
- Vitamin K
- Iron dextran (Imferon)
- Protamine sulfate
B. Vitamin K
A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?
- International Normalized Ratio (INR)
- Accelerated Partial Thromboplastin Time (APTT)
- Bleeding time
- Sedimentation rate
A. International Normalized Ratio (INR)
A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?
- Alanine aminotransferase (ALT)
- Serum aspartate aminotransferase (AST)
- Total lactate dehydrogenase (LDH)
- Troponin T (cTnT)
D. Troponin T (cTnT)
A woman comes to the emergency department reporting signs and symptoms determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? Select all that apply.
- Severe fatigue
- Sense of unease
- Choking sensation
- Chest pain relieved by rest
- Pain radiating down the left arm
A. Severe fatigue
B. Sense of unease
A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client?
- Prevent dyspnea
- Prevent cyanosis
- Increase oxygen concentration to heart cells
- Increase oxygen tension in the circulating blood
C. Increase oxygen concentration to heart cells
A nurse is reinforcing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. The nurse determines that additional teaching or clarification is needed when the client makes which statement?
- “I will restrict my physical activity.”
- “I will take one baby aspirin every day.”
- “I will continue my smoking cessation program.”
- “I will try to lose the extra weight I'm carrying around.”
A. “I will restrict my physical activity.”
A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? Select all that apply.
- Iced tea
- Red meat
- Club soda
- Hot cocoa
- Chocolate pudding
A. Iced tea
D. Hot cocoa
E. Chocolate pudding
A client with cardiac dysrhythmia is undergoing drug therapy. The primary health-care provider instructs the nurse to monitor the client for fatigue, dizziness, and tachycardia. Which medication may be responsible for the client’s condition?