Question 1

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?

Accepted Answer

Apical pulse rate of 110 and 4+ pitting edema of feet.

Question 2

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 heart to pump effectively\" is written. Which short-term goal would be best for the client? The client will:

Accepted Answer

Have an audible S1 and S2 with no S3 heard by end of shift.

Question 3

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.

Accepted Answer

2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table.

Question 4

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?

Accepted Answer

Assist the client to a sitting position THEN vital and check pulse ox then sponge the client\'s forehead

Question 5

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?

Accepted Answer

The client is able to perform ADLs without dyspnea.

Question 6

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?

Accepted Answer

An elevated B-type natriuretic peptide (BNP). specific test, higher the number worse the condition

Question 7

CK-MB indicate MI not heart failure

Accepted Answer

A positive D-dimer indicate pulmonary embolism

Question 8

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?

Accepted Answer

Teach the client how to prevent orthostatic hypotension. - if cough stop the medication - may cause hyperkalemia - take 1 hour before meals or 2 hours after meals

Question 9

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?

Accepted Answer

The client diagnosed with myocardial infarction who has an audible S3 heart sounds.  - S3 is ventricular failure it is an emergency

Question 10

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

Accepted Answer

Help position the client who is having a portable x-ray done. - unstable patient from ICU is not delegated - teaching is not delegated

Question 11

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?

Accepted Answer

Monitor the client\'s potassium level and assess the client\'s intake of bananas and orange juice. - most probable cause of the pain is hypokalemia - peripheral edema may cause calf tightness not cramping

Question 12

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced RN? 1. The client diagnosed with congestive heart fialure who is being discharge in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough

Accepted Answer

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.   These are symptoms of shock and make the patient unstable. Cardiac chest pain does not fluctuate with inspiration.

Question 13

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction?

Accepted Answer

Troponin. - elvated within 1-2 hours - CK-MB within 12-24 - LDH within 24-36

Question 14

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?

Accepted Answer

Diaphoresis and cool clammy skin. - these are systemic reaction

Question 15

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

Accepted Answer

Have the client sit down immediately. - decreases the need for oxygen, may help decrease the chest pain

Question 16

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.

Accepted Answer

- Administer an aspirin orally. - Apply oxygen via a nasal cannula. PAY ATTENTION THE ROUTES! - MORPHINE ONLY IV - NITROGLYCERIN ONLY SUBLINGUAL IN THIS SITUATION

Question 17

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?

Accepted Answer

CARDIAC REHABILITATION

Question 18

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?

Accepted Answer

Assess the client\'s chest dressing and vital signs. - if the chest pain is expected postop or if it is a complication

Question 19

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?

Accepted Answer

3. The client is complaining of numbness in the right foot. - indicate decreased blood supply to the right foot - do neurovascular assessment after PTCA - keep legs straight for 6-8 hours

Question 20

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

Accepted Answer

Notify the health-care provider immediately. - means left ventricular failure, should be reported ASAP

Question 21

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication?

Accepted Answer

The client\'s blood pressure is 90/62. - apical pulse between 60-100 can give - serum calcium is not monitored for Ca channel blockers - if BP lower than 90 do not give

Question 22

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?

Accepted Answer

Assess the client\'s neurovascular status. - assess for pulses, paresthesia, paralysis, coldness and pallor - HOB elevated no more than 10 degrees, client kept in bedrest

Question 23

The nurse is administering a CCB to the client diagnosed with a MI. Which assessment data would cause the nurse to question adminstering this medication? 1. The client\'s apical pulse is 64. 2. The client\'s calcium level is elevated. 3. The client\'s telemetry shows occasional PVCs 4. The client\'s BP is 90/62.

Accepted Answer

4. The client\'s BP of 90/62 is low and a CCB could cause the BP to bottom out

Question 24

normal apical pulse

Accepted Answer

60-100 beats per minute

Question 25

The client diagnosed with a MI is on bedrest. The UAP is encouraging the client to move the legs. Which action should the nurse implement?

Accepted Answer

Praise the UAP for encouraging the client to move legs

Question 26

The client diagnosed with an MI asks the nurse, \" Why do I have to rest and take it easy? My chest doesn\'t hurt anymore.\"

Accepted Answer

Your heart is damaged and needs about 4 to 6 weeks to heal. Stress or activity can cause heart failure

Question 27

Sublingual Nitroglycerin tablets

Accepted Answer

1. Should be kept in dark colored bottle 2. Tablets will burn under tongue 3. Bottle should be kept with pt. at all times 4. If angina occurs, take one tablet every 5 minutes. After 3 tablets if angina persists go to the ER 5. Bottle should be replaced every 6 months 6. Move slowly after administration d/t orthostatic hypotension 7. Take 5-10 minutes before activity

Question 28

Describing chest pain to a CAD pt.

Accepted Answer

Chest pain is caused by decreased oxygen to the heart muscle

Question 29

Chest pain in medical terms

Accepted Answer

ischemia to the myocardium as a result of hypoxemia

Question 30

Congestive heart failure

Accepted Answer

the heart muscle is unable to pump effectively to perfuse the body

Question 31

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform Passive ROM 2. Assess the client\'s neurovascular status 3. Keep client in High Fowler\'s 4. Asses the gag reflex prior to feeding the client

Accepted Answer

2. Assess the client\'s neurovascular stress (assessing pt. for pulses, paresthesia, paralysis, coldness, and pallor.  HOB should be elevated less than 10 degrees.

Question 32

The client has just returned from a cardiac catheterization. Which assesment data would warrant immediate intervention from the nurse? 1. The client\'s BP is 110/70 and pulse is 90. 2. The client\'s groin dressing is dry and intact. 3. The client refuses to keep the leg straight 4. The client denies any numbness and tingling.

Accepted Answer

3. The client refusing to keep the leg straight.   Bending the leg can cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly.

Question 33

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?

Accepted Answer

The client has an apical pulse of 56.  A beta blocker decreases sympathetic stimulation to the heart which dec. HR.

Question 34

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?

Accepted Answer

Assess the client\'s serum potassium level. - assess apical pulse not radial pulse

Question 35

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.

Accepted Answer

1. Encourage a low-fat, low-cholesterol diet to dec. atherosclerosis 2. Instruct client to walk 30 minutes a day to inc. collateral circulation 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet to remove cholesterol

Question 36

When should salt be restricted?

Accepted Answer

In a hypertensive pt.

Question 37

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?

Accepted Answer

\"Are you sexually active?\" - sexual activity is a risk factor for angina from coronary disease BUT client\'s being elderly should not affect teaching about sexual activity

Question 38

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?

Accepted Answer

Do not walk outside if it is less than 40ËF. - when it is cold outside, it causes vasoconstriction and lower oxygen to heart muscles - perform isotonic (inc. muscle tone) exercises not isometric (weight lifting) - walk at least 30 minutes for 3-4 times - wear supportive shoes not sandals!

Question 39

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?

Accepted Answer

Stop the activity immediately and rest. - that is first action , then nitroglycerine

Question 40

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?

Accepted Answer

Instruct client to keep a diary of activity, especially when having chest pain. - important, so physician can compare ECG recordings with different level of activity - it should not be removed for any reason - does not affect meds regimen - perform all activities as usual while wearing Holter

Question 41

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? (low cholesterol & low fat)

Accepted Answer

\"I should bake or grill any meats I eat.\" - grill or bake do not fry - no more than 3 eggs a week, especially yolk - low fat milk, not whole milk

Question 42

pork is prohibited in what type of diet?

Accepted Answer

lowering sodium

Question 43

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. 44 yo client diagnosed with MI 2. 65 yo client admitted with unstable angina 3. 75 yo client scheduled for cardiac catheterization 4. 50 yo client complaining of chest pain

Accepted Answer

The 75-year-old client scheduled for a cardiac catheterization. - not a client diagnosed with MI- necrotic myocardial tissue has high risk for complications and needs extensive teaching - not a client with unstable angina- at risk for life threatening complications - not a client who complaining of chest pain- could be having an MI

Question 44

The telemetry nurse is unable to read the telemetry monitor at the nurse\'s station. Which intervention should the telemetry nurse implement first? 1. Go to the client\'s room to check on the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client\'s room.

Accepted Answer

3. Contact the client on the client call system. If the client is not experiencing chest pain there is probably a monitor artifact which is not a life-threatening emergency. Then, send a nurse in to check on the pt.  The telemetry nurse should not leave the monitor unattended at any time.

Question 45

The client shows ventricular fibrillation on the telemetry at the nurse\'s station. Which action should the telemetry nurse implement first?

Accepted Answer

Call a STAT code. - STAT code will bring a crash cart to the room & health care team -The first person at the bedside should start CPR - THEN defibrillation

Question 46

Lidocaine

Accepted Answer

suppresses ventricular ectopy and is the DOC for ventricular dysrhythmias

Question 47

Atropine

Accepted Answer

decreases vagal stimulation and is the DOC for asystole

Question 48

Digoxin

Accepted Answer

slows the heart rate, increases contractility and is the DOC for A fib

Question 49

Adenosine

Accepted Answer

DOC for supraventricular tachycardia

Question 50

The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which COLLABORLATIVE treatment should the nurse anticipate being implemented?

Accepted Answer

Prepare for insertion of a pacemaker. - client is symptomatic and will need a pacemaker - PAY ATTENTION IT SAYS COLLABORATIVE, NOT INDEPENDENT!  - assessment is independent action

Question 51

A pt. with sinus bradycardia or complete heart block will need a..

Accepted Answer

pacemaker

Question 52

What to do when defibrillating a pt.

Accepted Answer

-Shout \"all clear\" prior to defibrillating the client. - if anybody is touching the client or bed , that person could possibly be shocked  - adults defibrillated at 360 joules - oxygen should be removed to prevent spark  - use defib pads or defib gel

Question 53

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client?

Accepted Answer

1. Instruct the client to use a soft-bristle toothbrush. - they will be on anticoagulants, risk for bleeding - scheduled INR test for therapeutic levels of warfarin, PTT for heparin - synchronized cardioversion for new-onset atrial fib not chronic

Question 54

Synchronized cardioversion is pt. teaching for..

Accepted Answer

new onset a fib or v fib with a pulse

Question 55

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?

Accepted Answer

Assess the apical pulse and BP to determine if the pt. is in cardiac arrest and then treat as ventricular fibrillation.   If the client\'s heart is beating the nurse would then administer lidocaine

Question 56

The pt. is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT ECG 4. Notify the health care provider

Accepted Answer

2. Atropine will dec. vagal stimulation and inc. the HR  THEN notify the health care provider and prepare to insert a pacemaker

Question 57

The pt. is in ventricular fibrillation. Which interventions should the nurse implement?

Accepted Answer

1. Start Cardiopulmonary resuscitation 3. Prepare to defibrillate the pt. 4. Bring the crash cart to the bedside 5. Prepare to administer the antidysrhythmic amiodarone IVP

Question 58

What is amiodarone used for?

Accepted Answer

ventricular dysrhythmias

Question 59

What does V fib mean?

Accepted Answer

the pt. does not have a heartbeat

Question 60

The pt. is one day postop coronary artery bypass and is exhibiting sinus tachycardia. What intervention should the nurse implement?

Accepted Answer

Sinus tachycardia means that the SA node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fear. The nurse must determine the cause and treat appropriately.   There is no specific med for sinus tachycardia

Question 61

The pt\'s telemetry reading shows a P wave before each QRS complex and the rate is 78. What action should the nurse implement?

Accepted Answer

The nurse should document this as normal sinus rhythm.

Question 62

Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Dec. cardiac output 3. Impaired gas exchange 4. Activity Intolerance

Accepted Answer

2. Dec. Cardiac output

Question 63

Which population is at a higher risk for dying from an MI? 1. caucasion males 2. hispanic females 3. asian males 4. Black females

Accepted Answer

4. Black females

Question 64

What preprocedure info should be taught to the female client having an exercise stress test in the morning?

Accepted Answer

NPO for 4 hours to dec the chance of aspiration in case of emergency. If a pt. just had a meal the blood supply will be shunted to the stomach for digestion and away from the heart, leading to an inaccurate test result.

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