MED SURG 170 Exam 3 Evolve NCLEX Review

1. 1.ID: Which explanation best assists a client in differentiating type 1 diabetes from type 2 diabetes? A. Most clients with type 1 diabetes are born with it. B. People with type 1 diabetes are often obese. C. Those with type 2 diabetes make insulin, but in inadequate amounts. Correct D. People with type 2 diabetes do not develop typical diabetic complications. People with type 2 diabetes make some insulin but in inadequate amounts, or they have resistance to existing insulin. Although type 1 diabetes may occur early in life, it may be caused by immune responses. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for complications, especially cardiovascular complications. 2. 2.ID: The nurse receives report on a 52-year-old client with type 2 diabetes: Which complication of diabetes does the nurse report to the provider? A. Poor glucose control B. Visual changes C. Respiratory distress D. Decreased peripheral perfusion Correct A cold, mottled toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization; this must be reported to avoid potential gangrene and amputation. Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted. 3. 3.ID: A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client should be monitored for hypoglycemia at which time? A. 7:30 a.m. B. 11:00 a.m. Correct C. 2:00 p.m. D. 7:30 p.m. Onset of regular insulin is ½ to 1 hour; peak is 2 to 4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m. For regular insulin received at 7:00 a.m., 7:30 a.m., 2:00 p.m., and 7:30 p.m. are not the anticipated peak times. 4. 4.ID: A client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client’s family? A. Causes and treatment of hyperglycemia B. Causes and treatment of hypoglycemia Correct C. Dietary control D. Insulin administration The causes and treatment of hypoglycemia must be understood by the client and family to manage the client’s diabetes effectively. The causes and treatment of hyperglycemia is a topic for secondary teaching and is not the priority for the client with diabetes. Dietary control and insulin administration are important, but are not the priority in this situation. 5. 5.ID: The nurse is providing discharge teaching to a client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching? A. “I can break in my shoes by wearing them all day.” Correct B. “I need to monitor my feet daily for blisters or skin breaks.” C. “I should never go barefoot.” D. “I should quit smoking.” Shoes should be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering. People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated. Tobacco use further decreases peripheral circulation in a client with diabetes. 6. 6.ID: 4615471564 The nurse is teaching a client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? Physical Assessment Diagnostic Findings Provider Prescriptions Lungs clear Glucose 179 mg/dL Regular insulin 8 units if blood glucose 250 to 275 mg/dL and cold to touch Right great toe mottled Hemoglobin A1c 6.9% Regular insulin 10 units if glucose 275 to 300 mg/dL Client states wears eyeglasses to read A. “I should begin exercising for at least an hour a day.” Correct B. “I should monitor my diet.” C. “If I lose weight, I may not need to use the insulin anymore.” D. “Weight loss can be a sign of diabetic ketoacidosis.” For long-term maintenance of major weight loss, large amounts of exercise (7 hr/wk) or moderate or vigorous aerobic physical activity may be helpful, but the client must start slowly. Monitoring the diet is key to type 2 diabetes management. Weight loss can minimize the need for insulin and can also be a sign of diabetic ketoacidosis. 7. 7.ID: The nurse is providing discharge teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? A. “If I become hyperglycemic, it is a medical emergency.” B. “If I become hypoglycemic, I could become unconscious.” Correct C. “Medical personnel may need confirmation of my insurance.” D. “I may need to be admitted to the hospital suddenly.” Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Hyperglycemia is not a medical emergency unless it is acidosis; people with diabetes tolerate mild hyperglycemia routinely. Insurance information and information needed for hospital admission do not appear on a MedicAlert bracelet. 8. 8.ID: The nurse is teaching a client about the manifestations and emergency treatment of hypoglycemia. In assessing the client’s knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates a correct understanding of hypoglycemia management? A. “I should drink a glass of water.” B. “I should eat three graham crackers.” Correct C. “I should give myself 1 mg of glucagon.” D. “I should sit down and rest.” Eating three graham crackers is a correct management strategy for mild hypoglycemia. Water or resting does not remedy hypoglycemia. Glucagon should be administered only in cases of severe hypoglycemia. 9. 9.ID: A client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess in the client before providing instruction about the disease and its management? A. Current lifestyle B. Educational and literacy level Correct C. Sexual orientation D. Current energy level A large amount of information must be synthesized; typically written instructions are given. The client’s educational and literacy level is essential information. Although lifestyle should be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide selfcare. Although energy level will influence the ability to exercise, it is not essential. 10. 10.ID: A client expresses fear and anxiety over the life changes associated with diabetes, stating, “I am scared I can’t do it all and I will get sick and be a burden on my family.” What is the nurse’s best response? A. “It is overwhelming, isn’t it?” B. “Let’s see how much you can learn today, so you are less nervous.” C. “Let’s tackle it piece by piece. What is most scary to you?” Correct D. “Other people do it just fine.” Suggesting the client tackle it piece by piece and asking what is most scary to him or her is the best response; this approach will allow the client to have a sense of mastery with acceptance. Referring to the illness as overwhelming is supportive, but is not therapeutic or helpful to the client. Trying to see how much the client can learn in one day may actually cause the client to become more nervous; an overload of information is overwhelming. Suggesting that other people handle the illness just fine is belittling and dismisses the client’s concerns. 11. 11.ID: A client recently admitted with new-onset type 2 diabetes will be discharged with a self-monitoring blood glucose machine. When is the best time for the nurse to explain to the client the proper use of the machine? A. Day of discharge B. On admission C. When the client states readiness D. While performing the test in the hospital Correct Teaching the client about the operation of the machine while performing the test in the hospital is the best way for the client to learn. The teaching can be reinforced before discharge. Instructing the client on the day of admission or the day of discharge would be overwhelming to the client because of all of the other activities taking place on those days. The client may never feel ready to learn this daunting task; the nurse must be more proactive. 12. 12.ID: Which is the best referral that the nurse can suggest to a client who has been newly diagnosed with diabetes? A. American Diabetes Association Correct B. Centers for Disease Control and Prevention C. Health care provider office D. Pharmaceutical representative The American Diabetes Association can provide national and regional support and resources to clients with diabetes and their families. The Centers for Disease Control and Prevention does not focus on diabetes. The client’s health care provider’s office is not the best resource for diabetes information and support. A pharmaceutical representative is not an appropriate resource for diabetes information and support. 13. 13.ID: A diabetic client has a glycosylated hemoglobin (HbA1C) level of 9.4%. What does the nurse say to the client regarding this finding? A. “Keep up the good work.” B. “This is not good at all.” C. “What are you doing differently?” Correct D. “You need more insulin.” Assessing the client’s regimen or changes he or she may have made is the basis for formulating interventions to gain control of blood glucose. HbA1C levels for diabetic clients should be less than 7%; a value of 9.4% shows poor control over the past 3 months. Telling the client this is not good, although true, does not take into account problems that the client may be having with the regimen and sounds like scolding. Although it may be true that the client needs more insulin, an assessment of the client’s regimen is needed before decisions are made about medications. 14. 14.ID: The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? A. “I should go barefoot in my house so that my feet are exposed to air.” B. “I must inspect my shoes for foreign objects before putting them on.” Correct C. “I will soak my feet in warm water to soften calluses before trying to remove them.” D. “I must wear canvas shoes as much as possible to decrease pressure on my feet.” To avoid injury or trauma to the feet, shoes should be inspected for foreign objects before they are put on. Diabetic clients should not go barefoot because foot injuries can occur. To avoid injury or trauma, a callus should be removed by a podiatrist, not by the client. The diabetic client must wear firm support shoes to prevent injury. 15. 15.ID: 4615471548 An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make? A. Urine output B. 12-lead electrocardiogram (ECG) C. Potassium level Correct D. Rate of IV fluids With insulin therapy, serum potassium levels fall rapidly as potassium shifts into the cells. Detecting and treating the underlying cause is essential. Insulin treats symptoms of diabetes by putting glucose into the cell as well as potassium; ectopy, indicative of cardiac irritability, is not associated with changes in urine output. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the cause. 16. 16.ID: In reviewing the health care provider admission requests for a client admitted in a hyperglycemic-hyperosmolar state, which request is inconsistent with this diagnosis? A. 20 mEq KCl for each liter of IV fluid B. IV regular insulin at 2 units/hr C. IV normal saline at 100 mL/hr D. 1 ampule NaHCO3 IV now Correct NaHCO3 is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state, which presents with hyperglycemia and absence of ketosis/acidosis. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from diuresis. IV regular insulin at 2 units/hr will correct hyperglycemia. IV normal saline at 100 mL/hr will correct dehydration. 17. 17.ID: 4615471556 The nurse caring for four diabetic clients has all of these activities to perform. Which is appropriate to delegate to unlicensed assistive personnel (UAP)? A. Perform hourly bedside blood glucose checks for a client with hyperglycemia. Correct B. Verify the infusion rate on a continuous infusion insulin pump. C. Monitor a client with blood glucose of 68 mg/dL for tremors and irritability. D. Check on a client who is reporting palpitations and anxiety. Performing bedside glucose monitoring is an activity that may be delegated because it does not require extensive clinical judgment to perform; the nurse will follow up with the results. Intravenous therapy and medication administration are not within the scope of practice for UAP. The client with blood glucose of 68 mg/dL will need further monitoring, assessment, and intervention not within the scope of practice for UAP. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention; this client must be assessed by licensed nursing staff. 18. 18.ID: The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? A. Client taking repaglinide (Prandin) who has nausea and back pain B. Client taking glyburide (Diabeta) who is dizzy and sweaty Correct C. Client taking metformin (Glucophage) who has abdominal cramps D. Client taking pioglitazone (Actos) who has bilateral ankle swelling The client taking glyburide (Diabeta) who is dizzy and sweaty has symptoms consistent with hypoglycemia and should be assessed first because this client displays the most serious adverse effect of antidiabetic medications. Although the client taking repaglinide who has nausea and back pain requires assessment, the client taking glyburide takes priority. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone. 19. 19.ID: The nurse has just received change-of-shift report on the endocrine unit. Which client does the nurse see first? A. Client with type 1 diabetes whose insulin pump is beeping “occlusion” Correct B. Newly diagnosed client with type 1 diabetes who is reporting thirst C. Client with type 2 diabetes who has a blood glucose of 150 mg/dL D. Client with type 2 diabetes with a blood pressure of 150/90 mm Hg Because glucose levels will increase quickly in clients who use continuous insulin pumps, the nurse should assess this client and the insulin pump first to avoid diabetic ketoacidosis. Thirst is a symptom of hyperglycemia and, although important, is not a priority; the nurse could delegate a fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL is mildly elevated, this is not an emergency. Mild hypertension is also not an emergency. 20. 20.ID: Which nursing action can the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? A. Assist the client’s spouse in choosing appropriate dietary items. B. Evaluate the client’s use of a home blood glucose monitor. C. Inspect the extremities for evidence of poor circulation. D. Assist the client with washing the feet and applying moisturizing lotion. Correct Assisting with personal hygiene is included in the role of home health aides. Assisting with dietary choices, evaluating the effectiveness of teaching, and performing assessments are complex actions that should be implemented by licensed nurses. 21. 21.ID: Which of these clients with diabetes does the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A. A 58-year-old with sensory neuropathy who needs teaching about foot care B. A 68-year-old with diabetic ketoacidosis who has an IV running at 250 mL/hr C. A 70-year-old who needs blood glucose monitoring and insulin before each meal Correct D. A 76-year-old who was admitted with fatigue and shortness of breath A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit. The 58-year-old with sensory neuropathy, the 68-year-old with diabetic ketoacidosis, and the 76-year-old with fatigue and shortness of breath all have specific teaching or assessment needs that are better handled by nurses more familiar with caring for older adults with diabetes. 22. 22.ID: A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, “I can’t catch my breath.” The client’s vital signs are: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action does the nurse take first? A. Check the blood glucose. Correct B. Administer oxygen. C. Offer reassurance. D. Attach a cardiac monitor. The client’s clinical presentation is consistent with diabetic ketoacidosis, so the nurse should initially check the client’s glucose level. Based on the oxygen saturation, oxygen administration is not necessary. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. Cardiac monitoring may be implemented, but the first action should be to obtain the glucose level. 23. 23.ID: 4615471572 A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action does the nurse plan to take next? A. Instruct the client to continue with the current diet and metformin use. B. Discuss the need to check blood glucose several times every day. C. Talk about the possibility of adding rapidacting insulin to the regimen. D. sk the client about current dietary intake and medication use. Correct The nurse’s first action should be to assess whether the client is adherent to the currently prescribed diet and medications. The client’s current diet and medication use have not been successful in keeping glucose in the desired range. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data. The HbA1C indicates that the client’s average glucose level is not in the desired range, but discussing the need to check blood glucose several times every day assumes that the client is not compliant with the therapy and glucose monitoring. The nurse should not assume that adding insulin, which must be prescribed by the provider, is the answer without assessing the underlying reason for the treatment failure. 24. 24.ID: A client with type 2 diabetes has been admitted for surgery, and the health care provider has placed the client on insulin in addition to the current dose of metformin (Glucophage). The client wants to know the purpose of taking the insulin. What is the nurse’s best response? A. “Your diabetes is worse, so you will need to take insulin.” B. “You can’t take your metformin while in the hospital.” C. “Your body is under more stress, so you’ll need insulin to support your medication.” Correct D. “You must take insulin from now on because the surgery will affect your diabetes.” Because of the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for the client who uses oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides. No evidence suggests that the client’s diabetes has worsened; however, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital; however, not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed. 25. 25.ID: Which action is correct when drawing up a single dose of insulin? A. Wash hands thoroughly and don sterile gloves. B. Shake the bottle of insulin vigorously to mix the insulin. C. Pull back plunger to draw air into the syringe equal to the insulin dose. Correct D. Recap the needle and save the syringe for the next dose of insulin. The plunger is pulled back to draw an amount of air into the syringe that is equal to the insulin dose. The air is then injected into the insulin bottle before withdrawing the insulin dose. Although handwashing is important before any medication administration, sterile gloves are not required. The bottle of insulin should be rolled gently in the palms of the hands to mix the insulin, not shaken. Insulin syringes are never recapped or reused; the syringe and needle should be disposed of (without recapping) in a puncture-proof container. Chapter 33 1. 1. 1.ID: 4615494467 The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? A. Right atrial pressure is 4 mm Hg. B. Mean arterial pressure (MAP) is 58 mm Hg. Correct C. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. D. PO2 is reported as 78 mm Hg. To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg. 2. 2.ID: The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? A. No intervention is needed; this is a normal reading. B. Collaborate with the health care provider to administer a positive inotropic agent. Correct C. dminister a STAT dose of metoprolol (Lopressor). D. Ask the client to perform the Valsalva maneuver. A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output. 3. 3.ID: Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? A. Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted B. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Correct C. Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain D. Client who has many questions about the electrophysiology studies (EPS) scheduled for today The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN. An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable; the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS; the newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently. 4. 4.ID: Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? A. Assess preprocedure medications the client took that day. B. Have the client sign the consent form before the procedure is performed. C. Educate the client about the need to remain on bedrest after the procedure. D. Obtain client vital signs and a resting electrocardiogram (ECG). Correct Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN. 5. 5.ID: An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? A. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures B. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index Correct C. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging D. A client with acute coronary syndrome who has just been admitted and needs an admission assessment The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan. 6. 6.ID: All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is mostimportant to report to the health care provider before the procedure begins? A. The client has had intermittent substernal chest pain for 6 months. B. The client develops wheezes and dyspnea after eating crab or lobster. Correct C. he client reports that a previous arteriogram was negative for coronary artery disease. D. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed. 7. 7.ID: 4615494483 A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? A. White blood cell count B. Low-density lipoproteins C. Serum troponin I level Correct D. C-reactive protein Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem. 8. 8.ID: The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? A. Auscultate the client’s precordium for murmurs. B. Teach the client about the reason for the TEE. C. Reassure the client that the test is painless. D. Validate that the client has remained NPO. Correct Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur; auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable. 9. 9.ID: A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? A. Dietary consult B. Sodium restriction C. Daily weight monitoring Correct D. Restricted activity A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions. 10. 10.ID: 4615494475 A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? A. Maintains NPO (nothing by mouth) until this resolves B. Calls in another nurse for a second opinion C. Performs a complete neurologic assessment and notifies the health care provider Correct D. Explains to the client and family that this is expected after sedation Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention. Be confident in this decision; this assessment does not warrant a second opinion. Keeping the client NPO and waiting for symptoms to resolve is not appropriate. Slurred speech is not expected after sedation. 11. 11.ID: Which statement about diagnostic cardiovascular testing is correct? A. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. B. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Correct C. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. D. The left side of the heart is catheterized first and may be the only side examined. Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing. 12. 12.ID: Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? A. “I don’t know how I am going to change my lifestyle.” B. “I don’t need to change. It hasn’t killed me yet.” Correct C. “I don’t think it is as bad as the doctors say.” D. “I will have to change my diet and exercise more.” A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because “it hasn’t killed me yet” indicates maladaptive denial. Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicates a willingness to change. 13. 13.ID: 4615494491 A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? A. “Monitor the pulses in your feet when you get home.” B. “Keep your affected leg straight for 2 to 6 hours.” Correct C. “Do not take your blood pressure medications on the day of the procedure.” D. “Take your oral hypoglycemic with a sip of water on the morning of the procedure.” The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure; therefore, antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating; they are not taken when the client is NPO for procedures or surgery. 14. 14.ID: A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? A. Fatigue Correct B. Swelling of one leg C. Slow heart rate D. Brown discoloration of lower extremities Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of longstanding venous stasis, such as occurs with varicose veins. 15. 15.ID: Which client has the highest risk for cardiovascular disease? A. Man who smokes and whose father died at 49 of myocardial infarction (MI) Correct B. Woman with abdominal obesity who exercises three times per week C. Woman with diabetes whose highdensity lipoprotein (HDL) cholesterol is 75 mg/dL D. Man who is sedentary and reports four episodes of strep throat Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease. 16. 16.ID: Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? A. Client with abdominal pain and belching B. Client with pressure in the midabdomen and profound diaphoresis Correct C. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows D. Client with claudication and fatigue Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease. 17. 17.ID: Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? A. This blood pressure is good because it is a normal reading. B. This blood pressure indicates that the client has hypertension or high blood pressure. C. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. Correct D. This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension. Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg. 18. 18.ID: Which statement reflects correct cardiac physical assessment technique? A. Auscultate the aortic valve in the second intercostal space at the right sternal border. Correct B. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. C. Palpate the apical pulse over the third intercostal space in the midclavicular line. D. Assess for carotid bruit by auscultating over the anterior neck. The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck. 19. 19.ID: A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? A. C-reactive protein of 1 mg/dL B. Homocysteine level of 13 mmol/L C. Creatine kinase (CK) of 125 mg/dL D. Troponin of 5.2 ng/mL Correct The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A Creactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage. 20. 20.ID: The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? A. Saline infusion B. Morphine sulfate C. No treatment, continue monitoring D. Intravenous furosemide Correct Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure. Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse should collaborate with the provider to decrease the right atrial pressure. 21. 21.ID: The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? A. Men do not tend to report chest pain. B. Men are more likely than women to die after MI. C. Men more than women tend to deny the importance of symptoms. D. Women may experience extreme fatigue and dizziness as sole symptoms. Correct Women may have atypical symptoms, including absence of chest pain. Women often present with a “triad” of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to “catch the breath” (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or viselike. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women. 22. 22.ID: After a cardiac catheterization, the client should increase his or her fluid intake for which reason? A. NPO status will cause the client to be thirsty. B. The dye causes an osmotic diuresis. Correct C. The dye contains a heavy sodium load. D. The pedal pulses will be more easily palpable. The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment. Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodinebased. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids. 23. 23.ID: The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? A. Calcium 8.5 mEq/L B. Potassium 3.0 mEq/L Correct C. Magnesium 2.1 mEq/L D. International normalized ratio (INR) of 1.0 Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value. 24. 24.ID: 4615494459 The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? A. “This is a noninvasive test performed to assess your heart rhythm.” B. You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease.” C. “This is a painless test that is done to assess the structure of your heart using sound waves.” D. “This test evaluates you for potentially fatal cardiac rhythms.” Correct EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography. 25. 25.ID: Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) A. Troponin 3.2 ng/mL Correct B. Myoglobin 234 mcg/L Correct C. C-reactive protein 13 mg/dL D. Triglycerides 400 mg/dL E. Lipoprotein-a 18 mg/dL Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS. 26. 26.ID: Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) A. Consuming a diet rich in fiber B. Elevated C-reactive protein levels Correct C. Low blood pressure D. Elevated high-density lipoprotein (HDL) cholesterol level E. Smoking Correct Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective. 27. 27.ID: Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.) A. Squeezing, vise-like chest pain B. Chest pain relieved by sitting upright Correct C. Chest and abdominal pain relieved by antacids D. Sudden-onset chest pain relieved by antiinflammatory agents Correct E. Pain in the chest described as sharp or stabbing Correct The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by antiinflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing; squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer. CHAPTER 34 1. 1.ID: The nurse is caring for a client with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? A. ST segment B. Heart rate Correct C. Troponin D. Myoglobin The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand. ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol. 2. 2.ID: The nurse is caring for a client with atrial fibrillation. In addition to an antidysrhythmic, what medication does the nurse plan to administer? A. Heparin Correct B. Atropine C. Dobutamine D. Magnesium sulfate The loss of coordinated atrial contractions in atrial fibrillation can lead to pooling of blood, resulting in thrombus formation. The client is at high risk for pulmonary embolism! Thrombi may form within the right atrium and then move through the right ventricle to the lungs. In addition, the client is at risk for systemic emboli, particularly an embolic stroke, which may cause severe neurologic impairment or death. Heparin and other anticoagulants (e.g., enoxaparin [Lovenox] and warfarin [Coumadin]) are used to prevent thrombus development in the atrium and the consequence of embolization (i.e., stroke). Atropine is used to treat bradycardia and heart blocks; atrial fibrillation, unless controlled with medication, is typically rapid. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted. 3. 3.ID: The nurse is caring for a client on a telemetry unit with a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are as follows: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8° F. All of these medications are available on the medication record. What action does the nurse take? A. Administer atropine. B. Administer digoxin. C. Administer clonidine. D. Continue to monitor. Correct The client is displaying normal sinus rhythm. Atropine is used in emergency treatment of symptomatic bradycardia. This client has normal vital signs. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia. 4. 4.ID: Which client is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit? A. The 64-year-old client admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min Correct B. The 71-year-old client admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min C. The 88-year-old client admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min D. The 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min The 64-year-old has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the client develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This client can be managed by a nurse with less cardiac dysrhythmia training. The 71-year-old is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse. 5. 5.ID: 4615515332 A client with atrial fibrillation with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? A. Synchronized cardioversion B. Electrophysiology studies (EPS) C. Anticoagulation Correct D. Radiofrequency ablation therapy Because of the risk for thromboembolism, anticoagulation is necessary. The client has stabilized; cardioversion is not needed at this time. EPS are indicated for recurring, symptomatic dysrhythmia. Ablation therapy is ordered for recurring and symptomatic atrial fibrillation. 6. 6.ID: The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? A. Defibrillate the client at 200 joules. B. Check the client for a pulse. Correct C. Cardiovert the client at 50 joules. D. Give the client IV lidocaine. The nurse needs to assess the client to determine stability before proceeding with further interventions. If the client has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular tachycardia with a pulse is amiodarone. If the client is pulseless or nonresponsive, the client is unstable and defibrillation is used. 7. 7.ID: A client admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? A. Prepare for defibrillation. Correct B. Establish IV access. C. Place an oral airway and ventilate. D. Start cardiopulmonary resuscitation (CPR). Defibrillating is the priority before any other resuscitative measures, according to advanced cardiac life support protocols. After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation. 8. 8.ID: In teaching clients at risk for bradydysrhythmias, what information does the nurse include? A. “Avoid potassium-containing foods.” B. “Stop smoking and avoid caffeine.” C. “Take nitroglycerin for a slow heartbeat.” D. “Use a stool softener.” Correct Clients at risk for bradydysrhythmias should avoid bearing down or straining during a bowel movement; the Valsalva maneuver can cause bradycardia. Taking a stool softener helps prevent this. Clients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the client is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people should stop smoking, clients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia. 9. 9.ID: Which waveform indicates proper function of the sinoatrial (SA) node? A. The QRS complex is present. B. The PR interval is 0.24 second. C. A P wave precedes every QRS complex. Correct D. The ST segment is elevated. A P wave is generated by the SA node and represents atrial depolarization. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead. The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Elevation of the ST segment indicates myocardial injury. 10. 10.ID: The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? A. The client is semi-recumbent in bed. B. Chest leads are placed as for the previous ECG. C. The client is instructed to breathe deeply through the mouth. Correct D. The client is instructed to lie still. While obtaining a 12-lead ECG, remind the client to be as still as possible in a semi-reclined position, breathing normally. Any repetitive movement will cause artifact and could lead to inaccurate interpretation of the ECG. Normal breathing is required or artifacts will be observed, perhaps leading to inaccurate interpretation of the ECG. Placing the client in a semi-reclined position is correct and does not require the nurse to intervene. ECGs are valid when electrode placement is identical at each test. The client must lie still to avoid artifacts and inaccurate interpretation of the ECG. 11. 11.ID: 4615515367 How does the nurse recognize that atropine has produced a positive outcome for the client with bradycardia? A. The client states he is dizzy and weak. B. The nurse notes dyspnea. C. The client has a heart rate of 42 beats/min. D. The monitor shows an increase in heart rate. Correct An expected outcome after the administration of atropine is an increased heart rate. By definition, the bradydysrhythmia has resolved when the heart rate is greater than 60 beats/min. Dizziness and weakness indicate symptoms of decreased cerebral perfusion and intolerance to the bradydysrhythmia. Dyspnea indicates intolerance to the bradydysrhythmia. Atropine is used to treat bradycardia; a heart rate of 42 beats/min indicates that bradycardia is unresolved. 12. 12.ID: What teaching does the nurse include for a client with atrial fibrillation who has a new prescription for warfarin? A. “It is important to consume a diet high in green leafy vegetables.” B. “You should take aspirin or ibuprofen for headache.” C. “Report nosebleeds to your provider immediately.” Correct D. “Avoid caffeinated beverages.” Warfarin causes decreased ability to clot; a nosebleed could be indicative of excessive dosing. Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; they should be eaten in moderate amounts. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time and the international normalized ratio, causing predisposition to bleeding; these should be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin. 13. 13.ID: The nurse is caring for a client with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? A. Defibrillation Correct B. Cardiopulmonary resuscitation (CPR) C. Administration of epinephrine D. Administration of oxygen Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over. In asystole, there is no rhythm to interrupt; therefore, this intervention is not used. If drug therapy fails to restore effective rhythm, CPR is initiated. Epinephrine is used to increase heart rate in asystole. Hypoxia may be a cause of cardiac arrest; the administration of oxygen would be appropriate. 14. 14.ID: The nurse receives a report that a client with a pacemaker has experienced loss of capture. Which situation is consistent with this? A. The pacemaker spike falls on the T wave. B. Pacemaker spikes are noted, but no P wave or QRS complex follows. Correct C. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. D. The client demonstrates hiccups. Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode. Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 beats/min with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly; demand pacing should cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation. 15. 15.ID: Which intervention provides safety during cardioversion? A. Setting the defibrillator at 200 joules B. Obtaining informed consent C. Setting the defibrillator to the synchronized mode Correct D. Removing oxygen Setting the defibrillator to the synchronized mode avoids discharging the shock during the vulnerable period on the T wave, which may cause ventricular fibrillation. Cardioversion is performed with a lower rate of energy than 200 joules. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen should be turned off because it presents a safety issue; fire could result. 16. 16.ID: Which teaching is essential for a client who has had a permanent pacemaker inserted? A. Avoid talking on a cell phone. B. Avoid operating electrical appliances over the pacemaker. Correct C. Avoid sexual activity. D. Do not take tub baths. The client should avoid operating electrical appliances directly over the pacemaker site because this may cause the pacemaker to malfunction. It is not necessary to avoid a telephone or a cell phone; radio transmitter towers, arc welding, and strong electromagnetic fields may pose a hazard. No hazard exists with sexual activity. Bathing and showering are permitted. 17. 17.ID: 4615515375 A client’s rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia Correct D. Sinus rhythm with premature ventricular contractions These are the characteristics of sinus tachycardia. A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions. 18. 18.ID: The nurse is teaching a client with a new permanent pacemaker. Which statement by the client indicates a need for further discharge education? A. “I will be able to shower again soon.” B. “I need to take my pulse every day.” C. “I might trigger airport security metal detectors.” D. “I no longer need my heart pills.” Correct All prescribed medications are still needed after the pacemaker is implanted. Once the wound from the surgery heals, the client will be able to shower. The client’s pulse will have to be taken and recorded for 1 full minute at the same time each day. The metal in the pacemaker will trigger the alarm in metal detector devices; a card can be shown to authorities to indicate that the client has a pacemaker. 19. 19.ID: The nurse administers amiodarone (Cordarone) to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply.) A. Respiratory rate B. QT interval Correct C. Heart rate Correct D. Heart rhythm Correct E. Urine output Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed. Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone. 20. 20.ID: The nurse is caring for a client with heart rate of 143 beats/min. For which manifestations does the nurse observe? (Select all that apply.) A. Palpitations Correct B. Increased energy C. Chest discomfort Correct D. Flushing of the skin E. Hypotension Correct Tachycardia is a heart rate greater than 100 beats/min; the client with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope (“blackout”) from hypotension. Chest discomfort may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue. 21. 21.ID: The nurse is caring for a client who has developed a bradycardia. Which possible causes does the nurse investigate? (Select all that apply.) A. Bearing down for a bowel movement Correct B. Possible inferior wall myocardial infarction (MI) Correct C. Client stating that he just had a cup of coffee D. Client becoming emotional when visitors arrived E. Diltiazem (Cardizem) administered 1 hour ago Correct Excessive vagal (parasympathetic) stimulation to the heart causes a decreased rate of sinus node discharge. It may result from carotid sinus massage, vomiting, suctioning, Valsalva maneuvers (e.g., bearing down for a bowel movement or gagging), ocular pressure, or pain. Inferior wall MI is a cause of bradycardia and heart block. Calcium channel blockers such as diltiazem may cause bradycardia. Caffeine intake results in an increased heart rate. Stress, such as an emotional encounter, can result in tachycardia. 22. 22.ID: Which risk factors are known to contribute to atrial fibrillation? (Select all that apply.) A. Use of beta-adrenergic blockers B. Excessive alcohol use Correct C. Advancing age Correct D. High blood pressure Correct E. Palpitations The incidence of atrial fibrillation increases with age. Risk factors include hypertension, previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, Caucasian race, and excessive alcohol. Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause. CHAPTER 35 1. 1. 1.ID: The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What acti