NURS 618 | NURS618 Saunders Med Surg Cardiovascular Revised 2020 ( A Grade)

NURS 618 Saunders Med Surg Cardiovascular Revised 2020 Saunders Med Surg Cardiovascular 1. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? • Glipizide • Metformin • Repaglinide • Regular insulin Answer: 2. Metformin Rationale: Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization. 3. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Notify the health care provider. 4. Continue to monitor for any rhythm change. Answer: 4. Continue to monitor for any rhythm change. Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change. 4. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? • Call a code. • Call the health care provider. • Check the client's status and lead placement. • Press the recorder button on the electrocardiogram console. Answer: 3. Check the client's status and lead placement. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment. 7. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? • Sinus tachycardia • Sinus bradycardia • Sinus dysrhythmia • Normal sinus rhythm Answer: 1. Sinus tachycardia Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute. 8. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? • The neurovascular status is normal because of increased blood flow through the leg. • The neurovascular status is moderately impaired, and the surgeon should be called. • The neurovascular status is slightly deteriorating and should be monitored for another hour. • The neurovascular status is adequate from an arterial approach, but venous complications are arising. Answer: 1. The neurovascular status is normal because of increased blood flow through the leg. Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations. 12. The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? • "I need to be sure not to go barefoot around the house." • "If I cut my toenails, I need to be sure that I cut them straight across." • "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." • "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." Answer: 4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." Rationale: Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements, and indicate that the teaching has been effective. 13. The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? • Bananas • Broccoli • Antacids • Cantaloupe Answer: 3. Antacids Rationale: The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium. 14. The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? • Use nail polish to protect the nail beds from injury. • Wear gloves for all activities involving the use of both hands. • Stop smoking because it causes cutaneous blood vessel spasm. • Always wear warm clothing, even in warm climates, to prevent vasoconstriction Answer: 3. Stop smoking because it causes cutaneous blood vessel spasm. Rationale: Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. It is not necessary to wear gloves for all activities, nor should warm clothing be worn in warm climates. 15. The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? • Keep the legs aligned with the heart. • Elevate the legs higher than the heart. • Clean the skin with alcohol every hour. • Position the client onto the side during every shift. Answer: 2. Elevate the legs higher than the heart. Rationale: In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention. 16. The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? • Heart failure • Atrial fibrillation • Myocardial infarction • Ventricular tachycardia Answer: 3. Myocardial infarction Rationale: Cardiac troponin T or cardiac troponin I have been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation. 17. The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? 1. Hypotension 2. Flat neck veins 3. Complaints of nausea 4. Complaints of headache Answer: 1. Hypotension Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. 18. The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1. Listening to lung sounds 2. Palpating for organomegaly 3. Assessing for jugular vein distention 4. Assessing for peripheral and sacral edema Answer: 1. Listening to lung sounds Rationale: The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with rightsided heart function. Lung sounds constitute an accurate indicator of left-sided heart function. 19. The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? 1. "This is a normal finding." 2. "This is indicative of atrial flutter." 3. "This is indicative of atrial fibrillation." 4. "This is indicative of impending reinfarction." Answer: 1. "This is a normal finding." Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. The remaining options are incorrect and indicate that further education is needed. 20. The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1. Anxiety related to the need to make lifestyle changes 2. Boredom resulting from having already learned the material 3. An attempt to ignore or deny the need to make lifestyle changes 4. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions Answer: 3. An attempt to ignore or deny the need to make lifestyle changes Rationale: Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session. 21. A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1. A stage 1 ulcer 2. A vascular ulcer 3. An arterial ulcer 4. A venous stasis ulcer Answer: 3. An arterial ulcer Rationale: Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion. 22. The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? 1. Maintain activity level as prescribed. 2. Maintain the affected leg in a dependent position. 3. Administer an opioid analgesic every 4 hours around the clock. 4. Apply cool packs to the affected leg for 20 minutes every 4 hours. Answer: 1. Maintain activity level as prescribed. Rationale: Standard management for the client with DVT includes maintaining the activity level as prescribed by the health care provider; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse should maintain the prescribed activity level, which could be bed rest or ambulation. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen. 23. A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective? 1. "It involves tying off the veins so that circulation is redirected in another area." 2. "It involves surgically removing the varicosity, so anesthesia will be required." 3. "It involves tying off the veins to prevent sluggishness of blood from occurring." 4. "It involves injecting an agent into the vein to damage the vein wall and close it off." Answer: 4. "It involves injecting an agent into the vein to damage the vein wall and close it off." Rationale: Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with the use of a hook and wires applied through multiple small incisions in the leg. Other treatments include the application of radiofrequency (RF) energy, in which the vein is heated from the inside by the RF energy and shrinks; collateral veins nearby take over. Laser treatment is another alternative to surgery; in this treatment a laser fiber is used to heat and close the main vessel that is contributing to the varicosity. 25. The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? 1. "Oxygen has a calming effect." 2. "Oxygen will prevent the development of any thrombus." 3. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." 4. "Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle." Answer: 3. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." Rationale: The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client. 26. A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? 1. "I need to cut down on cigarette smoking." 2. "I am so relieved that my heart is repaired." 3. "I need to adhere to my dietary restrictions." 4. "I am so relieved that I can eat anything I want to now." Answer: 3. "I need to adhere to my dietary restrictions." Rationale: After angioplasty, the client needs to be instructed on the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart. 27. The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? 1. Tea 2. Cola 3. Coffee 4. Raspberry juice Answer: 4. Raspberry juice Rationale: A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI. 28. The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? 1. "Where is the pain located?" 2. "Are you having any nausea?" 3. "Are you allergic to any medications?" 4. "Do you have your nitroglycerin with you?" Answer: 1. "Where is the pain located?" Rationale: If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, location, duration, and quality. Although the questions in the remaining options all may be components of the assessment, none of these questions is the initial assessment question for this client. 29. The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. "I'll need to become a strict vegetarian." 2. "I should use polyunsaturated oils in my diet." 3. "I need to substitute eggs and whole milk for meat." 4. "I should eliminate all cholesterol and fat from my diet." Answer: 2. "I should use polyunsaturated oils in my diet." Rationale: The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian. 30. A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? 1. "I'm not supposed to eat cold cuts." 2. "I can have most fresh fruits and vegetables." 3. "I'm going to weigh myself daily to be sure I don't gain too much fluid." 4. "I'm going to have a ham and cheese sandwich and potato chips for lunch." Answer: 4. "I'm going to have a ham and cheese sandwich and potato chips for lunch." Rationale: When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium. 31. The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? 1. Age 2. Hypertension 3. Hyperlipidemia 4. Glucose intolerance Answer: 4. Glucose intolerance Rationale: Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors for CAD. Age is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor. 32. The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? 1. "I need to start exercising more to improve my health." 2. "I will be sure to keep my appointment with the cardiologist." 3. "I don't have anyone to help me with doing heavy housework at home." 4. "I think I have a good understanding of what all my medications are for." Answer: 3. "I don't have anyone to help me with doing heavy housework at home." Rationale: To ensure the best outcome, clients should be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital after an MI. All of the options except the correct one indicate that the client will be successful in these areas. 33. The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1. "I will eat enough daily fiber to prevent straining at stool." 2. "I will try to exercise vigorously to strengthen my heart muscle." 3. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels." Answer: 1. "I will eat enough daily fiber to prevent straining at stool." Rationale: Standard home care instructions for a client with this problem include, among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload. 34. A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1. Ambulates 10 feet (3 meters) farther each day 2. Verbalizes the benefits of increasing activity 3. Chooses a healthy diet that meets caloric needs 4. Sleeps without awakening throughout the night Answer: 1. Ambulates 10 feet (3 meters) farther each day Rationale: Each of the options indicates a positive outcome on the part of the client. Both option 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more actionoriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping. 35. The health care provider (HCP) has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? 1. Questions the client about allergies to iodine or shellfish 2. Has the client sign an informed consent form for an invasive procedure 3. Tells the client that the procedure is painless and takes 30 to 60 minutes 4. Keeps the client on nothing by mouth (NPO) status for 2 hours before the procedure Answer: 3. Tells the client that the procedure is painless and takes 30 to 60 minutes Rationale: Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client. 36. A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? 1. Eat breakfast just before the procedure. 2. Wear firm, rigid shoes, such as work boots. 3. Wear loose clothing with a shirt that buttons in front. 4. Avoid cigarettes for 30 minutes before the procedure. Answer: 3. Wear loose clothing with a shirt that buttons in front. Rationale: The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that buttons in the front. The client should receive nothing by mouth after bedtime or for a minimum of 2 hours before the test. The client should wear rubber-soled, supportive shoes, such as athletic training shoes. The client should avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with the potential for a false-positive result. 37. A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? 1. Chest pain 2. Urge to cough 3. Warm, flushed feeling 4. Pressure at the insertion site Answer: 1. Chest pain Rationale: The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site. 38. A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1. Weigh self on a daily basis. 2. Sleep with the head of the bed flat. 3. Take a double dose of the diuretic if peripheral edema is noted. 4. Withhold prescribed digoxin if slight respiratory distress occurs. Answer: 1. Weigh self on a daily basis. Rationale: The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported to the health care provider (HCP). The client should sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the HCP. 39. A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? 1. "It will really hurt when the catheter is first put in." 2. "I will receive general anesthesia for the procedure." 3. "I will have to go to the operating room for this procedure." 4. "I probably will feel tired after the test from lying on a hard x-ray table for a few hours." Answer: 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours." Rationale: It is common for the client to feel fatigued after the cardiac catheterization procedure. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. Other preprocedure teaching points include the fact that the procedure is done in a darkened cardiac catheterization room. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection. 40. A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1. Apnea monitor 2. Oxygen flowmeter 3. Telemetry cardiac monitor 4. Oxygen saturation monitor Answer: 4. Oxygen saturation monitor Rationale: Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea episodes, such as when the client has stopped breathing briefly. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias. 41. The nurse is listening to a lecture about angina. Which statement by the nurse indicates that the teaching has been effective? 1. "Stable angina is chronic." 2. "Variant angina is caused by emotional stress." 3. "Unstable angina is not a life-threatening condition." 4. "Intractable angina rarely limits the client's lifestyle." Answer: 1. "Stable angina is chronic." Rationale: Stable angina is triggered by a predictable amount of effort or emotion and is a chronic condition. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Intractable angina is chronic and incapacitating and is refractory to medical therapy. 43. The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? 1. "I will avoid using table salt with meals." 2. "It is best to exercise once a week for 1 hour." 3. "I will take nitroglycerin whenever chest discomfort begins." 4. "I will use muscle relaxation to cope with stressful situations." Answer: 2."It is best to exercise once a week for 1 hour." Rationale: Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously caused the pain and to take the medication at the first sign of chest discomfort. 45. The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? 1. The client is not experiencing dyspnea. 2. The client is not experiencing nausea or vomiting. 3. The pain has not been relieved by rest and nitroglycerin tablets. 4. The client says the pain began while she was trying to open a stuck dresser drawer. Answer: 3. The pain has not been relieved by rest and nitroglycerin tablets. Rationale: The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief. The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and frequently is accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety). 46. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? 1. Ad lib activities as tolerated 2. Strict bed rest for 24 hours after transfer 3. Bathroom privileges and self-care activities 4. Unsupervised hallway ambulation for distances up to 200 feet (60 meters) Answer: 3. Bathroom privileges and self-care activities Rationale: On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client should ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet (15, 30 and 60 meters). 47. A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy? 1. Tarry stools 2. Nausea and vomiting 3. Orange-colored urine 4. Decreased urine output Answer: 1. Tarry stools Rationale: Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood. 48. The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking? 1. "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 2. "Because most of the damage has already been done, it will be all right to cut down a little at a time." 3. "If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Answer: 4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Rationale: The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. The statements in the remaining options are incorrect. 50. A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1. Left atrium 2. Right atrium 3. Left ventricle 4. Right ventricle Answer: 3. Left ventricle Rationale: Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. The remaining options are not the chambers that are primarily responsible for this disease process, although these chambers may be affected as the disease becomes more chronic. 58. The registered nurse (RN) is orienting a new RN assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction? 1. "A cardiac output of 2 L/min is normal." 2. "A cardiac output of 4 L/min is normal." 3. "A cardiac output of 6 L/min is normal." 4. "A cardiac output of 7 L/min is normal." Answer: 1."A cardiac output of 2 L/min is normal." Rationale: The cardiac cycle consists of contraction and relaxation of the heart muscle. In adults, the cardiac output ranges from 4 to 7 L/min. Therefore, option 1 identifies a low cardiac output. 59. The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1. "Pulse rate will increase." 2. "Blood pressure will decrease." 3. "Edema will be present in the legs." 4. "Crackles in the lungs will be present." Answer: 1."Pulse rate will increase." Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid overload. 60. A client who has been exercising in a gymnasium stops to measure his pulse and places his fingers over both carotid arteries simultaneously. The nurse exercising nearby is correct when cautioning the client to check the pulse on only one side, primarily for which reason? 1. It is unnecessary to use both hands. 2. The client could occlude the trachea. 3. The heart rate and blood pressure could drop. 4. Feeling dual pulsations may lead to an incorrect measurement. Answer: 3.The heart rate and blood pressure could drop. Rationale: Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to drop reflexively. In addition, the manual pressure could interfere with the flow of blood to the brain, causing possible dizziness and syncope. Although the information in the remaining options may be correct, these are not the primary reasons. 61. A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective? 1. "The peripheral arteries and veins; when stimulated they cause vasoconstriction." 2. "Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." 3. "The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." 4. "Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation." Answer: 1."The peripheral arteries and veins; when stimulated they cause vasoconstriction." Rationale: Found in the peripheral arteries and veins, alpha-adrenergic receptors cause a powerful vasoconstriction when stimulated. The remaining options are incorrect statements. 62. The nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin notes that the heart rate is 52 beats/min. The nurse should make which interpretation of this information? 1. Normal, because of the client's age 2. Abnormal, requiring further assessment 3. Normal, as a result of the effects of digoxin 4. Normal, because this is the reason the client is receiving digoxin Answer: 2. Abnormal, requiring further assessment Rationale: The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would report the finding to the health care provider for further instruction. The remaining options are incorrect interpretations because the heart rate of 52 beats/min is not normal. 63. The client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. The nurse provides education to the client about increased cardiac response based on which physiological concept? 1. Pulse rate is not a reflection of cardiac response. 2. Cardiac index is the mechanism that allows blood to flow better. 3. Cardiac output is the body's attempt to meet metabolic demands. 4. Stroke volume is an artificial number used to determine the adequacy of cardiac output. Answer: 3. Cardiac output is the body's attempt to meet metabolic demands. Rationale: The client's symptoms are the direct result of the body's attempt to meet the metabolic demands generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital organs of the body. With exercise, these demands increase, and the heart must beat faster (increased heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting the cardiac output for body surface area. 64. The nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The health care provider (HCP) tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the blockage is located in which area? Rationale: The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and a few other structures. The circumflex coronary artery bifurcates from the left coronary artery and supplies the left atrium and the lateral wall of the left ventricle. The RCA supplies the right side of the heart, including the right atrium and right ventricle. The PDA supplies the posterior wall of the heart. 1. Circumflex coronary artery 2. Right coronary artery (RCA) 3. Posterior descending coronary artery (PDA) 4. Left anterior descending coronary artery (LAD) Answer: 4. Left anterior descending coronary artery (LAD) Rationale: The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and a few other structures. The circumflex coronary artery bifurcates from the left coronary artery and supplies the left atrium and the lateral wall of the left ventricle. The RCA supplies the right side of the heart, including the right atrium and right ventricle. The PDA supplies the posterior wall of the heart. 65. A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? 1. Increased heart rate and increased blood pressure 2. Increased heart rate and decreased blood pressure 3. Decreased heart rate and increased blood pressure 4. Decreased heart rate and decreased blood pressure Answer: 4.Decreased heart rate and decreased blood pressure Rationale: Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect. 66. A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept? 1. Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. 2. Vagus nerve stimulation causes an increase in heart rate and cardiac contractility. 3. Sympathetic nerve stimulation causes a decrease in heart rate and cardiac contractility. 4. Sympathetic nerve stimulation causes an increase in heart rate and cardiac contractility. Answer: 1. Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. Rationale: Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic nervous system has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis. 68. Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? 1. Chloride level of 98 mEq/L (98 mmol/L) 2. Sodium level of 135 mEq/L (135 mmol/L) 3. Potassium level of 6.8 mEq/L 6.8 mmol/L) 4. Magnesium level of 1.6 mEq/L (0.8 mmol/L) Answer: 3. Potassium level of 6.8 mEq/L 6.8 mmol/L) Rationale: Hyperkalemia can cause tall, peaked, or tented T waves on the ECG. Levels of potassium 5.0 mEq/L (5.0 mmol/L) or greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels. 71. The nurse is concerned about the adequacy of peripheral tissue perfusion in the post–cardiac surgery client. Which action should the nurse include within the plan of care for this client? 1. Use the knee gatch on the bed. 2. Cover the legs lightly when sitting in a chair. 3. Encourage the client to cross the legs when sitting in a chair. 4. Provide pillows for the client to place under the knees as desired. Answer: 2.Cover the legs lightly when sitting in a chair. Rationale: Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels. The nurse plans postoperative measures to prevent venous stasis. These include applying elastic stockings or leg wraps, use of pneumatic compression boots, and discouraging crossing of the legs. Clients should be encouraged to perform passive and active range-of-motion exercises. The knee gatch on the bed and pillows under the knees should be avoided because they place pressure on the blood vessels in the popliteal area, impeding venous return. 73. The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse should report the cardiac rhythm to be which rhythm? 1. Sinus bradycardia 2. Sick sinus syndrome 3. Normal sinus rhythm 4. First-degree heart block Answer: 3. Normal sinus rhythm Rationale: Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively. 75. The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? 1. "Ventricular fibrillation appears as irregular beats within a rhythm." 2. "Ventricular fibrillation does not have P waves or QRS complexes." 3. "Ventricular fibrillation is a regular pattern of wide QRS complexes." 4. "Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves." Answer: 2. "Ventricular fibrillation does not have P waves or QRS complexes." Rationale: Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Premature ventricular contractions (PVCs) appear as irregular beats within a rhythm. Ventricular tachycardia is a regular pattern of wide QRS complexes. Sinus tachycardia has a recognizable P wave, QRS complex, and T wave. Each of the incorrect options has a recognizable complex that appears on the monitoring screen. 76. A client with myocardial infarction is experiencing new, multiform premature ventricular contractions and short runs of ventricular tachycardia. The nurse plans to have which medication available for immediate use to treat the ventricular tachycardia? 1. Digoxin 2. Verapamil 3. Acebutolol 4. Amiodarone Answer: 4.Amiodarone Rationale: Amiodarone is an antidysrhythmic that may be used to treat ventricular dysrhythmias. {Xylocaine can also be used to treat ventricular dysrhythmias}. Digoxin is a cardiac glycoside; verapamil is a calcium channel–blocking agent; acebutolol is a betaadrenergic blocking agent. Digoxin can be used to treat supraventricular dysrhythmias, but is inactive against ventricular dysrhythmias. {Digoxin is also used to treat Atrial Fibrillation}. Verapamil is used to slow the ventricular rate for a client with atrial fibrillation or atrial flutter, or to terminate supraventricular tachycardia. Acebutolol is a beta blocker used to treat dysrhythmias. 77. A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if which finding is noted with regard to the PVCs? 1. They occur in pairs. 2. They appear to be multifocal. 3. They fall on the second half of the T wave. 4. They decrease to a frequency of less than 6 per minute. Answer: 4. They decrease to a frequency of less than 6 per minute. Rationale: PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client's cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly dysrhythmias. 78. The nurse is assessing the client's condition after cardioversion. Which observation should be of highest priority to the nurse? Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority, 1. Heart rate 2. Skin color 3. Status of airway 4. Peripheral pulse strength Answer: 3.Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority, 81. A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? 1. Bilateral edema 2. Increased calf circumference 3. Diminished distal peripheral pulses 4. Coolness and pallor of the affected limb Answer: 2. Increased calf circumference Rationale: The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication. 82. The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's (HCP's) prescriptions? Select all that apply. 1. Elevation of the right leg 2. Administration of acetaminophen 3. Application of moist heat to the right leg 4. Monitoring for signs of pulmonary embolism 5. Ambulation in around the nursing unit every hour Answers: 1. Elevation of the right leg 2. Administration of acetaminophen 3. Application of moist heat to the right leg 4. Monitoring for signs of pulmonary embolism Rationale: Standard management of the client with deep vein thrombosis includes possible bed rest for 5 to 7 days or as prescribed; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Although the health care provider may allow ambulation, hourly ambulation around the nursing unit is not encouraged because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism. 83. A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying measures to help the client cope with lifestyle changes needed to control the disease process. The nurse plans to refer the client to which member of the health care team? 1. Dietitian 2. Medical social worker 3. Pain management clinic 4. Smoking cessation program Answer: 4. Smoking cessation program Rationale: Buerger's disease is a vascular occlusive disease that affects the medium and small arteries and veins. Smoking is highly detrimental to the client with Buerger's disease, so stopping smoking completely is recommended. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients with Buerger's disease, symptoms are relieved or alleviated once smoking stops. A dietitian, a medical social worker, and a pain management clinic are not specifically associated with the lifestyle changes required in this disorder, although they may be needed if secondary problems arise. 85. The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. 1. Soak the feet in hot water daily. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Answers: 2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity are contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further. 87. A client who had coronary artery bypass surgery states to the home health nurse, "I get so frustrated. I can't even do my gardening." The nurse then assesses the client for activity level since the surgery. Which client statement indicates a need for further teaching? 1. "I pace my activities throughout the day." 2. "I plan regular rest periods during the day." 3. "I avoid outdoor physical activity during the heat of the day." 4. "I try to walk immediately after lunch, after I've finished my morning house cleaning." Answer: 4."I try to walk immediately after lunch, after I've finished my morning house cleaning." Rationale: Exercise is an integral part of the rehabilitation program. It is necessary for optimal physiological functioning and psychological well-being. Postoperative physical rehabilitation must be progressive, with planned periods of rest. Exercise tolerance is judged by the client's response, such as heart rate and endurance. Planning regular rest periods, pacing activities, and avoiding outdoor activities during the heat of the day are appropriate client activities. The correct option lacks planned periods of rest, and the client has grouped too many activities in a brief period of time, which will decrease endurance. Also, exercise after meals can decrease the client's tolerance because of shunting of blood to the gastrointestinal tract for digestion. 88. The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How should the nurse interpret this rhythm? 1. Bradycardia 2. Tachycardia 3. Atrial fibrillation 4. Normal sinus rhythm (NSR) Answer: 3. Atrial fibrillation Rationale: In atrial fibrillation, the P waves are absent and replaced by fibrillatory waves. There is no PR interval, and the QRS duration usually is normal and constant and the rhythm is irregular. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second, and the QRS interval is 0.06 to 0.10 second. 89. The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving intravenous doses of furosemide. The client is attached to cardiac telemetry, and the nurse is monitoring the client's cardiac status. The nurse notes that the client's cardiac rhythm has changed to this pattern. The nurse determines that the most likely cause of this cardiac rhythm in the client is which problem? Refer to Figure. View Figure 1. Pacemaker dysfunction 2. The presence of hypokalemia 3. The effectiveness of the furosemide 4. An impending myocardial infarction (MI) Answer: 2.The presence of hypokalemia Rationale: This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs). PVCs may be insignificant, or they may occur with myocardial ischemia or MI; heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, a diuretic that causes the excretion of potassium. The most likely cause of the PVCs in this client is hypokalemia. Option 3 is an incorrect interpretation. The question presents no data indicating that this client has a pacemaker or has signs or symptoms of an impending MI. 90. A client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on the monitor. The nurse quickly assesses the client, knowing that this rhythm is indicative of which rhythm? Refer to Figure. View Figure 1. Atrial fibrillation 2. Ventricular fibrillation (VF) 3. Ventricular tachycardia (VT) 4. Premature ventricular complexes Answer: 3.Ventricular tachycardia (VT) Rationale: In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. 91. The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? 1. 1+ edema 2. 2+ edema 3. 3+ edema 4. 4+ edema Answer: 1. 1+ edema Rationale: Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen. 94. A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1. Limiting oral and intravenous fluids 2. Measuring the client's pulse each shift 3. Providing the client with short, frequent walks 4. Eliminating sources of caffeine from meal trays Answer: 4. Eliminating sources of caffeine from meal trays Rationale: Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Measuring the pulse each shift will not decrease the heart rate. In addition, the pulse should be taken more frequently than each shift. 95. A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. Which finding indicates that further preparation is needed for the procedure? 1. The client's digoxin has been withheld for the last 48 hours. 2. The client is wearing a nasal cannula delivering oxygen at 2 L/min. 3. The defibrillator has the synchronizer turned on and is set at 120 joules (J). 4. The client has received an intravenous dose of a conscious sedation medication. Answer: 2.The client is wearing a nasal cannula delivering oxygen at 2 L/min. Rationale: During the procedure, any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing. Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after the countershock. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level typically is set at 120 to 200 J for a biphasic machine. The client typically receives a dose of an intravenous sedative or antianxiety agent. 96. The nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which starting energy range level, depending on the specific health care provider (HCP) prescription? 1. 120 joules 2. 200 joules 3. 250 joules 4. 350 joules Answer: 1. 120 joules Rationale: For cardioversion procedures, the defibrillator is charged to the energy level prescribed by the HCP. Countershock usually is started at 120 to 200 joules. The number of joules in the remaining options are incorrect. 97. A client