Cardio Exam 2(52
The nurse has entered a client's room and found the client unresponsive and not breathing.
What is the nurse's next appropriate action?
Palpate the client's carotid pulse.
Illuminate the client's call light.
Begin performing chest compressions.
Activate the Emergency Response System (ERS). - ANSWERSCorrect response:
Activate the Emergency Response System (ERS).
Explanation:
After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment
of carotid pulse should follow and chest compressions may be indicated. Illuminating the call
light is an insufficient response.
A client with aortic valve regurgitation is asking about the disease process. What would the
nurse tell the client is the first sign of aortic valve regurgitation?
Tachycardia
Left-sided heart failure
Pain
Dysrhythmias - ANSWERSCorrect response:
Tachycardia
Explanation:
Tachycardia is one of the first signs of cardiac compensation. When valve damage affects the left
ventricle, the client becomes aware of forceful heart contractions (palpitations). At first,
palpitations occur only when lying flat or on the left side. Aortic valve regurgitation does not
produce left-sided heart failure, pain, or dysrhythmias as the first symptom of disease.
,The nurse visits the home of a client with heart failure. Which assessment finding indicates to
the nurse that the client's tolerance to activity is deteriorating?
Weight loss of 0.5 kg (1.1 lbs.)
Bilateral lower extremity edema +1
Needs to use a scooter for shopping
Fatigue after walking to answer the door - ANSWERSCorrect response:
Fatigue after walking to answer the door
Explanation:
The client's response to activity needs to be monitored. If the client is at home, the degree of
fatigue felt after the activity can be used to assess the response. Weight loss is not used to
assess activity tolerance but would be helpful to determine the response to medication therapy.
Lower extremity edema is not used to assess activity tolerance but would be helpful to
determine the response to medication therapy. Tolerance to exercise would be assessed by
monitoring heart rate, which should return to baseline within 3 minutes after the activity. Since
the client's heart rate returned to baseline in 2 minutes, the activity is being tolerated. Use of a
motorized scooter for shopping would not be the best indicator of exercise and/or activity
tolerance.
Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously
increased. The nurse should collaborate with the other members of the care team to prevent
the development of which complication?
Pulmonary edema
Pericardiocentesis
Cardiac tamponade
Pericarditis - ANSWERSCorrect response:
Cardiac tamponade
Explanation:
An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the
heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this
,complication. Pericarditis and pulmonary edema do not result from this pathophysiologic
process.
Which of the following does the nurse recognize as the therapeutic goal of radiofrequency
catheter ablation for a client with cardiac arrhythmias?
Reperfusion of ischemic heart tissue
Dilation of arterial blood vessels
Destruction of errant tissue
Stimulation of the impulse center - ANSWERSCorrect response:
Destruction of errant tissue
Explanation:
The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue, in hopes of
allowing impulse conduction to travel over appropriate pathways. The goal does not include
dilation of blood vessels or reperfusion of heart tissue. There is no stimulation of the heart.
The nurse is providing care to a client who has just undergone an electrophysiologic (EP) study.
The client reports being nervous about "things going wrong" during the procedure. What is the
nurse's best response?
"This is basically a risk-free procedure."
"Thousands of clients undergo EP every year."
"Remember that this is a step that will bring you closer to enjoying good health."
"The whole team will be monitoring you very closely for the entire procedure." -
ANSWERSCorrect response:
"The whole team will be monitoring you very closely for the entire procedure."
Explanation:
Clients who are to undergo an EP study may be anxious about the procedure and its outcome. A
detailed discussion involving the client, the family, and the electrophysiologist usually occurs to
, ensure that the client can give informed consent and to reduce the client's anxiety about the
procedure. It is inaccurate to state that EP is "risk-free" and stating that it is common does not
necessarily relieve the client's anxiety. Characterizing EP as a step toward good health does not
directly address the client's anxiety.
The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the
emergency room. What is the most important cardiac marker for the client?
creatine kinase
lactate dehydrogenase
myoglobin
troponin - ANSWERSCorrect response:
troponin
Explanation:
This client exhibits signs of myocardial infarction (MI), and the most accurate serum
determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin
tests can show evidence of muscle injury, but the studies are less specific indicators of
myocardial damage than troponin.
A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of
postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level
would alert the nurse to notify the health care provider?
2.6
3.0
3.4
3.8 - ANSWERSCorrect response:
3.8
Explanation:
The nurse has entered a client's room and found the client unresponsive and not breathing.
What is the nurse's next appropriate action?
Palpate the client's carotid pulse.
Illuminate the client's call light.
Begin performing chest compressions.
Activate the Emergency Response System (ERS). - ANSWERSCorrect response:
Activate the Emergency Response System (ERS).
Explanation:
After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment
of carotid pulse should follow and chest compressions may be indicated. Illuminating the call
light is an insufficient response.
A client with aortic valve regurgitation is asking about the disease process. What would the
nurse tell the client is the first sign of aortic valve regurgitation?
Tachycardia
Left-sided heart failure
Pain
Dysrhythmias - ANSWERSCorrect response:
Tachycardia
Explanation:
Tachycardia is one of the first signs of cardiac compensation. When valve damage affects the left
ventricle, the client becomes aware of forceful heart contractions (palpitations). At first,
palpitations occur only when lying flat or on the left side. Aortic valve regurgitation does not
produce left-sided heart failure, pain, or dysrhythmias as the first symptom of disease.
,The nurse visits the home of a client with heart failure. Which assessment finding indicates to
the nurse that the client's tolerance to activity is deteriorating?
Weight loss of 0.5 kg (1.1 lbs.)
Bilateral lower extremity edema +1
Needs to use a scooter for shopping
Fatigue after walking to answer the door - ANSWERSCorrect response:
Fatigue after walking to answer the door
Explanation:
The client's response to activity needs to be monitored. If the client is at home, the degree of
fatigue felt after the activity can be used to assess the response. Weight loss is not used to
assess activity tolerance but would be helpful to determine the response to medication therapy.
Lower extremity edema is not used to assess activity tolerance but would be helpful to
determine the response to medication therapy. Tolerance to exercise would be assessed by
monitoring heart rate, which should return to baseline within 3 minutes after the activity. Since
the client's heart rate returned to baseline in 2 minutes, the activity is being tolerated. Use of a
motorized scooter for shopping would not be the best indicator of exercise and/or activity
tolerance.
Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously
increased. The nurse should collaborate with the other members of the care team to prevent
the development of which complication?
Pulmonary edema
Pericardiocentesis
Cardiac tamponade
Pericarditis - ANSWERSCorrect response:
Cardiac tamponade
Explanation:
An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the
heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this
,complication. Pericarditis and pulmonary edema do not result from this pathophysiologic
process.
Which of the following does the nurse recognize as the therapeutic goal of radiofrequency
catheter ablation for a client with cardiac arrhythmias?
Reperfusion of ischemic heart tissue
Dilation of arterial blood vessels
Destruction of errant tissue
Stimulation of the impulse center - ANSWERSCorrect response:
Destruction of errant tissue
Explanation:
The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue, in hopes of
allowing impulse conduction to travel over appropriate pathways. The goal does not include
dilation of blood vessels or reperfusion of heart tissue. There is no stimulation of the heart.
The nurse is providing care to a client who has just undergone an electrophysiologic (EP) study.
The client reports being nervous about "things going wrong" during the procedure. What is the
nurse's best response?
"This is basically a risk-free procedure."
"Thousands of clients undergo EP every year."
"Remember that this is a step that will bring you closer to enjoying good health."
"The whole team will be monitoring you very closely for the entire procedure." -
ANSWERSCorrect response:
"The whole team will be monitoring you very closely for the entire procedure."
Explanation:
Clients who are to undergo an EP study may be anxious about the procedure and its outcome. A
detailed discussion involving the client, the family, and the electrophysiologist usually occurs to
, ensure that the client can give informed consent and to reduce the client's anxiety about the
procedure. It is inaccurate to state that EP is "risk-free" and stating that it is common does not
necessarily relieve the client's anxiety. Characterizing EP as a step toward good health does not
directly address the client's anxiety.
The nurse is assessing a client with severe angina pectoris and electrocardiogram changes in the
emergency room. What is the most important cardiac marker for the client?
creatine kinase
lactate dehydrogenase
myoglobin
troponin - ANSWERSCorrect response:
troponin
Explanation:
This client exhibits signs of myocardial infarction (MI), and the most accurate serum
determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase, and myoglobin
tests can show evidence of muscle injury, but the studies are less specific indicators of
myocardial damage than troponin.
A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of
postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level
would alert the nurse to notify the health care provider?
2.6
3.0
3.4
3.8 - ANSWERSCorrect response:
3.8
Explanation:
