ATI Targeted Medical-Surgical 2019: Cardiovascular
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?
A. "My arthritis is really bothering me because I haven't taken my aspiring in a week."
b. "My blood pressure shouldn't be high because I took my BP medication this morning."
c. "I took my warfarin last night according to my usually schedule."
d. "I will check my BP because I took a reduced dose of insulin this morning." C: "I took my warfarin last night according to my usually schedule."
Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.
A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?
A. Administering IV morphine sulfate
B. Administering oxygen at 2:/min via nasal cannula
C. Helping the client to the bedside commode
D. Assisting with thrombolytic therapy D. Assisting with thrombolytic therapy
Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?
A. Hemoglobin 14.4 g/dl
b. History of peripheral arterial disease. c. Urine output 200 ml/4 hr.
D. Previous allergic reaction to shellfish D. Previous allergic reaction to shellfish
Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.
A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?
A. Obtain clients current weight
B. Review serum electrolyte values
C. Determine the time of the last digoxin dose
D. Check the clients urine output) B. Review serum electrolyte values
Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
A. "I can't get rid of these hiccups."
b. "I feel dizzy when I stand."
c. "My incision site stings."
d. "I have a headache." A. "I can't get rid of these hiccups."
Rationale:
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
A. Ventricular depolarization
B. Guillain-Barre syndrome
C. Myelodysplastic syndrome
D. Valvular disease D. Valvular disease
Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is caring for a client who is being treated for HF and has prescriptions for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication?
A. SOB
b. Lightheadedness
c. Dry cough
d. Metallic taste b. Lightheadedness
Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find?
A. Inc abdominal girth
b. Weak peripheral pulses
c. Jugular vein distention
d. Dependent edema b. Weak peripheral pulses
Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-
sided heart failure.
A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect?
A. Confusion
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?
A. "My arthritis is really bothering me because I haven't taken my aspiring in a week."
b. "My blood pressure shouldn't be high because I took my BP medication this morning."
c. "I took my warfarin last night according to my usually schedule."
d. "I will check my BP because I took a reduced dose of insulin this morning." C: "I took my warfarin last night according to my usually schedule."
Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.
A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?
A. Administering IV morphine sulfate
B. Administering oxygen at 2:/min via nasal cannula
C. Helping the client to the bedside commode
D. Assisting with thrombolytic therapy D. Assisting with thrombolytic therapy
Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?
A. Hemoglobin 14.4 g/dl
b. History of peripheral arterial disease. c. Urine output 200 ml/4 hr.
D. Previous allergic reaction to shellfish D. Previous allergic reaction to shellfish
Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.
A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?
A. Obtain clients current weight
B. Review serum electrolyte values
C. Determine the time of the last digoxin dose
D. Check the clients urine output) B. Review serum electrolyte values
Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
A. "I can't get rid of these hiccups."
b. "I feel dizzy when I stand."
c. "My incision site stings."
d. "I have a headache." A. "I can't get rid of these hiccups."
Rationale:
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
A. Ventricular depolarization
B. Guillain-Barre syndrome
C. Myelodysplastic syndrome
D. Valvular disease D. Valvular disease
Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
A nurse is caring for a client who is being treated for HF and has prescriptions for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication?
A. SOB
b. Lightheadedness
c. Dry cough
d. Metallic taste b. Lightheadedness
Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.
A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find?
A. Inc abdominal girth
b. Weak peripheral pulses
c. Jugular vein distention
d. Dependent edema b. Weak peripheral pulses
Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-
sided heart failure.
A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect?
A. Confusion
