The Client with Acute Coronary Syndromes
68. The stethoscope is placed at the second inter- costal space right of sternum (1) to assess the aortic
area. (2) is the pulmonic valve area, (3) is Erb’s point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.
CN: Physiological adaptation; CL: Apply
1
Midsternum
Midclavicular line 2
3 4
5
read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.
CN: Reduction of risk potential;
CL: Apply
62.
2, 3, 4. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake, yellow cake, and peppers are listed by the National Kidney Foundation as low in potassium.CN: Pharmacological and parenteral therapies; CL: Apply
63.
2. A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fi fth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fi fth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.CN: Physiological adaptation;
CL: Analyze
64.
1. The ankle edema suggests fl uid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.CN: Physiological adaptation;
CL: Synthesize
65.
3. Heart failure is a complex and chronic condition. Education should focus on health promo- tion and preventive care in the home environment.Signs and symptoms can be monitored by the client.
Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 lb or more. This may indicate fl uid overload, and treatment can be prescribed early and on an outpatient basis, rather than wait- ing until the symptoms become life-threatening.
Following a high-fi ber diet is benefi cial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles every day, would not be appropriate at discharge. The client’s exercise program would need to be planned in consultation with the physician and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not pre- scribe an exercise program for the client, a sedentary lifestyle should not be recommended.
CN: Reduction of risk potential;
CL: Create
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necessary to prevent hemorrhage or thromboembo- lism. Some clients are maintained on lifelong antibi- otic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modifi cation, activity restrictions, and dental care are important; however, they do not have as much signifi cance postoperatively as medi- cation therapy does.
CN: Reduction of risk potential;
CL: Evaluate
75.
4. Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed.Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some envi- ronmental factors that affect recovery from valve replaceent surgery.
CN: Reduction of risk potential;
CL: Synthesize
76.
2, 3, 4. The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR & PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and sever- ity of bleeding, therefore availability of blood prod- ucts should be confi rmed by calling the blood bank.Close monitoring of blood loss from the mediastinal chest tubes should be done. Coumadin is an antico- agulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechani- cal heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done fi rst. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.
CN: Physiological adaptation;
CL: Synthesize
77.
1. Many factors help prevent wound infec- tions, including washing hands carefully, using sterile prepackaged supplies and equipment, clean- ing the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in prevent- ing wound infections is to wash the hands care- fully before and after changing dressings. Careful hand washing is also important in reducing other69.
2, 3, 4. For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are with- held unless specifi cally ordered. A urinary drainage catheter is rarely required for this procedure.CN: Reduction of risk potential;
CL: Apply
70.
3. Assessment of circulatory status, includ- ing observation of the puncture site, is of primary importance after a cardiac catheterization. Labora- tory values and skin warmth and turgor are impor- tant to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.CN: Reduction of risk potential;
CL: Analyze
71.
3. Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis.Chickenpox, poliomyelitis, and meningitis are not associated with mitral stenosis.
CN: Physiological adaptation;
CL: Analyze
72.
2. Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremi- ties, excessive perspiration, hypotension, seizures, and fi nally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.CN: Pharmacological and parenteral therapies; CL: Analyze
73.
2. The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is per- formed if the client experiences chest pain. A reduc- tion in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.CN: Physiological adaptation;
CL: Synthesize
74.
1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprostheses are maintained indefi nitely on anticoagulant therapy. Adhering strictly to a dos- age schedule and observing specifi c precautions areBillings_Part 2_Chap 3_Test 01.indd 340
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82.
1. Verbalized concerns from this client may stem from her anxiety over the changes her body has gone through after open heart surgery.Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the changes in her body image. The client is not concerned about altered tissue perfusion.
CN: Psychosocial adaptation;
CL: Analyze
The Client with Hypertension
83.
1. The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at fi rst may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output.CN: Pharmacologicl and parenteral therapies; CL: Evaluate
84.
1, 3, 5. Clonidine (Catapres) is a central- acting adrenergic antagonist. It reduces sympa- thetic outfl ow from the central nervous system. Dry mouth, impotence, and sleep disturbances are pos- sible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.CN: Pharmacological and parenteral therapies; CL: Apply
85.
200 mcgFirst, calculate the number of milligrams per milliliter:
50 mg 1 mg 0.2 mg = = 250 mL 5 mL 1 mL
Next, calculate the number of micrograms in each milligram:
0.2 mg × 1,000 mcg = 200 mcg.
CN: Pharmacological and parenteral therapies; CL: Apply
86.
2, 3. Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.CN: Reduction of risk potential;
CL: Create infections often acquired in hospitals, such as
urinary tract and respiratory tract infections.
CN: Reduction of risk potential;
CL: Synthesize
78.
1. In an immobilized client, calcium leaves the bone and concentrates in the extracellular fl uid.When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi.
Nursing interventions that help prevent calculi include ensuring a liberal fl uid intake (unless con- traindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solu- bility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limit- ing foods rich in calcium, such as dairy products, will help in preventing renal calculi.
CN: Physiological adaptation;
CL: Synthesize
79.
3. INR is the value used to assess effective- ness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial throm- boplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium’s anticoagulant effect, whereas protamine sulfate reverses the effects of hepa- rin. Warfarin sodium will help to prevent blood clots.CN: Pharmacological and parenteral therapies; CL: Apply
80.
1. Daily dental care and frequent checkups by a dentist who is informed about the client’s condition are required to maintain good oral health.Use of an electric toothbrush, an irrigation device, or dental fl oss may cause gums to bleed and allow bacteria to enter mucous membranes and the blood- stream, increasing the risk of endocarditis.
CN: Reduction of risk potential;
CL: Create
81.
2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoid- ing heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Shower- ing or bathing is allowed as long as the incision is well approximated with no open areas or drainage.Activities should be gradually resumed on discharge.
CN: Safety and infection control;
CL: Evaluate
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93.
1. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vaso- dilation, or block conversion of angiotensin I to angiotensin II.CN: Pharmacological and parenteral therapies; CL: Apply
94.
3. Compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hyper- tension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the prior- ity goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Los- ing weight may be necessary and will contribute to lower blood pressure, but the client must fi rst accept the need for a lifelong management plan to control the hypertension.CN: Psychosocial adaptation;
CL: Synthesize
95.
1. Renal disease, including renal insuffi - ciency and failure, is a complication of hyperten- sion. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not com- plications of hypertension.CN: Reduction of risk potential;
CL: Synthesize
96.
1. Hypertension is referred to as the silent killer for adults, because until the adult has signifi - cant damage to other systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infarction is generally related to coronary artery disease.CN: Reduction of risk potential;
CL: Create
97.
2. The client may be asymptomatic and the underlying cause should be assessed. Drugs that block the AV node should be avoided, such as beta blockers (Atenolol), calcium channel blockers, digoxin, and amiodarone. Symptomatic clients are treated with atropine and transcutaneous pacing.There is no indication for a fl uid bolus, cardiover- sion, or arterial line.
CN: Pharmacological and parenteral therapies; CL: Synthesize
87.
1. Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a physician’s order.Blood pressure needs to be monitored more fre- quently than annually in a client who is newly diag- nosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.
CN: Pharmacological and parenteral therapies; CL: Synthesize
88.
3. Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-cal- orie, low-fat, low-salt diet. Dietary restrictions of all types are complex and diffi cult to implement with clients who are basically asymptomatic.CN: Basic care and comfort; CL: Apply
89.
4. Possible dizziness from orthostatic hypotension when rising from a crouched or bent position increases the client’s risk of being injured by the equipment. The nurse should assess the cli- ent’s blood pressure in all three positions (lying, sitting, and standing) at all routine visits. The client may experience muscle aches, or thirst from work- ing in a warm, dry room, but these are not as poten- tially dangerous as orthostatic hypotension. The client should not be experiencing lethargy.CN: Reduction of risk potential;
CL: Analyze
90.
4. Tailoring or individualizing a program to the client’s lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client’s spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.CN: Psychosocial adaptation;
CL: Synthesize
91.
3. A plan to reduce or stop smoking begins with establishing the client’s personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.CN: Psychosocial adaptation;
CL: Synthesize
92.
3. American Heart Association standards defi ne hypertension as a consistent systolic blood pressure level greater than 140 mm Hg and a consistent dia- stolic blood pressure level greater than 90 mm Hg.CN: Reduction of risk potential;
CL: Analyze
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The Client Requiring
Cardiopulmonary Resuscitation
102.
3. Transcutaneous pads should be placed on the client with third degree heart block. For a client who is symptomatic, transcutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defi brillation is performed for ven- tricular fi brillation or ventricular tachycardia with no pulse.CN: Management of care; CL: Synthesize
103.
3. The presence of a pulse determines the treatment for ventricular tachycardia. It is also important to assess the client’s heart rate and level of consciousness. Cardioversion may be used to treat hemodynamically unstable tachycardias. Assess- ment of instability is required before cardioversion.It is not appropriate to begin CPR unless the pulse is absent. Defi brillation is used to treat ventricular fi brillation or pulseless ventricular tachycardia.
CN: Physiological adaptation;
CL: Synthesize
104.
1, 3, 4. A conducting agent is placed between the skin and the paddles to conduct the electrical current when discharged. The nurse must make sure to call “clear” before discharging the electrical cur- rent to prevent injury to others who may be helping with the client. Each paddle is placed directly on the conductive pads that are on the client’s skin.Applying approximately 20 to 25 lb of pressure on each paddle is recommended to ensure good skin contact. The nurse must record the amount of elec- trical current delivered and the resulting rhythm.
CN: Reduction of risk potential;
CL: Synthesize
105.
2. Pupillary reaction is the best indication of whether oxygenated blood has been reaching the client’s brain. Pupils that remain widely dilated and do not react to light probably indicate that serious brain damage has occurred. The pulse rate may be normal, mucous membranes may still be pink, and systolic blood pressure may be 80 mm Hg or higher, and serious brain damage may still have occurred.CN: Reduction of risk potential;
CL: Evaluate
106.
3. Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fi brillation, and atrial fl utter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.CN: Pharmacological and parenteral therapies; CL: Evaluate
The Client with a Permanent Pacemaker
98.
1, 5. The nurse must teach the client how to take and record his pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to heal and full range of motion to return. The client should avoid heavy lifting until approved by the physician.The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions.
Prolonged immobilization is not required. Micro- wave ovens are safe to use and do not alter pace- maker function.
CN: Reduction of risk potential;
CL: Create
99.
1. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defi brillation and a lidocaine infusion are not indicated for the treatment of third- degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pace- maker can be inserted.CN: Physiological adaptation;
CL: Synthesize
100.
2. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artifi cial pacemaker implantation. The client should have continuous electrocardiographic monitor- ing until proper pacemaker functioning is verifi ed.Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the fi rst 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours.
CN: Reduction of risk potential;
CL: Synthesize
101.
3. Education is a major component of the dis- charge plan for a client with an artifi cial pacemaker.The client with a permanent pacemaker needs to be able to state specifi c information about safety pre- cautions, such as to refrain from lifting more than 3 lb or stretching and bending and to count the pulse once per week, that are necessary to maintain proper pacemaker function. The client will not necessar- ily be placed on a low cholesterol diet. The client should resume activities as he is able, and does not need to remain on bed rest. The client should know signs and symptoms of MI, but is not at risk because of the pacemaker.
CN: Basic care and comfort; CL: Evaluate
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