Question 1

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?

Accepted Answer

Urine output of less than 30 mL/hr may indicate low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Given this client's heart failure, low urine output is likely due to decreased cardiac function and buildup of fluid in the lungs. The nurse should assess the lung sounds for crackles and report to the HCP, who can prescribe loop diuretics. (Option B) The client with heart failure is at risk for fluid overload. Fluids should not be encouraged before consulting with the HCP to determine the cause of decreased urine output. If this client had dehydration, fluids would be encouraged. (Options C and D) Always assess the client first, and then report to the HCP. A diuretic may be prescribed by the HCP if crackles and dyspnea are present. Educational objective: Decreased urine output of <30 mL/hr could be due to low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Always assess the client first, and then report to the HCP.

Question 2

A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting. The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse?

Accepted Answer

11ecbb05_c94e_6026_b433_ad04f3a73010_MD0009_00 MIDCAB does not involve a sternotomy incision or placement on cardiopulmonary bypass. Several small incisions are made between the ribs. A thoracotomy scope or robot is used to dissect the internal mammary artery (IMA) that is used as a bypass graft. Radial artery or saphenous veins may be used if the IMA is not available. Recovery time is typically shorter with these procedures and clients are able to resume activities sooner than with traditional open chest coronary artery bypass graft surgery. However, clients may report higher levels of pain with MIDCAB due to the thoracotomy incisions made between the ribs. (Option A) The client may need pain medication, but this response does not answer the initial question. The nurse should first answer the client's question, then assess if pain medication is necessary. (Option B) Before calling the HCP for an increase in dosage, the nurse should assess the client's pain level and if pain medication has been effective. However, this should be done after answering the client's question. (Option C) The client needs to move, cough, breathe deeply, splint the chest, and use the incentive spirometer. However, the client is asking the nurse a question that should be addressed before reinforcing these teachings. Educational objective: The nurse should teach the client that incisional pain from thoracotomy incisions between the ribs may be very painful after MIDCAB surgery. The nurse should encourage the client to take pain medication before the pain is too intense. The client should also be instructed to cough, breathe deeply while splinting the chest with a pillow, and use the incentive spirometer routinely to reduce the incidence of postop complications.

Question 3

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit.  Which assessment technique by the new nurse requires intervention by the RN?

Accepted Answer

The pulses in the neck should be palpated for information on arterial blood flow. The carotid arteries should be palpated separately to avoid vagal stimulation causing dysrhythmias such as bradycardia or a syncopal episode. Pulse symmetry for other key arteries (eg, temporal, brachial, radial, posterior tibial) is assessed by bilaterally palpating each pair simultaneously. (Option A) Erb's point is located at the third left intercostal space (ICS) near the sternum and is an appropriate location to auscultate heart sounds for murmurs. (Option C) Jugular venous distension should be assessed with the client in semi-Fowler's position (ie, head of the bed elevated at a 30- to 45-degree angle). (Option D) To assess the point of maximal impulse (PMI) the client is positioned supine or with the head of the bed elevated to 45 degrees; the nurse should palpate for a short tap at the midclavicular line of the fourth or fifth ICS (pulsation may or may not be visible). A displaced PMI (eg, below the fifth ICS) may be an indication of an enlarged heart. Educational objective: The nurse should not palpate the carotid arteries simultaneously due to possible vagal stimulation resulting in bradycardia or syncope. Each carotid artery should be palpated separately.

Question 4

A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority?

Accepted Answer

11ecbb05_c950_5bf7_b433_21501ea43d30_MD0009_00 This client with a tender calf that feels warm to the touch is exhibiting signs and symptoms of a possible deep vein thrombosis (DVT). Additionally, the client has several risk factors for DVT (age >60, being hospitalized and in bed for 3 days). The nurse will need to notify the health care provider (HCP) immediately. However, prior to this, the nurse must perform a thorough assessment of the client to report to the HCP. The priority action by the nurse should include a thorough neurovascular assessment of the extremities, including presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. (Options A, B, and C) These are all assessments that the nurse should collect to report to the HCP but are not as high of a priority or as relevant to the specific situation that the client is currently experiencing. Educational objective: The nurse that suspects DVT should perform a thorough neurovascular assessment of the client's extremities, including presence and quality of DP and PT pulses, temperature of extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison. The findings should be reported immediately to the HCP.

Question 5

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern?

Accepted Answer

11ecbb05_c946_bf01_b433_9dcc7cdbae12_MD0009_00 Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair. Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to decreased renal perfusion and potential kidney injury. The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine output. Urine output should be at least 30 mL/hr. This client should have an output of at least 120 mL of urine in a 4-hour period. (Option A) Diminished breath sounds in the lung bases are a common occurrence after surgery, especially in a client who has an abdominal incision that is painful with deep inspiration. The nurse should medicate the client for pain and encourage coughing, deep breathing, and use of an incentive spirometer. (Option B) Hypoactive bowel sounds are typical after abdominal surgery as the bowel has been handled and manipulated. Clients often have a nasogastric tube for suction until bowel sounds return. The nurse should continue to monitor for bowel sounds and the presence of flatus. (Option D) A decreased or absent pulse, together with cool, pale, or mottled extremities, would be cause for concern. This client has warm extremities. Pulses should be compared with preoperative status and can be verified with a Doppler if needed. Educational objective: The nurse should carefully monitor renal status in a client who has had abdominal aortic aneurysm repair. BUN, creatinine, and urine output should be assessed. Urine output of at least 30 mL/hr is expected.

Question 6

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

Accepted Answer

Dysrhythmias are the most frequent complication following myocardial infarction (MI). Ventricular fibrillation is the most common of these dysrhythmias and is regularly the cause of sudden cardiac death in clients with MI. The nurse should attach the cardiac monitor to the client before performing any other interventions. If ventricular tachycardia or premature ventricular contractions (PVCs) are observed, the client should be treated quickly (with antidysrhythmic drugs) as these rhythms usually precede ventricular fibrillation; early identification and treatment are imperative to improve outcomes. ST segment should also be monitored as reinfarction may occur; the client may or may not have the usual MI-related symptoms (eg, chest pain, shortness of breath, vomiting). (Option A) Jugular venous distension may indicate development of heart failure following MI; this is an important assessment but should be performed after the cardiac monitor is attached to the client. (Options C and D) Assessment of vital signs and auscultation of the heart and lungs are also important but should be performed after the cardiac monitor is attached to the client. Educational objective: Dysrhythmias are the most common complication following myocardial infarction. The nurse should immediately attach the cardiac monitor when the client is admitted before taking vital signs and performing other assessments.

Question 7

The nurse is performing a cardiac assessment on a client.  The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border.  How should the nurse document this finding?

Accepted Answer

11ecbb05_c949_3004_b433_83e7e71f758a_MD0009_00 Murmurs are produced by turbulent blood flow across diseased or malformed cardiac valves. They can be characterized as musical, blowing, swooshing, or rasping sounds heard between normal heart sounds. The aortic area is located at the second intercostal space, right sternal border. (Option A) An arterial bruit is a turbulent blood flow sound heard in a peripheral artery. (Option C) A pericardial friction rub is a high-pitched, scratchy sound during S₁ or S₂ at the apex of the heart. It is best heard with the client sitting and leaning forward and at the end of expiration. It occurs when inflamed surfaces of the heart rub against each other. (Option D) An S₃ gallop is an extra heart sound that occurs closely after S₂. It is a low-pitched sound heard in early diastole that is similar to the sound of a horse's gallop. The mitral area is located at the fifth intercostal space, medial to the mid-clavicular line. Educational objective: Murmurs indicate turbulent blood flow across diseased or malformed cardiac valves. They are often described as musical, blowing, or swooshing sounds that occur between normal heart sounds. They may be auscultated at the aortic, pulmonic, tricuspid, or mitral areas.

Question 8

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine. The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days. Which question is most important for the nurse to ask next?

Accepted Answer

A major problem in the long-term management of hypertension is poor adherence to the treatment plan, often due to unpleasant side effects (eg, fatigue, dizziness, reduced libido, erectile dysfunction) and medication cost. This problem can worsen if a client must take multiple medications. Determining whether a client is taking medications as prescribed is a priority, as sudden or abrupt discontinuation of antihypertensive medications can cause rebound hypertension and possibly hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath) (Option B). (Option A) The nurse should assess for peripheral edema, which may indicate heart failure. However, this can be done after assessing medication adherence. (Options C and D) Stress can elevate blood pressure. Some over-the-counter medications (eg, decongestants, NSAIDs) can also increase blood pressure. However, poor adherence to prescribed medications is the number one cause of uncontrolled hypertension. The nurse should ask about all other medications the client has taken and the client's stress level after confirming that the prescribed blood pressure medications are being taken correctly. Educational objective: A major problem in long-term management of hypertension is poor adherence to the treatment plan, often due to unpleasant side effects and medication cost. Assessing for medication adherence is important, as abrupt discontinuation of antihypertensive medications can cause rebound hypertension and hypertensive crisis.

Question 9

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply.

Accepted Answer

A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected so that a special camera can produce images of the heart. Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion. Pre-procedure client instructions include the following: Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications (Option C). Avoid caffeine products 24 hours before the test (Option B). Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option A). Do not take theophylline 24-48 hours prior to the test (if tolerated). If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option E). Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: Nitrates (nitroglycerine or isosorbide) Dipyridamole Beta blockers (Option D) Educational objective: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; avoid both caffeinated and decaffeinated products for 24 hours before the test; and avoid taking theophylline or antianginal medications unless otherwise instructed by the health care provider.

Question 10

The nurse is caring for a client with cardiomyopathy and coronary artery disease. The client is reporting increasing chest pain and has bilateral lung crackles on auscultation. The health care provider has written several new prescriptions. Which new prescription should the nurse clarify? Select all that apply.

Accepted Answer

Cardiomyopathy is a group of diseases in which the heart muscle (ie, myocardium) has a reduced ability to pump blood effectively, placing clients at risk for cardiogenic shock. Cardiogenic shock is manifested by reduced cardiac output (eg, hypotension, narrow pulse pressure), which can lead to pulmonary edema (eg, tachypnea, bibasilar crackles, decreased oxygen saturation) caused by blood "backing up" into the pulmonary capillaries. To compensate, catecholamines (eg, epinephrine) and vasopressin are released by the adrenal glands to increase cardiac output. However, this compensatory mechanism eventually fails, causing decreased perfusion and oxygenation of tissues as well as death. The client may need additional support with ionotropic agents (eg, norepinephrine) in these situations. Supplemental oxygen is appropriate for treatment given low oxygen saturation, chest pain, and tachypnea (Option C). If chest pain is present, obtaining an ECG and testing cardiac enzymes (eg, creatine kinase-MB, troponin I) are appropriate (Options D and E). (Option A) IV fluids should not be given rapidly (ie, bolused) in cardiogenic shock as this will suddenly increase circulating volume and cardiac workload, which may precipitate pulmonary edema. (Option B) Nitroglycerin can worsen hypotension and should be held. Other pain medications (eg, morphine) may be given for chest pain if blood pressure is low. Educational objective: Clients with cardiomyopathy may develop cardiogenic shock due to the heart's inability to circulate blood effectively, causing reduced cardiac output. Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme testing, and interventions to reduce cardiac workload.

Question 11

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply.

Accepted Answer

11ecbb05_c947_5b42_b433_6f92aff88ce8_MD0009_00 Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Signs and symptoms of cardiac tamponade include: Hypotension with narrowed pulse pressure (Option A) Muffled or distant heart tones (Option D) Jugular venous distension (Option E) Pulsus paradoxus Dyspnea, tachypnea Tachycardia (Option B) Bounding pulses may be present during fluid overload or hypertension. They may also be present with anxiety or fever. The client with possible tamponade will have evidence of decreased cardiac output and is more likely to have weak, thready pulses. (Option C) Decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax. Educational objective: The client with a moderate to large pericardial effusion is at risk for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, narrowed pulse pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The nurse should report these findings to the health care provider immediately and prepare for a pericardiocentesis.

Question 12

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first?

Accepted Answer

11ecbb05_c948_1e93_b433_59068129f1b0_MD0009_00 The client with pericardial effusion should be seen first. This client is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distension) of developing cardiac tamponade, a life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart. The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Emergency pericardiocentesis is needed. Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. (Option A) These are symptoms typically seen in the client with endocarditis. The nurse should further assess the murmur to see if it has worsened or changed, but this should be done after the client with pericardial effusion is seen. (Option C) The new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable; this client is not a priority over the client with possible tamponade. Atrial fibrillation is often a chronic arrhythmia and is managed with ventricular rate control and anticoagulation. (Option D) Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic. IV diuretics can worsen the hypotension. The client is watching TV, an indication that the client is stable. The nurse can delegate to the unlicensed assistive personnel directions for the client to stay in bed due to the hypotension until the nurse can perform further assessment. Educational objective: Clients with pericardial effusion should be monitored and assessed closely for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular venous distension, and pulsus paradoxus.

Question 13

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply.

Accepted Answer

The Dietary Approaches to Stop Hypertension (DASH) diet is often suggested to clients with hypertension due to its ability to reduce blood pressure. The diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats, which all contribute to increased blood pressure. The DASH diet focuses on: Including fresh fruits and vegetables, and whole grains in the daily diet Choosing fat-free or low-fat dairy products Choosing meats lower in cholesterol (eg, fish, poultry) and alternate protein sources (eg, legumes) instead of red meats (Option A) Limiting intake of sweets, foods high in sodium (eg, potato chips, frozen meals, canned foods), and sugary beverages to the occasional treat (Options B and C) (Option D) Limiting milk intake is unnecessary; however, the nurse may need to educate the client about choosing low-fat or skim milk over whole milk. (Option E) Taking the salt shaker off the table may be a good first step in reducing sodium intake. However, it will not be enough as salt is found in many foods. Educational objective: The Dietary Approaches to Stop Hypertension (DASH) diet is often recommended to reduce blood pressure in clients with hypertension. The client is taught to limit intake of sugar, sodium, cholesterol, and trans or saturated fats, and instead choose healthier options (eg, fresh fruit and vegetables, low-fat dairy products).

Question 14

The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client?

Accepted Answer

The priority teaching topic for this client is taking blood pressure medications as prescribed. A major problem with long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant side effects, including fatigue, dizziness, and erectile dysfunction. Client may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. The nurse should determine whether the client has been taking the medications consistently. There may be a need for a dosage change or addition of another medication. The client's blood pressure is not well controlled, and the TIA places this client at a high risk for a stroke. (Options A, B, and C) Decreasing sodium intake and stress levels, plus increasing activity level, are all helpful in managing hypertension. The client should be doing all these, and the teaching topics need to be reinforced. However, they are a lower priority than taking the blood pressure medications as prescribed. Educational objective: A major problem with long-term management of hypertension is poor adherence to the treatment plan. The nurse should teach the client the importance of taking blood pressure medications as prescribed.

Question 15

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply.

Accepted Answer

A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) (Option D) The client may feel warm or flushed while the contrast dye is being injected (Option B) Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis (Option A) (Option C) If the procedure is just a diagnostic study, the client often goes home the same day. Hospitalization for 1-3 days may be required if angioplasty or stent placement is performed. (Option E) General anesthesia is not used during coronary angiography. Sedating medications are given during the procedure. Educational objective: Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed.

Question 16

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?

Accepted Answer

11ecbb05_c949_a535_b433_51b2f70b1114_MD0009_00 Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a 30- to 45-degree angle. The nurse will observe for distension and prominent pulsation of the neck veins. The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload. pulsation (Options B and C) JVD may still be present at 60- and 90-degree angles if marked fluid overload is present. Placement this high might miss mild to moderate JVD. (Option D) JVD may be present while the client is flat. This is not considered abnormal, and the client with possible fluid overload or respiratory issues may not be able to lie flat. Educational objective: The nurse should position the client with the head of the bed at a 30- to 45-degree angle to assess for the presence of JVD.

Question 17

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit.  The new RN is measuring orthostatic blood pressure (BP) for a client.  Which situation would warrant intervention by the experienced nurse?

Accepted Answer

The experienced nurse should intervene if the new RN starts BP measurement with the client in the standing position. Orthostatic BP measurement may be done to detect volume depletion or postural hypotension caused by medications or autonomic dysfunction. Procedure for measurement of orthostatic BP Have the client lie down for at least 5 minutes (Option A) Measure BP and HR Have the client stand Repeat BP and HR measurements after standing at 1- and 3-minute intervals (Option D) A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal (Option B). Educational objective: To measure orthostatic BP, the nurse should have the client lie supine for 5-10 minutes and then measure BP and HR. The nurse should then have the client stand for 1 minute, measure BP and HR, and repeat the measurements at 3 minutes. Findings are significant if the systolic BP drops ≥20 mm Hg or the diastolic BP drops ≥10 mm Hg.

Question 18

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis?

Accepted Answer

Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3 (Option B) A blood pressure of 120/80 mm Hg (MAP 93 mm Hg) is too low for an initial goal. This rapid drop from the client's initial pressure of 250/145 mm Hg (MAP 180 mm Hg) is a decrease of greater than 25% and could cause organ damage. However, it may be necessary to lower the SBP below 120 mm Hg if the client is experiencing an aortic dissection, as a higher BP can cause rupture. (Option C) The nurse should monitor HR and rhythm for signs of MI or heart failure. However, the priority goal for this client is to achieve a therapeutic blood pressure, not HR. (Option D) The nurse should carefully monitor urine output as an indicator of renal function. Output should be greater than 30 mL/hr, but this is not the priority goal in management of hypertensive crisis. Educational objective: Hypertensive crisis may require continuous infusion of an IV vasodilator. BP should be lowered slowly to prevent organ damage. The initial goal is to lower MAP by 25% or less or to maintain MAP of 110-115 mm Hg.

Question 19

A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI).  Which laboratory test should the nurse monitor to determine if the client has had an MI?

Accepted Answer

Troponin is a cardiac specific serum marker that is a highly specific indicator of MI and has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) or CK-MB. Serum levels of troponin T and I increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline in 10-14 days. However, MI is not diagnosed alone by serum cardiac markers. Electrocardiogram findings and client health history along with a history of pain and risk factors are also used to make the diagnosis of MI. (Option A) D-dimer is a laboratory test that measures the amount of cross-linked fibrin fragments resulting from clot degradation. It is ordered for clients with suspected pulmonary embolism. (Option B) LDL is used in determining cardiac disease risk, not for diagnosing MI. (Option C) Myoglobin is released into the circulation within 2 hours after MI. Although it may be the first serum cardiac marker to appear after MI, it lacks cardiac specificity and its role in diagnosing MI is limited. Educational objective: The nurse should monitor serum troponin levels when there is suspicion of MI as it is the most sensitive and specific serum cardiac marker.

Question 20

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform?

Accepted Answer

11ecbb05_c951_1f48_b433_8b7d2e964b29_MD0009_00 This client is exhibiting symptoms of intermittent claudication or ischemic muscle pain that can be due to peripheral artery disease (PAD). PAD impairs circulation to the client's extremities. The nurse should first check for the adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality. Poor circulation to the extremities can place the client at increased risk for development of arterial ulcers and infection. The quality of circulation to the extremities will guide the treatment plan for this client; management will include risk factor modification for cardiovascular disease, drug therapy, and possibly surgical revascularization. (Option A) Dry, scaly skin can be present in the client with PAD. It is a chronic condition of PAD and is not the priority assessment. (Option B) When circulation to the extremities is impaired, the skin on the lower legs becomes thin, shiny, and taut; hair loss also occurs on the lower legs. This develops over time and would indicate that PAD has been present for a period of time and is not the priority assessment. (Option D) The nurse should obtain a dietary history to assess for risk factors associated with cardiovascular disease. However, this is a lower level priority in this situation. Educational objective: The nurse caring for a client with intermittent claudication from PAD should assess the adequacy of circulation to the extremities by palpating and assessing the quality of posterior tibial and dorsalis pedis pulses. The quality of circulation will guide the treatment plan including risk factor modification, drug therapy, and possible surgical revascularization.

Exam 1: Adult Health

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN?

A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority?

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern?

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding?

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply.

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply.

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first?

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply.

The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA) . The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client?

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply.

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse?

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis?

A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI) . Which laboratory test should the nurse monitor to determine if the client has had an MI?

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform?