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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?
1. Regular insulin
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)
4.
Metformin (Glucophage) 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.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Planning
Content Area: Adult Health: Cardiovascular
Strategy(s): Comparable or Alike Options
Priority Concepts: Perfusion, Safety

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and


QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes
measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a
correct interpretation based on these characteristics?
1.Sinus bradycardia
2.Sick sinus syndrome
3.Normal sinus rhythm
4.First-degree heart block
3.
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 0.12 to 0.20 second and
0.04 to 0.10 second, respectively.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion

A client is wearing a continuous cardiac monitor, which begins to sound its


alarm. A nurse sees no electrocardiographic complexes on the screen. Which is
the priority action of the nurse?
1.Call a code.
2.Call the health care provider.
3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console.
3.
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.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Adult Health: Cardiovascular
Strategy(s): Strategic Words, Steps of the Nursing Process

A client is having frequent premature ventricular contractions. The nurse should


place priority on assessment of which item?
1.Sensation of palpitations
2.Causative factors, such as caffeine
3.Precipitating factors, such as infection
4.Blood pressure and oxygen saturation
4.
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority
is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can
lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations.
Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or
by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by
intake of caffeine, nicotine, or alcohol.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Strategic Words, ABCsAirway, Breathing, Circulation
Priority Concepts: Clinical Judgment, Perfusion

The nurse is evaluating a client's response to cardioversion. Which observation


would be of highest priority to the nurse?

1.Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness
2.
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then
oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia
detection.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Evaluation
Content Area: Adult Health: Cardiovascular
Strategy(s): Strategic Words, ABCsAirway, Breathing, Circulation
Priority Concepts: Clinical Judgment, Perfusion

The nurse is caring for a client who has just had implantation of an automatic
internal cardioverter-defibrillator. The nurse immediately would assess which
item based on priority?
1.Anxiety level of the client and family
2.Presence of a Medic-Alert card for the client to carry
3.Knowledge of restrictions of postdischarge physical activity
4.Activation status of the device, heart rate cutoff, and number of shocks it is
programmed to deliver
4.
The nurse who is caring for the client after insertion of an automatic internal cardioverterdefibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker.
Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above
which it will fire, and the number of shocks it is programmed to deliver. The remaining options
are also nursing interventions but are not the priority.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Strategic Words, Maslow's Hierarchy of Needs Theory
Priority Concepts: Perfusion, Safety

A client's electrocardiogram strip shows atrial and ventricular rates of 110


beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08
second, and the PP and RR intervals are regular. How should the nurse correctly
interpret this rhythm?

1.Sinus dysrhythmia
2.Sinus tachycardia
3.Sinus bradycardia
4.Normal sinus rhythm
2.
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.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion

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?
1.The neurovascular status is normal because of increased blood flow through
the leg.
2.The neurovascular status is moderately impaired, and the surgeon should be
called.
3.The neurovascular status is slightly deteriorating and should be monitored for
another hour.
4.The neurovascular status is adequate from an arterial approach, but venous
complications are arising.
1.
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.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
Strategy(s): Subject
Priority Concepts: Clinical Judgment, Perfusion